Understanding Internet Gaming Addiction in Clinical Practice PDF

Summary

This article reviews internet gaming disorder (IGD), a condition characterized by preoccupation with online gaming, impacting physical and psychological well-being. It examines IGD's conceptualisations, risk factors, and treatments. The article also details the historical progression of IGD research and diagnostic criteria.

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BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 Understanding internet gaming ARTICLE addiction in clinical practice Devika Gu...

BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 Understanding internet gaming ARTICLE addiction in clinical practice Devika Gupta , Lydia Bennett-Li, Richard Velleman , Sanju George & Abhijit Nadkarni phone), hardware used to play (e.g. keyboard, Devika Gupta is an Early Career SUMMARY Research Fellow with motion sensors) and internet connectivity (e.g. Internet gaming disorder (IGD) is a condition in online or offline), with players collaborating or com- Sangath, India and a doctoral student which the individual is preoccupied with playing at the London School of Hygiene and peting to achieve some objective (Griffiths 2012). Tropical Medicine. Her interest is online video games and unable to regulate this Each video game has its own version of what it in the mental health needs of women behaviour, resulting in adverse physical and psy- and young people who have experi- chological consequences. Although there is means to succeed. The most popular type of online enced intimate partner violence. some debate about whether IGD is an addiction game is massively multiplayer online role-playing Lydia Bennett-Li is an undergradu- or a coping mechanism, global evidence indicates games (MMORPGs), which integrate several of ate student of global studies at the that the condition is increasing in prevalence with these characteristics into a single experience. Video University of Sussex, Brighton, UK. recent advances in technology and its higher games have a psychological effect on gamers, as She is interested in the role and impact of addictions and the burden penetration into routine life. Male children and they allow them to engage with an alternate of mental illness in low- and middle- adolescents located in East Asian countries are reality, experience different emotions, socialise income countries. Richard at higher risk than others in the world. Attention- with new people, change their mood or simply pass Velleman is Co-Director of the deficit hyperactivity disorder, depression and anx- time (Ryan 2006). Addictions Research Group at iety are typically associated with IGD. Given the Sangath in Porvorim, India, and Increasing instances of gamers being unable to Emeritus Professor of Mental Health continuing ambiguity regarding the diagnosis and control their gaming behaviour have compelled clin- Research at the University of Bath in screening tools for the disorder, it has become all icians and researchers to consider whether gaming the UK. He is both a practising clinical the more relevant for mental health practitioners psychologist and an academic and academics to attend to this condition and may have the potential to cause significant harm psychologist. His main research develop evidence-based treatments. This review (Kuss 2012) and have given rise to the development interests relate to addiction, with a summarises both the existing evidence for the dis- of the diagnostic categories of ‘gaming disorder’ (as particular interest in the impact of order and the debates that surround it. described in ICD-11; World Health Organization addiction on other family members, including children. Sanju George is 2018b) and ‘internet gaming disorder’ (as described Professor of Psychiatry and LEARNING OBJECTIVES in DSM-5; American Psychiatric Association 2013). Psychology at the Rajagiri College of After reading this article you will be able to: Social Sciences in Kochi, Kerala, understand the differing definitions and concep- India. His primary research interest is Terminology tualisations of internet gaming disorder (IGD) behavioural addictions. Abhijit recognise risk factors, clinical features and Before proceeding, we would like to acknowledge a Nadkarni is Associate Professor of evidence-based treatment associated with IGD conceptual problem within the field of addiction to Global Mental Health at the London School of Hygiene and Tropical recognise the challenges ahead surrounding the internet gaming, i.e. the three overlapping concepts Medicine and Co-Director of the diagnosis and treatment of IGD. – internet addiction, gaming disorder and internet Addictions Research Group at gaming disorder. These terms, often used inter- Sangath, India. He is an addictions KEYWORDS psychiatrist with a special interest in changeably, are subtly different from each other. Internet gaming disorder; gaming disorder; internet global mental health and addictions Internet addiction is an umbrella term historically research in low- and middle-income addiction; DSM-5; ICD-11. used to describe the behaviour of people who were countries. excessively engaged with online activities such as Correspondence Devika Gupta. chatting and gaming. There is a repository of Email: [email protected] A video game is a form of interactive digital enter- research on internet addiction, although the condi- First received 27 May 2020 tainment that has to be ‘played’ by the user in an tion itself has never formally entered the medical Final revision 30 Sep 2020 act known as video or digital gaming (or simply, lexicon (Griffiths 2016). More recent studies have Accepted 6 Oct 2020 gaming) – one of the most popular acts of leisure asserted that the term internet addiction lacks speci- Copyright and usage in everyday life for children, adolescents and ficity (as it is not possible for an individual to be © The Authors 2020 adults in the world (Przybylski 2017). Video addicted to the internet itself) and that the internet games can be of many different kinds, depending merely facilitates increased engagement in certain on the genre (e.g. strategy games, shooting games, behaviours (Griffiths 2016). Gaming disorder is simulations), number of players (e.g. single-player, the term used to describe an addiction to both multiplayer), platform (e.g. arcade machine, digital games and video games, as used in ICD-11 gaming console, personal computer, mobile (World Health Organization 2018b). On the other 383 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Gupta et al hand, internet gaming disorder is used widely to understanding IGD as it stands today is impossible describe excessive online gaming behaviour, and is without acknowledging the history and burgeoning identified as a potential psychological condition in debate