Claw Machine-induced Gaming Disorder: A Case Report : Taiwanese Journal of Psychiatry (2024)

Gaming disorder is a condition included in the 11th International Classification of Diseases, the Eleventh Edition (ICD-11), characterized by a lack of control over a pattern of persistent online or offline gaming behavior, providing higher priority in daily life despite negative consequences, lasting for at least 12 months, and impairing one's personal social and occupational or other important areas of functioning [¹]. In contrast, Internet gaming disorder is identified as a condition for further study (pages 795-8) in the Diagnostic and Statistical Manual of Mental Disorders, the Fifth Edition (DSM-5) [²]. The proposed criteria involve a preoccupation with Internet games, corresponding withdrawal and tolerance symptoms, loss of control, loss of interest in other previous hobbies, excessive usage despite knowledge of negative consequences, deceiving others about its usage, using it to relieve negative emotions, and jeopardizing other important areas of functioning over a 12-month duration [²].

On the other hand, gambling disorder is included in both ICD-11 and DSM-5 [^1,2]. Gambling disorder describes a persistent gambling behavior with a need to gamble with increased stakes, feeling restless (withdrawal) when attempting to cut down, a loss of control, a preoccupation on gambling, often gambling when feeling distressed, “chasing” one's losses, lying to conceal the extent of gambling, with significant areas of functioning jeopardized, and relying on others to finance one's gaming habits [²].

The pooled prevalence of gaming disorder is 10.1% in the Southeast Asia region, which is highest among adolescents and adults [³]. The prevalence of gambling disorder is within 0.5%–3.0% depending on the diagnostic criteria used and forms of gambling [⁴]. While both gaming and gambling disorders have been described as distinct disorders, they both have essentially similar clinical characteristics, associations, and biological basis as substance use disorders, with clear demarcations from impulse-control and obsessive–compulsive disorders [⁵]. We herein intend to report a case of a patient with claw machine gaming disorder.

Case Report

The patient is a single 40-year-old male patient, who works as an undertaker and lives in a hostel provided by his employer. He has no history of underlying chronic physical illness or psychiatric illness. He was found unconscious in his room by a co-worker because he did not show up for work in the morning on June 11, 2020, and was brought to the emergency department, where he regained consciousness and revealed that he had ingested about 20 mL of paint thinner as he felt overwhelmed for the whole previous week. Then, his vital signs were normal and physical examination was unremarkable. Blood studies including complete blood count, renal, liver, and thyroid functions tests were normal in findings. He was then referred to an internist and a psychiatrist for further expertise management, and subsequently admitted to the medical ward for a two-day observation.

In the psychiatric interview, the patient explained that his incident of ingesting paint thinner was an impulsive act. He was pressured by loan sharks (unlicensed money lenders) to repay a debt of Ringgit Malaysia (RM) 30,000, equivalent to US$7,264 (US$1 = RM 4.13 in May 2021). The loan sharks had repeatedly threatened to kill him if he did not repay them. Hence, he tried to solve his problem by attempting to end his life. This debt was accrued from borrowing money to support his interest in playing claw machines over the previous two years.

The patient started to play with stuffed toy-dispensing claw machines two years ago. He had been visiting a local arcade (which housed only arcade machines without any other forms of arcade games or gambling devices) every day, spending about RM100 daily (US$24.20). He usually spent a few hours at the arcade before and after work. This was a big expense as he was spending more than his monthly income of RM1800 (US$435.80). He initially stole from his employers to fund his habit. But he was caught. Since then, he had refrained himself from stealing. He instead borrowed money from loan sharks. Over two years, he had borrowed from seven groups of loan sharks. To pay off his debt, his employer had attempted to arrange a monthly installment repay schedule previously. Even so, he continued to borrow money from other loan sharks.

The patient linked this habit to loneliness which he claimed to have “nothing to do,” and “nobody to spend with” after work. He felt “bored” and “empty” if he did not go to the arcade. Playing claw machines gave him a “purpose,” and he enjoyed the “sense of achievement” when he won a prize. He originally thought he could sell his winnings to generate cash but was unable to do so. He did not experience pervasive sadness, or other depressive or anxiety symptoms. He denied any family history of mental illness. He is neither a smoker nor a substance abuser.

The patient revealed that he had an episode of involving in gambling activities 20 years ago by frequenting an illegal casino near his workplace, and started those activities with making small bets. But he preferred playing the slot machine. Initially, he could spend many hours of entertainment with a budget of RM 10 (US$2.40). He had increased his bets gradually over the time, but he denied borrowing from loan sharks to finance his gambling habits. He could walk away from the casino when he ran out of chips. The casino was eventually shut down, which ended his involvement in it. Without any access to casinos (legal or illegal) near him, he instead went to the nearby arcade.

