internet gaming disorder may recover naturally. some countries, such as south korea, china, the netherlands, canada, and the united states, have responded to the perceived threat of video game addiction by opening treatment centres. china china was the first country to treat "internet addiction" clinically in 2008. the chinese government operates several clinics to treat those who overuse online games, chatting and web surfing. treatment for the patients, most of whom have been forced to attend by parents or government officials, includes various forms of pain including shock therapy. in august 2009, deng sanshan was reportedly beaten to death in a correctional facility for video game and web addiction. most of the addiction "boot camps" in china are actually extralegal militaristically managed centers, but have remained popular despite growing controversy over their practices. in 2019, china set up a curfew, banning minors from playing between certain hours. in 2021, china government published a new policy to force corporations to only serve underage teenagers on friday, saturday, and sunday between 8 pm to 9 pm. netherlands in june 2006, the smith and jones clinic in amsterdam—which has now gone bankrupt—became the first treatment facility in europe to offer a residential treatment program for compulsive gamers. keith bakker, founder and former head of the clinic, has stated that 90% of the young people who seek treatment for compulsive computer gaming are not addicted. canada at a computer addiction services center in richmond, british columbia, excessive gaming accounts for 80% of one youth counselor's caseload. united kingdom in 2018, the national health service announced its plans to open a treatment center, run by the central and north west london nhs foundation trust, that will initially focus on gaming disorder, but is planned to expand to cover other internet-based addictions. the specialist treatment center opened in 2019 for treating adolescents and young people aged 13–25 who are addicted to video games. outcomes physical health the most frequent physical health-related outcome are alterations in physical functioning such as somatization and sleep disturbances. preliminary evidence suggest that internet gaming disorder and the induced sedentarity may contribute to a lack of physical exercise, even though the relationship is not causal. epidemiology maximal mean prevalence of internet and video game addiction (ivga) and internet gaming disorder (igd) by region: fig.1 the prevalence of internet gaming disorder range from 0.7% to 25.5% worldwide, or 1.0% to 26.8% worldwide, and 3.5% to 17% in china, and is higher among males than females and among younger than older people, with geographical region being an insignificant contributor. the prevalence was found to be 5.06% among a high-school student population from sri lanka, suggesting an increasing trend in low- and middle-income countries as well. a longer time spent on video games predicts a tendency towards pathological gaming in the future. the studies, however, used various methodologies and definitions, which renders consensus difficult to achieve and may explain the wide range of prevalence. research debates on the classification a meta-analytic review of pathological gaming studies concluded that about 3% of gamers may experience some symptoms of pathological gaming. the report noted problems in the field with defining and measuring pathological gaming and concluded that pathological gaming behaviors were more likely the product of underlying mental health problems rather than the inverse. barnett and coulson expressed concern that much of the debate on the issue of addiction may be a knee jerk response stimulated by poor understanding of games and game players. such issues may lead both society and scholars to exaggerate the prevalence and nature of problematic gaming, and over-focus on games specifically, while ignoring underlying mental health issues. however, problem gamblers have a higher chance for getting mental illness as well. other scholars have cautioned that comparing the symptoms of problematic gaming with problematic gambling is flawed, and that such comparisons may introduce research artifacts and artificially inflate prevalence estimates. for instance, richard wood has observed that behaviors which are problematic in regards to gambling may not be as problematic when put into the context of other behaviors that are rewarding such as gaming. similarly, barnett and coulson have cautioned that discussions of problematic gaming have moved forward prematurely without proper understanding of the symptoms, proper assessment and consequences. rather than video gaming disorder being a subtype of gambling disorder, a majority of researchers support the idea of video game addiction being a part of a more comprehensive framework of impulse control disorders with "pathological technology use" with similar characteristics, including the pathological use of video games, internet, computers and other interactive medias. although internet and video game addictions are generally considered different from gambling disorder and substance abuse, there is a growing body of evidence indicating they share common features, including behavioral and neural features. indeed, it is suggested that while behavioral addiction may differ with drug addictions in magnitude, they share several characteristics, with hellman et al. proposing that the concept of addiction should be de-medicalized. on the contrary, a literature review found that as the video game addiction develops, online gaming addicts spend increasing amounts of time not only playing but also preparing for and organizing their playing sessions, suggesting this addiction may be behavioral rather than a disorder of impulse control. there is recent evidence suggesting that internet gaming disorder can cause two distinct types of dysfunctions: cognitive and metacognitive. griffiths has suggested that psycho-social dependence may revolve around the intermittent reinforcements in the game and the need to belong. hagedorn & young have suggested that social dependence may arise due to video games occurring online where players interact with others and the relationships "often become more important for gamers than real-life relationships". controversy and alternative viewpoints common challenges involve the reliability of the methodology and validity of the results in some studies. many rely on self-surveys from university students and also lack time frames making it difficult to study the impact, if any, of addiction on a long term