that mire its conceptualisation and accept- DSM-5 (American Psychiatric Association 2013). ance by the scientific and clinical community. We recognise the conceptual strength of the ICD- 11 definition of gaming disorder because it includes online and offline games (as DSM-5 internet gaming Origins and evolution of IGD disorder refers only to online games), even though Video games first emerged as a source of distress in the DSM-5 definition of internet gaming disorder the 1980s, a decade after they became commercially has been used more widely for critical analysis, diag- available to gamers. The first reference to video nosis and treatment. Through the course of this game ‘addiction’ was made in a study by two article, criticisms and controversies regarding both school counsellors (Soper 1983), who observed com- definitions will be discussed. Consequently, this pulsive behaviour, a lack of interest in other activ- article includes evidence on both gaming disorder ities and withdrawal symptoms (when made to and internet gaming disorder. We will use the abbre- stop playing video games) in their students. viation IGD as an umbrella term, unless the context Although the argument for video game addiction requires that a specific term be used. as a condition was strengthened by a handful of suc- cessful treatment studies during that time, most research in the 1980s involved case studies using Current conceptualisations and their observational or anecdotal data and focused on consequences only one form of gaming (Griffiths 2012). In the The ICD-11 defines gaming disorder as a ‘pattern 1990s, the scope of research on video game addic- of gaming behaviour (“digital-gaming” or “video- tion was broadened from arcade gaming to gaming gaming”) characterized by impaired control over on personal computers and consoles. In these gaming, increasing priority given to gaming over studies, researchers performed clinical assessments other activities to the extent that gaming takes pre- by using adapted versions of the DSM-III and cedence over other interests and daily activities, DSM-IV diagnostic criteria for gambling (Griffiths and continuation or escalation of gaming despite 2012). These studies were criticised and were ultim- the occurrence of negative consequences’ (World ately found to be assessing video game preoccupa- Health Organization 2018a). It further states that tion rather than video game addiction (Griffiths ‘for gaming disorder to be diagnosed, the behaviour 2012). In the next two decades, gaming became pattern must be of sufficient severity to result in sig- more sophisticated and complex, as did the research nificant impairment in personal, family, social, edu- on gaming addiction. With the advent of the internet cational, occupational or other important areas of and MMORPGs, the scope of research could span a functioning and would normally have been evident wider variety of games and include data that were for at least 12 months’. This definition, although not previously available from a broader sample of an improvement on the heavily criticised definition both males and females (Griffiths 2012). A big of internet gaming disorder provided by DSM-5 (dis- boost to research on the condition came in 2013 cussed in more detail below), does not enjoy the full when DSM-5 identified internet gaming disorder support of the clinical community, as it is considered as a ‘condition for further study’ (American to ‘over-pathologise’ a recreational activity and mis- Psychiatric Association 2013). classify a coping mechanism as an addiction dis- DSM-5 defines internet gaming disorder as ‘per- order (van Rooij 2018). sistent and recurrent use of the Internet to engage Consequences of IGD as captured by studies by in games, often with other players, leading to clinic- King & Delfabbro (2018), Kuss & Griffiths (2012) ally significant impairment or distress’ (American and Gentile et al (2011) include: mood changes Psychiatric Association 2013). The diagnostic and feeling bored, angry and/or irritable; depres- threshold in DSM-5 is meeting five or more of nine sion, anxiety and increased risk of suicide; poor criteria over a 12-month period. These criteria physical health, disrupted sleep patterns and poor include, for example, preoccupation with gaming diet, including overconsumption of caffeine; conflict behaviour, inability to regulate gaming behaviour. in social situations and interpersonal relationships withdrawal symptoms when gameplay is stopped, leading to loss of friendships, feelings of isolation loss of control over the gaming behaviour and sig- and even divorce; financial insecurity and reduced nificant harm resulting from the activity. This con- productivity at work, with absenteeism and drop- ceptualisation was met with widespread criticism as out. it was found to rely too heavily on the perceived Despite the growing clarity regarding the concep- addictive nature of gaming behaviours and to be tualisation of the disorder and its impact, built on established addiction research. 384 BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Understanding internet gaming addiction in clinical practice BOX 1 Ongoing debates about internet gaming disorder (IGD) Can IGD be considered an addiction? a week playing online games, and the cut-off used Winther 2014). It is argued that if the preoccupation Many scholars have argued that conceptualising IGD typically for problematic gameplay is 4 h per day or with gaming is accompanied by a measure of as an addiction is restrictive and precludes devel- 30 h per week (King 2018). In these cases, it severity (such as the time spent preoccupied with opment of evidence that suggests it might be a becomes difficult to define the player as a gaming thoughts of gaming and the intensity of those different condition, for instance a coping mechanism addict, even though they are engaging in a ‘dan- thoughts), it would be a more acceptable and for dealing with negative emotions, stress or fear, or gerous level’ of gameplay (Kuss 2017), as it can be effective diagnostic criterion (King 2018). The DSM- a diversion from reality (Kardefelt-Winther 2014; van argued that undertaking any activity as a paid pro- 5 diagnosis ‘internet gaming disorder’ requires a Rooij 2018). fession is conceptually entirely different from person to have five of a list of nine criteria to be undertaking what looks like similar activity, but in a considered as having the condition (American It has been argued that increased engagement with manner that is detrimental to the individual. Of Psychiatric Association 2013), without differentiat- gaming can be considered a ‘phase’, especially course it is also possible that some professional ing between primary symptoms and secondary during adolescence, when prevalence of IGD has gamers may also develop a gaming disorder – but symptoms. Finally, DSM-5 defines tolerance in been found to be the highest (Kuss 2017). On the the criteria used to define whether or not they have internet gaming disorder as ‘the need to spend other hand, brain imaging studies have shown that developed such a disorder would not include the increasing amounts of time engaged in Internet people addicted to gaming experience neural activity amount of time that they are paid to spend gaming. games’ (American Psychiatric Association 2013). similar to those with substance use disorders (Kuss What are the problems with the DSM-5 clinical This definition has not been found to be adequately 2018), strengthening the case for IGD to be consid- criteria? specific, as not every increase in time spent gaming ered an addiction. can be considered to be a result of tolerance (King It should be noted that ‘gaming’ is a lucrative The concept of preoccupation as associated with 2016). occupation for professional gamers, who are paid IGD has been met with criticism, as it is seen to salaries to compete with others for entertainment of pathologise an otherwise typical experience of child, themselves or others. These players spend 20–30 h adolescent and adult gamers alike (Kardefelt- Challenges in conceptualising IGD females and among adolescents as compared with In the wake of the DSM-5 classification, global con- other age groups (King 2018). A precise estimate sensus among researchers and clinicians has proven of the overall prevalence of IGD has proven elusive as two major theoretical explanations have elusive, owing to methodological inconsistencies emerged to explain IGD. The first is to consider it between studies, leading King & Delfabbro (2018) as a non-substance addiction; the other is to view to conclude that the most accurate estimate of it as a coping mechanism. To a large extent, much global prevalence is roughly 1%. At present, an of what is understood about IGD is drawn from appropriate technique to better understand preva- studies rooted in gambling addiction and substance lence of IGD is to look at nationally representative misuse – an approach that is contested by some epidemiological studies from different parts of the scholars, who question whether gaming is an addic- world. tion at all (van Rooij 2018). As mentioned earlier, a Müller et al (2015) conducted a study to measure recent critique asserted that the evidence base on the prevalence and psychopathological correlates of gaming disorder is too weak for its inclusion in DSM-5 internet gaming disorder in seven European ICD-11, and that gaming is better recognised as a countries (Germany, Greece, Iceland, The coping mechanism rather than a disorder in its Netherlands, Poland, Romania and Spain), finding own right (van Rooij 2018). This and other contro- that of the nearly 13 000 participants, 1.6% met versies are summarised in Box 1. the full DSM-5 criteria for the disorder and an add- itional 5.1% were at risk for developing the condi- tion. Age- and gender-specific effect sizes were Global prevalence of IGD found to be consistent with the global trends of Estimating the global prevalence of IGD continues males and younger adolescents having higher preva- to be a work in progress, as studies in different lence of problematic gaming. The prevalence was parts of the world use different theoretical bases, found to be consistent across game genres. A study tools and standards to measure problematic in Slovenia found the prevalence of DSM-5 internet gaming behaviours. There are some researchers gaming disorder to be 2.5% among a nationally rep- who have attempted to consolidate the scattered resentative sample of school students (mean age 13 data, finding with some certainty that problematic years 5 months) (Pontes 2016). internet gaming spans the globe, from Asia to Studies have indicated that Asian countries tend Europe and North America (Cheng 2018), and to have a higher prevalence of gaming-related condi- that the global level is higher among males than tions than other parts of the world (ranging from 1.7 BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 385 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Gupta et al BOX 2 Risk factors associated with internet gaming disorder (IGD) Individual risk factors Rule-breaking Lower socioeconomic status Male gender Substance use disorders/addictions Game-based structural characteristics Low confidence Anxiety Social factors Adolescence Low self-esteem Manipulation and control features of games Attention-deficit hyperactivity disorder Low self-efficacy Narrative and identity features of games Aggression External risk factors Reward and punishment features of games Impulsivity Single-parent family Game presentation Introversion Poor interfamily relationships Depression to 20%), although rates among the countries them- peer and media pressure (King 2018). In addition, selves vary widely (King 2018). For instance, in personality and psychological traits such as aggres- Singapore, a 2-year longitudinal study following siveness, introversion and rule-breaking are also primary (elementary) and secondary school students risk factors (King 2018). Intensive internet gamers found the prevalence of pathological gaming to be have also been reported as having lower self- approximately 9%, whereas studies in China and esteem, self-efficacy and confidence, and higher Taiwan have found the prevalence rates to be 10 levels of anxiety (Yen 2012). For individuals with and 7.5% respectively (Gentile 2011). In fact, these these problems, it is hypothesised that gameplay three countries recognise IGD as a significant ado- offers a platform within which they are able to lescent health problem. Possible reasons for the create an alternate self and seek unmet psycho- higher prevalence rates in the region include the cul- logical needs (Cheng 2018). tural influence of the top game developers (such as Psychopathologies – attention-deficit hyperactiv- Nintendo and Konami) and the high number of ity disorder (ADHD), impulsivity and major depres- players based in the area (King 2018). eSport has sive disorder – have been found to be the strongest been included as a competitive category in the overall risk factors for IGD (Hyun 2015). 