For the vast majority of video game enthusiasts, games are just games - a high-tech way to pass time, have fun and sometimes compete against real-world friends.
For a growing segment, however, it is serious business - to the point where it can be tough to separate the needs of reality from the needs of the game.
That's why the American Psychiatric Association is considering adding video game addiction to its next edition of the Diagnostic and Statistical Manual of Mental Disorders, the standard diagnosis book for mental health professionals.
The DSM-V will come out in 2012 - the first major revision since 1994. By then, the problem for some gamers might be even more pronounced, says Kimberly Young, a Pennsylvania psychologist and director of the Center for Internet Addiction and Recovery.
Ms. Young says video game addiction should be a formal diagnosis because until clinicians understand what they are dealing with, they cannot adequately help those who show symptoms.
"I have found that many people who have a problem with technology overuse have an addictive personality to begin with," she says. "We've seen traditional addictions like sex and gambling taken online. There is a whole new generation of people who are comfortable with technology, so they have more access to [their addictions]. The unique thing about gaming addiction, though, is it doesn't exist off-line. There is no way to access the games you crave without it."
To be fair, most of the people Ms. Young and other psychologists deal with are not casual game enthusiasts who enjoy an hour or two of Super Mario. Actual addiction symptoms, such as experiencing withdrawal symptoms and jeopardizing relationships, most often are found among those who intensely play Massive Multiplayer Online Role-Playing Games (MMORPG) such as EverQuest and World of Warcraft. These are complex games that are highly social, very strategic, extremely competitive and, most notably, never end.
An American Medical Association report says about 9 percent of gamers take part in MMORPGs. The report, which was submitted to the APA, says researchers have found that those who are most susceptible to overuse "are somewhat marginalized socially, perhaps experience high levels of emotional loneliness and/or difficulty with real life social interactions. The current theory is that these individuals achieve more control of their social relationships and more success in social relationships in the virtual reality realm than in real relationships."
Elizabeth Woolley of Nashville, Tenn., has seen that pattern firsthand. Her son, Shawn, then 21, committed suicide in 2001. She says video game addiction led to his death.
"He played for about 10 years and had no problem," Ms. Woolley says. "Then he discovered EverQuest. He just became a different person - withdrawn. Socially inactive. The game became the solution to all his problems. He would spend two-thirds of his day playing the game. He would stay up all night and play it. He had suffered from ADHD and stopped taking his medication."
Ms. Woolley has since founded On-line Gamers Anonymous (www.olganon.org), where others who get caught up in the games post their experiences and find support. Consider this post from a former gamer:
"I started to ignore my wife, ALOT, and sadly, my 2 daughters even more. Many times I would forget to eat and drink because I was so consumed with this game. Sometimes I had to go to the bathroom but I didn't want to get up because most of the time it was in the middle of a tough fight and I just couldn't leave my computer because the thought of even dying in this game is scary. ... Here I am now sitting in my apartment tonight, alone, no wife and no kids by my side. I could have avoided this if I hadn't played so much, but I did the contrary and that is a fact that I will have to live with for the rest of my life."
Jerald Block, an Oregon psychiatrist who has written medical journal articles in favor of a video game addiction diagnosis, says the majority of people who have an issue with gaming also have other disorders such as depression, anxiety or ADHD (attention deficit hyperactivity disorder).
"Doctors need to be trained to look for gaming addiction because it complicates other disorders," he says. "This is important because if a person has depression and anxiety, part of the goal of treatment is to get out and function in the real world. If computer use is holding them at home and the virtual world is so rewarding, then they won't want to get out in the real world."
Dr. Block points out that the United States already lags behind in recognizing the dangers of video game overuse. South Korea, for example, recognizes it as a serious public health problem and has trained 1,043 counselors in the treatment of Internet addiction at more than 190 hospitals and treatment centers.
In China, Tao Ran, director of Addiction Medicine at Beijing Military Region Central Hospital, recently reported that 13.7 percent of Chinese adolescent Internet users - about 10 million teens - meet Internet addiction diagnostic criteria.
As a result, in 2007 China began restricting computer game use; current laws now discourage more than three hours of daily game use.
Still, Dr. Block is skeptical that the United States will follow suit.
"The industry sells nine games every second," he says. "There are very powerful forces that are allied against ever seeing this diagnosis in the DSM."
Hal Halpin, president of the Entertainment Consumers Association, a gamers' advocacy group, says while substance addiction is a serious problem, it is unfair to single out gaming.
"What we're really talking about here is media addiction, but unfortunately we're not even talking about that," he says. "The issue has been politicized down to games, to the exclusion of all other media, including movies, music and television. It seems disingenuous on its face. Is there a small percentage of folks who turn their TV or movie watching or game playing into an obsession? Sure. There's an argument to be made for Trekkies, 'Star Wars' fans and even 'Sex and the City' devotees - all of whom repeat behaviors that can be paralleled with unhealthy substance addictions, but that does not a causal relationship make."
Addiction experts also fall on both sides of the argument.
"There is nothing here to suggest that this is a complex physiological disease state akin to alcoholism or other substance-abuse disorders, and it doesn't get to have the word 'addiction' attached to it," said Stuart Gitlow, a New York addiction psychiatrist, at the 2007 AMA meeting.
David Walsh, founder of the National Institute for Media and the Family, says the debate - as well as the number of gamers showing symptoms - is likely to grow between now and the time the next DSM is published.
"I think more and more clinicians are seeing gamers whose playing patterns are so similar to those who have drug and alcohol addiction," Mr. Walsh says. "I am not talking about kids who really like and enjoy video games; I am talking about players who get so involved in the game that other activities suffer, as does their physical health. The video game industry hates the term, though. The word addiction connotes a lot of issues they do not want to go near."