|Ahead of print publication
A clinical study of internet gaming disorder in adolescents with psychiatric disorders
Praveen Sachan1, Amit Arya1, Shweta Singh1, Pawan Kumar Gupta1, Vivek Agarwal1, Vishal Gupta2
1 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Psychiatry, District Early Intervention Centre, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||25-Jul-2021|
|Date of Acceptance||18-Sep-2021|
|Date of Web Publication||03-Feb-2022|
Pawan Kumar Gupta,
Department of Psychiatry, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objectives: The severity of different internet gaming disorder (IGD) symptoms criteria has not been explored much. The study describes the phenomenology of IGD in adolescents with comorbid psychiatric disorders attending child and adolescent psychiatry outpatient department (OPD). Materials and Methods: A total of 46 adolescents aged 13–16 years, who have attended child and adolescent psychiatry OPD, of a tertiary care teaching hospital for psychiatric disorders, with a history of gaming and who fulfilled criteria as per the fifth edition of Diagnostic and Statistical Manual (DSM-5) for IGD have been included. All the adolescents have then assessed using semi-structured pro forma, internet gaming disorder scale (IGDS), and K-SADS-PL. Results: In the study sample, the most common IGDS criterion was “conflict” and the least common criterion was “tolerance.” The IGDS mean score of “conflict” was the highest while of “displacement” was the least. “Escape” and “deception” were significantly higher for females. “Displacement” was significantly higher for urban domicile and online mode of gaming. “Persistence” was significantly higher for those who were gaming on personal devices and playing Massively Multiplayer Online Role-Playing Games (MMORPGs). Psychiatric disorders associated with IGD were ODD (46.66%), dissociative disorder (24.44%), attention-deficit hyperactivity disorder (ADHD, 17.77%), and depressive disorder (11.11%). Phenomenology of IGD was comparable across all psychiatric comorbidities, except subjects with dissociative disorders, who had significantly higher scores for “escape” than for ADHD and depression. Furthermore, subjects with ODD had significantly higher scores for “displacement” than the subjects with dissociative disorder in terms of IGDS scores. Conclusion: Significant differences in the severity of DSM-5-IGD symptoms criteria are found in terms of gender, domicile, gaming genre (MMORPGs), accessibility of smartphones, online/offline modes of gaming, and the associated psychiatric comorbidity.
Keywords: Comorbidities, internet gaming disorders, phenomenology
|How to cite this URL:|
Sachan P, Arya A, Singh S, Gupta PK, Agarwal V, Gupta V. A clinical study of internet gaming disorder in adolescents with psychiatric disorders. J Mental Health Hum Behav [Epub ahead of print] [cited 2022 Jun 25]. Available from: https://www.jmhhb.org/preprintarticle.asp?id=337224
| Introduction|| |
Video games are a popular entertainment method among all age groups, especially in adolescents and young adults. It has successfully captured the interests of many over the years. Many online addictions have been identified to date; however, gaming addiction has become a topic of continually evolving research because it can affect both physical and mental health and therefore recognized as a public health problem. This has been termed gaming disorder and currently considered a type of behavioral addiction., There are multiple similarities between gaming disorder and substance use disorder. The fifth edition of Diagnostic and Statistical Manual (DSM-5) defines internet gaming disorder (IGD) as the “persistent and recurrent use of the internet to engage in games, often with other players, leading to clinically significant impairment or distress,” as indicated by five (or more) out of nine proposed items in 12 months' duration. The APA has identified IGD as a new potential psychiatric condition and acknowledged that little is understood about the prevalence, validity of diagnostic criteria, and significance for internet gaming condition. Currently, the prevalence of IGD in adults is estimated to be between 0.5% and 27.5%. This variation in prevalence rate may be due to differences in assessment tools, study population, and diagnostic criteria of IGD. Prevalence rates are highest in Eastern Asian countries and in male adolescents aged 12–20 years.,
Concerning IGD, low parental support, elevated use of video games by parents, divorce, or separation of parents, and single-parent families have been associated with IGD. Many other correlates have also been identified as the predictors of IGD such as personality, especially impulsivity, conduct problems, low level of outdoor sports involvement, limited social interaction, and low self-esteem. Internet gaming can be comorbid with anxiety disorders, depression, behavioral disorders, social phobia, autism spectrum disorder, attention-deficit hyperactivity disorder (ADHD),,, obsessive–compulsive disorder, and personality disorders.,,,
Differing opinions are also present in terms of symptom criteria of internet gaming, and the primary limitation is the lack of homogeneity in research methods. There are controversies about the validity of IGD criteria. Studies have investigated the validity of the DSM-5 criteria. . Out of all the 9 proposed criteria, not all are considered to have equal diagnostic validity. For instance, “escape” and “preoccupation” were judged as less suitable for IGD diagnosis.,, “Deception” in the study of Ko et al. was less suited for identifying IGD, whereas other studies, found the opposite. “Giving up other activities” and “tolerance,” as well as “withdrawal” and “loss of control,” were also debated. In addition, Ko et al. suggested “craving” as a candidate criterion. Another controversy is the problem of a cutoff level of symptoms because of the lack of standard defining criteria for IGD.,, Despite the increasing number of studies in IGD, the phenomenology lacks a consensual definition. The APA included the IGD under Section III of the DSM-5, i.e., conditions for further research, not intended for clinical use, but to provide uniform guidelines for future studies. These criteria required further investigation to be used for clinical purposes.