2022 Asian Games, which is expected to contribute Furthermore, it has been suggested that those with to making online games more acceptable as a profes- IGD display similar symptoms to those with sub- sional sporting engagement (Bányai 2019). stance use disorders or other addictions and that North America also has high prevalence of IGD the latter are at higher risk of developing IGD, among children and adolescents, with a nationally owing to increased common vulnerability to addict- representative sample yielding pathological patterns ive behaviours (Cheng 2018). of play for 8% of young people between 8 and 18 years of age (Gentile 2009). External factors Constant or close to constant access to internet Risk factors for IGD devices places children and adolescents at higher A diverse range of risk factors for IGD has been risk for IGD (Gentile 2017). Parental or guardian identified and investigated (Hyun 2015). These control of internet use is therefore an important pro- can be categorised as individual, external and game- tective factor against IGD (King 2012). Various related (King 2018) (Box 2). familial factors that may affect monitoring of young people’s internet usage have been linked to IGD (King 2018). These include single-parent fam- Individual risk factors ilies, poor interfamily relationships and lower family There is consensus among researchers that males socioeconomic status. These factors may also have are at higher risk of developing IGD than females negative psychological effects on individuals, (Cheng 2018). This is not surprising considering further increasing their likelihood to use gaming as that, in general, more males engage in gaming in an escape from reality (Cheng 2018). comparison with females. However, females with IGD experience more severe symptoms than males (Müller 2015). Adolescents are at higher risk of Game-related factors developing IGD than other age groups, and this Certain game characteristics have been recognised might be due to their neurological and developmen- as risk factors for developing IGD. King et al tal vulnerability, as well as their susceptibility to (2010) discuss the characteristics of games that 386 BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Understanding internet gaming addiction in clinical practice may be influential in excessive game playing. They highlight five key features: social; narrative and BOX 3 Loot boxes identity; reward and punishment; manipulation Although the contemporary understanding of player bets money on a chance to win in- and control of the game; and presentation. Games gaming has evolved away from gambling, the game rewards without relying on any skill or that encourage social behaviour, for example emerging (and increasingly popular) feature of strategy. The emerging evidence on loot MMORPGs or multi-user domain games (MUDS), ‘loot boxes’ in online gaming is blurring the boxes points towards outcomes and patterns allow the user to create an online self through lines between gaming and gambling once in online gamers that are identical to gam- which they can interact with others in the game again (Drummond 2020). Players purchasing bling. This may present a complex situation to (Ng 2005). In games such as these, a player can loot boxes within online games is analogous clinicians where problem gaming may coexist make friends, have conversations and work in to gamblers playing the slot machines – the with problem gambling in some individuals. teams to achieve goals. These characteristics can be considered risk factors for IGD, as their socially interactive nature and ‘alternate world’ experience may encourage them to play more, hence further can lead the user to retreat into the virtual world increasing their susceptibility to IGD (Müller (Ng 2005; Müller 2015). The social aspect of a 2015). This demonstrates how risk factors for IGD game can also mean that players are encouraged can interact and overlap and result in an even to continue playing under the pressure of their higher risk for the disorder. online peers (King 2018). This pressure can lead Another game-related feature that may be consid- to extensive periods of gameplay, in which ered as influencing an individual’s excessive game- players may become less able to regulate the time play is the ability to manipulate or control their spent playing – a key risk factor for IGD (Cheng play. The user interface, which involves the way a 2018). user plays the game, e.g. by means of a computer MMPORGs also often include narrative and iden- keyboard or a hand-held device, provides the user tity features such as storytelling, and the ability to with an entirely new system to learn and master. A design one’s own avatar. When a player can player’s excessive gameplay has been recognised design the appearance and traits of their avatar, as synonymous with their obsession to ‘master’ a and then make decisions that will guide them user interface, for example by learning all of the through a story, they are able to create a bond and codes and combinations of a handheld control sense of identity with their avatar. This attachment device in order to reap the best game outcomes can encourage the player to invest further in game- (Griffiths 2017). There are aspects of games that a play, to ensure that their avatar succeeds, often user cannot control, such as loading screens, narra- extending their playing periods (King 2010). In tive scripts and waiting periods, and that cannot be fact, MMORPGs and first-person shooter (FPS) skipped. These features automatically extend the games have been found to be the most addictive length of playing time, often without the player among all game genres. This is attributable in part even realising. King et al (2010) suggest that, by dis- to the fact that both these genres include games persing these lower-attention requiring features with strong social, narrative and reward compo- throughout a game, the player is able to remain nents (Na 2017). more engaged for longer periods. In fact, they can Elsewhere, reward and punishment features, and even utilise waiting times to do tasks they would the ways in which they are dispersed through a otherwise have to stop their gameplay for, such as game, can be captivating for the player. For eating or using the lavatory. example, finding rare objects or levelling up Finally, the presentation of the game itself should through the game creates a sense of reward and pro- be considered. Exciting, high-definition visuals are gression that encourage users to continue playing appealing as they help the player immerse them- until they reach the next goal (King 2018). Game selves in the game. To add to this, sound use in designers strategically place reward features inter- games allows the player to create associations mittently throughout a game to encourage persistent between certain sounds or music and particular gameplay, as the player is always working towards emotions (King 2010). Identifying feelings of their next reward (Griffiths 2017). The relatively achievement or reward with a sound they hear recent introduction of ‘loot boxes’ adds another when they succeed can lead a player, especially dimension to the reward feature (Box 3). one with an unmet need for positive reinforcement, Punishment features in a game, such as losing a to play excessively in order to reap such positive life or getting points deducted, may have a