scale. other concerns also address the definition of addiction and how to measure it, questioning whether or not time is a proper unit to determine how addicted someone is to gaming. daria joanna kuss and mark d. griffiths have argued the current scientific knowledge on internet gaming addiction is copious in scope and complexity. they state that instead, a simple framework should be provided to allow all current and future studies to be categorized, as internet gaming addiction lies on a continuum beginning with etiology and risk factors all the way through the development of "full-blown" addiction and ending with ramifications and potential treatment. in addition, they caution the deployment of the label "addiction" since it heavily denotes the use of substances or engagement in certain behaviors. finally, the researcher promotes other researchers to assess the validity and reliability of existing measures instead of developing additional measurement instruments. other challenges include the lack of context of the participant's life and the negative portrayal of gaming addicts. some state that gamers sometimes use video games to either escape from an uncomfortable environment or alleviate their already existing mental issues—both possibly important aspects in determining the psychological impact of gaming. negative portrayal also deals with the lack of consistency in measuring addictive gaming. this leads to discussions that sometimes exaggerate the issue and create a misconception in some that they, themselves, may be addicted when they are not. the evidence of video game addiction to create withdrawal symptoms is very limited and thus debated, due to different definitions and low quality trials. the concept of video game disorder is itself being debated, with the overlap of its symptoms with other mental disorders, the unclear consensus on a definition and thresholds, and the lack of evidence raising doubts on whether or not this qualifies as a mental disorder of its own. despite the lack of a unified definition, there is an emerging consensus among studies that internet gaming disorder is mainly defined by three features: 1) withdrawal, 2) loss of control, and 3) conflict. although the dsm-5 definition of video game disorder has a good fit to current methodological definitions used in trials and studies, there are still debates on the clinical pertinence. michael brody, m.d., head of the tv and media committee of the american academy of child and adolescent psychiatry, stated in a 2007 press release that "... there is not enough research on whether or not video games are addictive." however, brody also cautioned that for some children and adolescents, "... it displaces physical activity and time spent on studies, with friends, and even with family." a major issue concerns the lack of consistent measures and definitions and of acquisition of follow-up data. furthermore, the study design quality has not greatly improved between the 2000s and 2017. for instance, most studies measured internet gaming behaviors in terms of frequency of use (total time spent), without considering the type of game (e.g., mmorpg), the social context (e.g., physically or virtually with friends), nor the motivations (e.g., competitive, achievement-oriented "grinding"). although the amount of time spent was postulated by johanssonn and götestam in 2004 to lead to pathological behaviors, it is unclear whether the time spent is a cause or a consequence of pathological use. these criticisms, however, mostly pertain to western research since there is more data of higher quality available in asian regions, where the internet gaming disorder is more prevalent. a survey conducted in 2019 of 214 scholars shown that 60.8% agreed that pathological video game use could be a mental health problems, whereas 30.4% were skeptical. however, only 49.7% agreed with the dsm-5 definition of internet gaming disorder, and 56.5% to the definition of the world health organization. most scholars were worried that who's and dsm-5's inclusion of internet gaming disorder was "overpathologizing normal youth" and "precipitated moral panic over video games". this indicates a lack of consensus on the issue as of 2019. a study published in 2010 reviewed the findings of video game addiction by use of a motorcycle riding computer game with 17 users. 9 of the users were “abstinent ecstasy users” and the other 8 served as the control group. the 2 groups had their dopamine releases monitored throughout the test. after playing, the control group showed reduced dopamine d2 receptor occupancy of 10.5% in the caudate compared to former baseline levels. the abstinent group reported no changes in their dopamine receptors. history video game addiction has been studied since the 1980s, and has seen a significant increase in the number of empirical studies since then. the press has reported concerns over online gaming since at least 1994, when wired mentioned a college student who was playing a mud game for 12 hours a day instead of attending class. press reports have noted that some finnish defence forces' conscripts were not mature enough to meet the demands of military life and were required to interrupt or postpone military service for a year. one reported source of the lack of needed social skills is overuse of computer games or the internet. forbes termed this overuse "web fixations" and stated they were responsible for 13 such interruptions or deferrals over the five years from 2000 to 2005. in an april 2008 article, the daily telegraph reported that surveys of 391 players of asheron's call showed that three percent of respondents experienced agitation when they were unable to play, or missed sleep or meals to play. the article reports that university of bolton lead researcher john charlton said, "our research supports the idea that people who are heavily involved in game playing may be nearer to autistic spectrum disorders than people who have no interest in gaming." on 6 march 2009, the canadian broadcasting corporation's (cbc) national news magazine program the fifth estate aired an hour-long report on video game addiction and the brandon crisp story, titled "top gun", subtitled "when a video gaming obsession turns to addiction and tragedy." in august 2010, wired reported that a man in hawaii, craig smallwood, sued the gaming company ncsoft for negligence and for not specifying that their game, lineage ii, was so addictive. he alleged he would not have begun playing if he was aware he would become addicted. smallwood says he has played lineage for 20,000 hours between 2004 and 2009. in 2013, a man