Imagine two patients, both of whom report roughly five hours a day of video gaming. The first spends that time building, laying out cities, automating supply chains, and solving puzzles with no stakes beyond his own satisfaction. The second spends it inside a mobile game that sells randomized item pulls for real money, chasing a prize he has already paid for twice and still doesn’t own. Without those details, the same screen-time count looks identical on paper for two patients who otherwise have very little in common.
This is a limitation built into the category itself. “Gaming” has become one of the least specific words a patient can offer, and “screen time,” even more vague.
Gaming is a loaded word
The term “gaming” spans an unusually wide range of behavior, all the way from solitary play to structured competition with strangers. It can mean staying connected to friends across time zones, coding for its own sake, or watching others play. However, it can also mean spending money on chance-based in-game purchases, structured around mechanics designed to keep a player engaged well past the point of clear intent. These are very different activities that happen to share an interface and a verb.
Medicine generally doesn’t tolerate this kind of imprecision elsewhere. “Substance use” prompts one to ask which substance, since the clinical picture for caffeine and the clinical picture for opioids are far from similar. A standard alcohol history asks about control, function, and consequence, not just volume per week. Gaming has, for understandable reasons, been slower to receive the same treatment.
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The diagnostic frameworks we have
The formal diagnostic frameworks go some distance toward addressing this. The World Health Organization’s ICD-11 gaming disorder diagnosis, introduced in 2019, centers on impaired control over gaming, gaming taking priority over other interests, and continued gaming despite negative consequences. The DSM-5 lists internet gaming disorder as a condition for further research, organized around criteria such as preoccupation, withdrawal, tolerance, unsuccessful efforts to cut down, and gaming used to regulate mood. Both frameworks are concerned, appropriately, with the functional consequences of the behavior. This includes whether it is impairing, whether the person can stop, whether it is displacing other domains of life.
What neither framework asks explicitly about is the structure of the game itself, specifically, whether the title in question monetizes through randomized, chance-based purchases. A patient could plausibly meet several criteria regardless of whether the game in question charges nothing at all or is built around reward schedules.
Not all gaming deserves scrutiny
This is not an argument that gaming, as a whole, deserves general suspicion. Some research on adolescents has suggested that the relationship between screen time and well-being is not strictly linear, and most gamers do not develop gaming disorder. Much of what falls under the word “gaming” is ordinary, social, or modestly skill-building, and over-pathologizing it is its own clinical error.
The features that warrant closer attention are the few that hour counts may not accurately capture, including loot boxes, near-miss events, or spending tied to randomized outcomes. Similarly, temporal design features like time-limited offers or decaying rewards are often intended to manufacture urgency. None of these show up in “five hours a day.” They can, however, be revealed in a few follow-up questions.
The new skill to learn
Counting hours may not be the best way to understand one’s relationship with a video game. Finding out what kind of gaming a patient is describing, alone or with others, competitive or creative, building or chasing something, can help. Ultimately, the goal is to explore what the patient is actually getting from their gaming experience. A small set of follow-up questions like “Is real money tied to chance-determined outcomes?” or “Does the game create urgency around continued engagement?” can be the difference between a harmless pastime and a harmful problem.
The patient in the first vignette likely needed nothing further from his clinician. The patient in the second likely needed a few more questions asked of him. Telling the two apart, not totaling their hours, is the real skill the next generation of doctors will need to learn.
Kamran Shukoor is a medical student. Salma Sher is a neuroscience researcher.