similar emotional feelings. Elsewhere, explicit game effect on the player, as they are motivated to earn content, ‘real-life’ product placement and even the back what has been taken from them (King 2010). ways in which the game is branded to the public For players with low self-esteem, self-efficacy or con- are enticing and influential to a player (Griffiths fidence, feeling rewarded from their gameplay efforts 2017). BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 387 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Gupta et al BOX 4 Case vignette: Raul Raul is a 14-year-old boy. He was doing very well in being assessed by a psychiatrist, it became evident that the games were his only escape from school class until last year, when his grades started to drop. that he was spending much of his time every night pressure. His interest in academic and extracurricular activ- playing video games online. He would retire to his With fear that his excessive gameplay was begin- ities reduced, and he started to isolate himself. Over room as often as possible and then play games ning to have negative impacts on Raul’s health and time, Raul completely isolated himself from his online, often staying awake late at night to play. school performance, his parents decided to seek friends and family, and would spend hours alone in After learning how long their son was playing online treatment for him with a psychiatrist. Raul under- his room. When his parents confronted him about games for each day, Raul’s parents decided to take went 12 weeks of cognitive–behavioural therapy to this, he would become aggressive and defensive. away his gaming devices each evening before he combat his preoccupation with his online games. Raul’s parents attempted to encourage him to take went to bed. With limited access to his games, Raul Over the 12 weeks, Raul’s mood and behaviour part in his previous extracurricular activities and to began lashing out at his parents and demanding he improved, and he no longer craved playing his games see his friends, but Raul would find excuses and have access to the games. He would steal his all the time. Instead, Raul decided to invest more avoid spending much time outside of his room. gaming devices from his parents and continue to time into sports as a stress reliever from his aca- Initially, his parents brought him to an ophthalmol- play each night, despite the impact it was having on demic studies. After his treatment, Raul’s parents no ogy department with complaints of dry eyes, wor- his school performance and friendships. When longer had to take his gaming devices away from sening short sight and frequent headaches. He was Raul’s parents confronted him about his continued him, as he was able to better self-regulate the also getting increasingly irritable, bad tempered and gameplay, he would become aggressive and argue amount of time he spend gaming online. disobedient at school and at home. Subsequently, on The neurobiological basis of IGD gambling. This suggests that IGD could be an addic- One of the ways of understanding IGD is by examin- tion syndrome (Spechler 2016). ing its underlying neurobiology. By comparing the Another study found a high prevalence of two spe- brain circuits of people who are considered addicted cific polymorphisms of the dopaminergic system (the to gaming with those who are not, it has been pos- Taq1A1 allele of the dopamine D2 receptor and sible for researchers to create a neurobiological Val158Met in the catecholamine-O-methyltransfer- profile of the condition, including the regions of cog- ase gene) in those addicted to gaming (Han 2007). nition, emotion and behaviour that are activated in Similarly, higher prevalences are found in substance the condition. addicts, and could indicate that there might be a A recent systematic review included 27 studies genetic component to internet game addiction. from different parts of the world (primarily East Asia and Europe) that had used a variety of neuroi- Clinical characteristics of persons with IGD maging methods to assess the neurobiological Although there is evidence to indicate that excessive mechanisms of IGD (Kuss 2018). The methods gaming behaviour can have clinically significant used were functional magnetic resonance imaging consequences (Kuss 2012), there is no consensus (fMRI), resting-state functional magnetic resonance on methods of assessment, diagnosis and treatment imaging (rsfMRI), voxel-based morphometry of the condition. Clinical studies differ in how they (VBM), positron emission tomography (PET) and have opted to conceptualise, identify and measure electroencephalography (EEG). IGD. The clinical characteristics of the condition, It was found that differences existed between the especially in treatment-seeking populations, have neurobiology of healthy gamers and those with been examined by a limited number of studies. IGD in a few key domains. Gamers with IGD were Before describing this literature, it is worthwhile found to have lower activity in the bilateral middle acknowledging that, because IGD is currently and inferior temporal gyri, indicating impaired termed a ‘potential’ clinical condition by DSM-5, visual and auditory functioning (Ding 2014). and ICD-11 does not come into effect until 2022, Further, gamers with IGD were found to have an individual cannot yet be ‘diagnosed’ with the con- poorer emotion regulation and cognitive control dition. Hence, in the absence of clear clinical guide- (Xing 2014) and experienced impaired response- lines, clinicians need to proceed with caution and inhibition and decision-making ability compared sensitivity while working with individuals experien- with gamers who did not have IGD. Additionally, cing mental health problems as a result of their impairments were identified in the functioning of gaming behaviours. their prefrontal cortex (Ding 2014). Most telling Some of the DSM-5 criteria can be recognised in was the fact that gamers with IGD displayed a defi- the case vignette described in Box 4 (the case vign- ciency in their neuronal reward system, which is also ettes in this article are fictitious). On the other found in people who experience substance addic- hand, ICD-11 has attempted to conceptualise IGD tions and non-substance addictions such as on a spectrum similar to the one used in diagnosing 388 BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Understanding internet gaming addiction in clinical practice alcohol-use disorders, using two mutually exclusive diagnoses: ‘gaming disorder’ and ‘hazardous BOX 6 Case vignette: Jemima gaming behaviour’ (Box 5). Hence, ICD-11 cate- Jemima is a 28-year-old woman. She lives would rarely leave her bedroom. Her room- gorises those with ‘risky’ gaming behaviour (before with a roommate in a small flat and, until mate became very concerned for her