There was a period where the patient could stay away from the arcade for eight weeks. This achievement coincided with the period when he entered his first and only romantic relationship with a lady. He reported feeling “happy” and did not feel the need to visit the arcade. But the courtship did not last, and he later returned to the arcade after breaking up.

Based on DSM-5[²], the patient fulfilled the criteria for gambling disorder in sustained remission. But no related diagnosis exists to address the issue of his claw machine gaming except Internet gaming disorder. But based on ICD-11[¹], the characteristics of his clinical presentation fulfilled the criteria for both gaming and gambling disorders. We used the self-rated 7-item Gaming Addiction Scale to assess his condition, and found that the patient met 7 criteria, meaning he is considered to have a gaming disorder [⁶].

After a psychiatric assessment, the patient was made aware of his addictive behavior to the claw machines and its consequences. Through shared decision-making with the psychiatrist, the patient agreed with receiving a nonpharmacological intervention. He received individual psychoeducation, given by the psychiatrist stressing on awareness to the risks of gaming behavior and effects on mental health, lifestyle modifications, as well as counseling on coping skills, and stress management.

At the follow-up clinic visit two weeks later, the patient had been noted trying to refrain himself from visiting the arcade. But he had shifted his attention to offline games. The psychiatrist gave him repeated psychoeducation two times a month. After four sessions, he was able to abstain himself from playing claw machines and to fill up his “loneliness” by spending time with friends and watching television. At this writing in March 2021, he is living a fruitful life after work.

Comment

No proper guidelines exist on gaming or gambling disorders, particularly on claw machine-related gaming disorders. But experts have suggested that treatment modalities are similar to substance use disorders [⁷]. Personalized holistic treatment modalities to address psychosocial issues such as psychotherapy, stress management, or coordination with family have been suggested [⁷]. There is a lack of data regarding pharmacotherapy for gaming or gambling disorders [⁷]. Any physical or psychiatric comorbidities should be managed accordingly. The treatment goals are to prevent recurrence and promote social occupational functioning [⁷].

In this case, our patient's primary issue was playing with claw machines and not online or offline games. Claw, or crane, machines are lottery games involving the player inserting coins into the machine, and allow the player to manipulate a claw through a joystick, grab hold of a prize, and then drop the prize off at a prize chute. The prizes are then dispensed to the player, providing a sense of achievement, and encouraging the intention to continue playing. Claw machines are easily available across shopping malls in Malaysia, targeting all age groups of the public, including children. As claw machines are not considered a gambling tool, there are no specific regulations, including payout rates on it.

Nevertheless, claw machines may involve an element of gambling as its rewards are distributed based on a variable ratio schedule (www.vox.com/2015/4/3/8339999/claw-machines-rigged). Modern claw machines are computerized, and modifiable features may include claw strength and aperture, claw pick up strength, claw movement speed, operator-adjusted payout rate (the operator can adjust how many tries players have to make before a payout is made, to ensure profit) (www.pandavending.com). The machine payout rate is decided by the machine operator.

Many forms of games, either online or offline, have been reported to have the potential to lead to the development of gaming disorders [⁸]. While studies have been done and suggested that people with Internet gaming disorder have a significant correlation with other mental health conditions such as depression, anxiety, social phobia, symptoms of attention deficit hyperactivity disorder, and obsessive–compulsive symptoms, information is scarce regarding potential comorbidities or any recurrence rate of offline gaming disorder [⁹].

In fact, no published papers exist on claw machine-induced gaming disorder in medical literature. Nevertheless, in Taiwan, there are reports of two persons being addicted to claw machines resulting in debts and crime-related behaviors [¹⁰]. As the claw machines gain popularity among the younger generation, claw machine addiction can possibly become a worldwide issue in the future.

In summary, we intend to highlight the possibility of claw machines-induced gaming disorder in this case report although it is limited to have only one case. The coin-operated shops for playing claw machine are popular in Taiwan [¹⁰]. While seeing a patient of all ages who is playing the claw machines, clinicians should be aware of the possibilities of addiction and its consequences as shown in this case report. Based on this case report, we suggest that clinicians should be more alert when encountering patients who have a particular fondness toward claw machine playing. (National Institute of Health Ministry of Health, Malaysia, wrote a letter for clearance on behalf of authors' ethics committee for human experiments for approving publication of this case report (reference number = NIH 8000-4/4/1 Jld 93 ⁽⁵⁵⁾ and date of the letter = April 5, 2021) with the need of obtaining a signed informed consent from the patient.)

Financial Support and Sponsorship

None.

Conflicts of Interest

The authors do not have any conflicts of interest in writing this letter.

Acknowledgment

We thank the Malaysian Director General of Health for his permission to publish this article.

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