well- it becomes a disorder) as showing ‘hazardous recently, she was working full time as a legal being, so decided to confront Jemima. gaming behaviour’; once the risk translates into secretary. Jemima was always extremely Jemima explained that she started gaming actual harm, the categorisation changes to ‘gaming hard working and excelled in her career. She because she was feeling unconfident and disorder’. At present, no diagnostic tools exist for was also in a long-term relationship, until her depressed after her break-up. Through gam- this classification. boyfriend broke up with her 4 months ago. ing, she could chat with people online and Jemima used to be outgoing and sociable, but connect with other people who were also after her break-up, she began spending feeling lonely. After playing for some time, Symptoms of IGD increasingly more time alone in her room. Her she became more invested in the game than A systematic review by Paulus et al (2018) indicated roommate would often hear Jemima awake in her real life, and after losing her job, she that symptoms most typically associated with people until the early hours of the morning, and when completely retreated into the virtual world. she asked Jemima what she was doing, she Jemima’s roommate decided to speak to experiencing IGD-like behaviours include increased learned that Jemima had begun online Jemima’s parents, who were living in another screen time, preoccupation with gaming, increased gaming. city. When her parents learned of Jemima’s tolerance for long gaming hours, impaired control As time progressed, Jemima began playing game-playing, they came to visit her imme- over gaming behaviour, internal conflicts related to online games for longer, and would often get diately. After some time, Jemima began gaming behaviour (‘conflictuousness’), increased no sleep because she was playing games all opening up to her parents. She then agreed to importance given to gaming in one’s life (salience), night. Her tiredness at work started to affect visit a counsellor to seek help for her feelings of depression and guilt when faced with con- her performance, and soon after, her boss depression, low self-esteem and excessive sequences of gaming, and relapse to gaming behav- decided to fire her. With no job, Jemima game-playing. iour after a brief period of abstinence (Kuss 2012). began playing games online all day, and Other studies have indicated that persons with IGD display emotional instability, shyness, low self-esteem, maladaptive coping behaviours and The case vignette in Box 6 shows how some symp- loneliness (Torres-Rodríguez 2018). Another study toms progress over time. A clear shift can be seen in found that individuals with video game addiction the individual’s priorities. Her focus shifts from her have lower school performance and social compe- job to online gaming, with subsequent detriment to tence compared with their peers (Gentile 2011). her career. This displays how salience can present King et al have emphasised that behaviours at the in someone with IGD. In addition, the vignette high- core of problematic gaming are impaired control lights how the individual’s tolerance for time spent over gaming behaviour, ‘conflictuousness’ and with- gaming increases over time, to the point where drawal (King 2013a), although there is no general gaming becomes the activity to which the majority consensus about this (Kuss 2017). of her time is devoted. Anxiety disorders, depression, suicidal ideation, ADHD, social phobia, autism spectrum disorder and personality disorders have all been found to be Screening and issues with diagnosis associated with IGD symptoms (Gentile 2011; Before DSM-5 was published, there were several Torres-Rodríguez 2018). scales available for screening for IGD, although they differed significantly in their conceptualisation of the condition, the aspects of the condition being BOX 5 ICD-11 definition of hazardous gaming captured and the terminology used. Since the inclu- sion of internet gaming disorder and gaming dis- ‘Hazardous gaming refers to a pattern of gaming, either order in DSM-5 and ICD-11 respectively, many online or offline that appreciably increases the risk of screening tools that use or reference these diagnostic harmful physical or mental health consequences to the criteria have been developed. A recent systematic individual or to others around this individual. The increased review evaluated 32 such tools for internet gaming risk may be from the frequency of gaming, from the amount disorder and gaming disorder, drawn from 320 of time spent on these activities, from the neglect of other studies conducted with 9- to 18-year-olds, primarily activities and priorities, from risky behaviours associated across Europe and East Asia (King 2020). The with gaming or its context, from the adverse consequences review found that the criteria most commonly used of gaming, or from the combination of these. The pattern of gaming often persists in spite of awareness of increased by screening tools were impaired control over risk of harm to the individual or to others.’ gaming behaviours and loss of a significant relation- (From section on ‘Problems associated with health beha- ship or school or work opportunity due to gaming viours’, World Health Organization 2018b) behaviour. The authors point out that the evidence base for most of these tools is limited, but also BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 389 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Gupta et al highlight the relative strengths and applications of studies and Zajac et al (2017) included 26. Some each tool, so that clinicians and academics can studies were included in both reviews and, allowing make informed decisions. For instance, clinicians for these overlaps, this leaves 37 unique studies looking for tools that have high coverage of the examined in the two reviews (Fig. 1). These system- DSM-5 criteria can use the nine-item Internet atic reviews comprise the most comprehensive ana- Gaming Disorder Scale–Short Form (IGDS9-SF) lyses so far of global treatment studies for IGD, and the ten-item Internet Gaming Disorder Test and therefore will be referred to throughout this (IGDT-10), both of which are based on the DSM-5 section. criteria, but must be mindful of the fact that the As stated, both reviews considered treatment tools have only been tested on convenience studies for both internet gaming disorder and inter- samples so far. Nearly half of the tools evaluated net addiction; for example, of the 30 studies exam- were tested with children and adolescents. ined in King et al (2017), 22 were for ‘internet Clinicians looking to screen adults can choose addiction’, as can be seen in Fig. 1. This is especially between most of 32 tools, although the Behavioral the case with earlier studies, which took place before Addiction Measure for Video Gaming (BAM-VG) internet gaming disorder had been conceptualised in has been tested only on adults (King 2020). DSM-5. These studies have been included despite not directly referencing internet gaming, as the Comorbidities term ‘internet addiction’ has been used to denote a range of internet-related disorders, including inter- As already mentioned, individuals who show symp- net gaming-related problems. For this reason there toms consistent with IGD have been found to have is a lack of clarity between treatments directed at psychiatric comorbidity with conditions such as IGD and those aiming to treat a range of patho- depression, anxiety, autism spectrum disorder, logical internet use problems, including IGD. ADHD, obsessive–compulsive disorder and Therefore, treatments for ‘internet addiction’ will conduct disorder (van Rooij 2014; Müller 2015; also be considered in this section, with attention King 2016). ADHD has found to be associated paid to their eligibility in relation to online gaming. with IGD as both a risk factor and a comorbid con- dition. Many manifestations of the bidirectional relationship between IGD and features of ADHD Types of treatment (inattention and impulsivity) exist – excessive A range of different treatment methods were gaming has been found to help adolescents with employed in the 37 studies. Over half of the studies ADHD cope with their symptoms (Stavropoulos used a psychological or counselling approach. The 2019). In some studies, younger players with most common approach was cognitive–behavioural gaming disorder symptoms have been found to therapy (CBT), but other approaches included have higher impulsivity scores, whereas in others, virtual reality training (VRT), psychotherapy and higher impulsivity scores have predicted the devel- family counselling. In addition, 7 studies utilised a opment of IGD (Stavropoulos 2019). Other studies pharmacological approach, treating with both anti- have linked inattention to the development of IGD depressant and psychostimulant drugs such as among adolescent players. Among older players bupropion, escitalopram and methylphenidate with IGD, depression, anxiety and substance use (Kim 2012). Some less evidence-based methods have been found to be typical comorbid conditions were also used, such as keeping a daily journal (Yen 2007; Yen et al., 2007). As can be seen in and electroacupuncture. Box 6, it is likely that Jemima developed depressive Over half of the 37 studies were from East Asian symptoms after her break-up which became exacer- countries such as China and South Korea, with the bated by her problem gaming, and that the clinician remainder from the USA, Brazil, India, Switzerland, she consults would have to consider responding to Norway and Germany (King 2017; Zajac 2017). her depression first. CBT has not been found to be significantly effect- ive in responding to the typical comorbid psychiatric Evidence-based treatments conditions, leading researchers to suggest that clini- cians adopt an integrative approach that caters to Despite the ongoing debate over the definition and the comorbidities (Torres-Rodríguez 2018). diagnostic criteria for IGD as described above, a range of treatments and interventions have been developed globally to treat the disorder. We found Limitations of the current evidence base on two recent systematic reviews of IGD treatments treatments (King 2017; Zajac 2017) (both in fact looked at In both King et al (2017) and Zajac et al (2017), the both internet gaming disorder and internet addic- authors identified a range of limitations to the tion). King et al (2017) included 30 treatment treatment studies they analysed, finding limited 390 BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Understanding internet gaming addiction in clinical practice (a) Zajac et al (2017) King et al (2017) (b) Zajac et al (2017) King et al (2017) 6 7 1 1 12 10 FIG 1 A comparison of treatment study literature from King et al (2017) and Zajac et al (2017), showing the overlap of the 37 unique treatment studies examined in the two reviews. (a) Studies on internet gaming disorder. (b) Studies on internet addiction. reliability for the studies to be used as evidence reports of the successful use of CBT to treat IGD bases for future treatments. As there is no agreed and the overall popularity of the method, the evi- definition of IGD, both systematic reviews high- dence base has several methodological limitations, lighted a lack of consistency in the definition, diag- and the interventions used are poorly described nosis and measurement of either internet gaming (King 2017; Zajac 2017). disorder or internet addiction. For instance, the Despite the array of treatment studies for IGD, studies utilised a range of diagnostic instruments there is a clear need for improved study designs (including the Internet Addiction Test (IAT), and more consistency in the diagnostic and measure- Young’s Diagnostic Questionnaire (YDQ) and the ment tools for the disorder. Additionally, the most Korean Internet Addiction Scale (K-IAS) (King popular treatment method, CBT, requires both far 2017)) and hence the comparability between the clearer explanations of exactly what is being pro- people identified with IGD is suspect. Even vided under the heading of ‘a CBT approach’ and among the studies dated after the 2013 DSM-5 def- far more rigorous evaluations of its effectiveness. inition of internet gaming disorder, only one (Sakuma 2017) employed the DSM-5 criteria as their assessment tool. Future directions In addition, both reviews acknowledged key meth- We have attempted to summarise here the state of odological limitations within the studies, such as a the current literature related to IGD. This has lack of randomisation and control groups, a lack of uncovered some clear conceptual debates over the masking (‘blinding’) and small sample sizes (King status of IGD as an addiction disorder, as well as 2017; Zajac 2017). There were also concerns that gaps in the existing evidence. Practitioners need to follow-up periods were uniformly short, with a lack actively acknowledge the current contradictions of long-term follow-up assessments (Zajac 2017; and debates over IGD and its diagnosis and treat- King 2017), making it impossible to understand ment, while at the same time attempting to provide the sustained effect of the interventions on the help to those with severe problems with their use ‘treated’ participants, a limitation that has been of internet and other gaming. We have highlighted widely acknowledged (King 2018). the key areas in which caution should be applied and indicated how to interpret risk factors for IGD, Emerging evidence on treatment particularly as regards comorbidities such as As stated above, studies utilising CBT either inde- ADHD, anxiety and depression. Overall, practi- pendently or as part of a treatment package were tioners treating IGD must be responsive and respon- the most common. This is not surprising given the sible in relation to the distress that patients and huge popularity of CBT approaches generally, and families might be going through. especially within addictions studies. According to Future directions for IGD research must take into the cognitive–behavioural model of IGD, those consideration the key issues that have been dis- with the disorder are more likely to show signs of cussed in this review. In particular, attention must impaired cognitive control and flexibility, and be paid to the quality of study designs, especially increased impulsivity (Sakuma 2017). Treatment in treatment studies. Researchers must attempt to studies using CBT do so on the assumption that it approach screening and diagnosis with uniformity will help patients improve in these areas (Sakuma and should ensure that their follow-up periods are 2017). The case vignette in Box 4 demonstrates sufficient to reliably contribute to the evidence the use of CBT as a treatment for IGD. The boy base for treating IGD. Ultimately, the goal of undergoes 12 sessions, after which his craving for future research into IGD should be to develop con- gaming is observed to have reduced, and his mood clusive evidence on the conceptualisation of the and behaviour have reportedly improved. Despite disorder. BJPsych Advances (2021), vol. 27, 383–393 doi: 10.1192/bja.2020.81 391 https://doi.org/10.1192/bja.2020.81 Published online by Cambridge University Press Gupta et al MCQ answers Conclusions Cheng C, Cheung MWL, Wang Hyi (2018) Multinational comparison of internet gaming disorder and psychosocial problems versus well-being: 1c 2d 3b 4b 5e Gaming is an immensely popular recreational activ- meta-analysis of 20 countries. Computers in Human Behavior, 88: 153–67. ity among males and females of all ages worldwide. Ding WN, Sun JH, Sun YW, et al (2014) Trait impulsivity and impaired pre- Playing online video games is an immersive experi- frontal impulse inhibition function in adolescents with internet gaming addic- tion revealed by a Go/No-Go fMRI study. Behavioural Brain Function, 10: 20. ence that can potentially take over the player’s life. When an individual plays such games to the point Drummond A, Sauer JD, Ferguson CJ, et al (2020) The relationship between problem gambling, excessive gaming, psychological distress where they are no longer in control of their behav- and spending on loot boxes in Aotearoa New Zealand, Australia, and iour and their daily routine, it has become known the United States-A cross-national survey. PLoS One, 15(3): 1–16. as internet gaming disorder (IGD). The aim of our Gentile D (2009) Pathological video-game use among youth ages 8 to 18: a review has been to synthesise and present the best national study. Psychological Science, 5: 594–602. current understanding of the conceptualisation, epi- Gentile DA, Choo H, Liau A, et al (2011) Pathological video game use among youths: a two-year longitudinal study. Pediatrics, 127: 119–29. demiology, clinical features and treatment of IGD. The inclusion of ‘internet gaming disorder’ in Gentile DA, Bailey K, Bavelier D, et al (2017) Internet gaming disorder in children and adolescents. Pediatrics, 140: S81–5. DSM-5 and of ‘gaming disorder’ in ICD-11 has sti- Griffiths MD, Kuss DJ, King DL (2012) Video game addiction: past, present mulated interest among clinicians and researchers. and future. Current Psychiatry Reviews, 8: 308–18. Although conceptual ambiguity limits unequivocal Griffiths M D (2016) The evolution of Internet addiction: A global perspective. interpretations, certain conclusions can be drawn Addictive Behaviors, 53: 193–195. doi: 10.1016/j.addbeh.2015.11.001. about IGD: it has an estimated prevalence of 1% in Griffiths MD, Nuyens F (2017) An overview of structural characteristics in the global population, there is a greater prevalence problematic video game playing. Current Addiction Reports, 4: 272–83. among males and among adolescents of both Han DH, Lee YS, Yang KC, et al (2007) Dopamine genes and reward genders and, finally, those in East Asia are more at dependence in adolescents with excessive internet video game play. Journal of Addiction Medicine, 1: 133–8. risk of developing this condition. Several individual, external and game-related risk factors have also Hyun GJ, Han DH, Lee YS, et al (2015) Risk factors associated with online game addiction: a hierarchical model. Computers in Human Behavior, 48: been consistently associated with IGD. We end 706–13. with a call for immediate further research into the Kardefelt-Winther D (2014) The moderating role of psychosocial well- comorbidity, diagnosis and treatment of IGD. being on the relationship between escapism and excessive online gam- ing. Computers in Human Behavior, 38: 68–74. Author contributions Kim SM, Han DH, Lee YS, et al (2012) Combined cognitive behavioral ther- apy and bupropion for the treatment of problematic on-line game play in D.G. wrote three sections of the article, responded to adolescents with major depressive disorder. Computers in Human all reviewer comments and coordinated with all co- Behavior, 28: 1954–9. authors on compiling edits and responding to feed- King D, Delfabbro P, Griffiths M (2010) Video game structural character- back. L.B.-L. wrote three sections of the article istics: a new psychological taxonomy. International Journal of Mental Health and Addiction, 8: 90–106. and responded to the first round of reviewer com- King DL, Delfabbro PH, Griffiths MD (2012) Clinical interventions for tech- ments. R.V. provided detailed feedback on sections nology-based problems: excessive Internet and video game use. Journal of the article and resolved some conceptual issues of Cognitive Psychotherapy, 26: 43–56. related to the subject matter. S.G. was commis- King DL, Delfabbro PH, Zwaans T, et alet al (2013a) Clinical features and axis sioned by the journal to write the article and pro- I comorbidity of Australian adolescent pathological Internet and video game users. Australian and New Zealand Journal of Psychiatry, 47: 1058–67. vided detailed feedback on the article sections. A. N. was the mentoring author, and provided detailed King DL, Delfabbro PH (2016) The cognitive psychopathology of internet gaming disorder in adolescence. Journal of Abnormal Child Psychology, feedback on the article sections and highlighted 44: 1635–45. latest developments in addictions research to be King DL, Delfabbro PH, Wu AM, et al (2017) Treatment of internet gaming incorporated into the article. disorder: an international systematic review and CONSORT evaluation. Clinical Psychology Review, 54: 123–33. 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