Given the lack of clinical studies concerning IGD, exploration of the clinical characteristics of people with IGD is much required, especially in the commonly affected adolescent population. This will help delineate the gaming disorder construct and help in future treatment plans. Indian studies are needed. Hence, this study aimed at evaluating the phenomenology of internet gaming in adolescents presenting to the child and adolescent psychiatry outpatient clinic of a tertiary care hospital in North India.
| Materials and Methods|| |
The study utilized nonprobability sampling method. Adolescents of 13–16 years of age (mean age 14.02 ± 1.20 years) presenting between October 11, 2019, and March 21, 2020, to the child and adolescent psychiatry outpatient services of the study center, primarily for mental health and who had complaints of video gaming (online or offline) in initial clinical interview were screened for selection criteria [Table 1]. Inclusion criteria were (1) availability of at least one of a parent as a reliable informant and (2) fulfilling 5 or more IGD criteria as per DSM-5. Exclusion criteria were (1) intellectual disability; (2) patients with suicidal risk; and (3) the presence of medical comorbidity that require urgent medical attention, to avoid risking patients' health or unreliable measurements. The G*Power 3.1 was performed to run a power analysis, which indicated that a sample size of 54 is required to obtain an average power of 0.95 to detect an effect size of 0.5 (medium ρ2) at the standard 0.05 alpha error probability for a one-tail linear difference between two dependent means (matched sample). A total of 74 adolescents were screened and 46 subjects fulfilled selection criteria and 28 subjects were excluded. The reasons for exclusion were (1) not fulfilling internet gaming disorder scale (IGDS) criteria (n = 10); (2) not fulfilling age criteria (n = 14); and (3) diagnosis of intellectual disability (n = 1). Parents of three subjects refused to give consent, hence they were also excluded.
A specifically designed semi-structured pro forma assessed basic demographic information (i.e., age, gender, domicile, and family type), significant medical history (past or present), description of key informants (relationship and reliability), and aspects of video-gaming activity (i.e., ownership and accessibility, frequency and duration of use, function and social context of gaming, and types of games played).
The K-SADS-PL (DSM-5) was used for dimensional and categorical assessment approaches to diagnose current and past episodes of psychopathology. It can be applied to children and adolescent between the ages of 6 and 18 years. It comprises two versions: (1) the current and (2) the lifetime. This tool is applied by interviewing both parents and children. The mode of application is subjective questioning using an example to illustrate the said statement. In this study, it was used to rule out the presence of psychiatric comorbidities at baseline interview. It has criteria available for childhood disorders such as ADHD, oppositional defiant disorder, and mood, anxiety, and psychotic and other stress-related disorders. Conditions that are not included in K-SADS-PL were assessed by clinical evaluation.
Intelligence quotient was derived from percentile scores of intelligence measured by a clinical psychologist by using Raven's standard progressive matrices and Raven's colored progressive matrices.
IGDS-long version 27 items was used to assess the symptom severity of IGD. The psychometric properties of this scale were tested among a representative sample of 2444 Dutch adolescents and adults aged 13–40 years. It serves as screening as well as a diagnostic tool. All items rated on point on 0–6 scores (0 = never, 1 = use 1–4 times in the last year, 2 = use 5–11 times in the last year, 3 = amount 1–3 times in a month, 4 = once or more a week, 5 = every day or almost every day). No cutoff scores suggested in the literature but meant to assess the severity of illness for future studies. Although this is a self-rating scale, the scale was administered by a clinician for better results in this study.
The diagnosis of IGD was made by consensus of the investigator and either of a consultant psychiatrist (PKG, VA, AA) involved in the study as per the DSM-5 criteria, which states that for the diagnosis of IGD, five of the nine diagnosis criteria (preoccupation or obsession, withdrawal, tolerance, loss of control, loss of interest, continued overuse, deceiving, escape of negative feelings, and functional impairment) must be met within a year to be diagnosed as IGD.
All the data collected by the above-mentioned methods were tabulated in MS Excel. Appropriate statistical analysis was performed using SPSS version 24.0 (IBM Corp, Armonk, NY) as follows: (1) proportions were calculated using Chi-square test; (2) comparisons were calculated either using student t-test or ANOVA.
The study was approved by the institutional ethics committee of King George's Medical University (KGMU), Lucknow, India. Written informed consent from the parents and ascent from the adolescents were taken.
| Results|| |
The sociodemographic details are provided in [Table 1].
In the present study, smartphones (91.31%) were the most common devices used. It commonly belonged to the parents (65.21%) or the adolescents themselves (28.26%). The online platform was the preferred mode of video gaming (65.21%). The Massively Multiplayer Online Role-Playing Games (MMORPGs) were the most common games that involved 58.69% of subjects.
The most common IGDS criterion was conflict (95.65%) followed by preoccupation (80.43%), withdrawal (76.08%), persistence (69.56%), problem (67.39%), displacement (56.52%), deception (54.34%), and escape (47.82%) and the least common criterion was tolerance (41.30%); however, in terms of severity measured by the mean IGDS scores, it was highest for conflict (9.83 ± 2.33) followed by persistence (9.78 ± 1.97), withdrawal (8.25 ± 1.78), tolerance (7.88 ± 1.58%), preoccupation (7.81 ± 2.48%), problem (7.77 ± 1.78%), deception (7.24 ± 2.04), and escape (6.95 ± 1.55%) and the least for displacement (6.88 ± 1.55%). ODD (46.66%) was the most common psychiatric disorder associated with IGD followed by dissociative disorder (24.44%), ADHD (17.77%), and depressive disorder (11.11%).
Subjects diagnosed with dissociative disorder have significantly higher scores for “escape” criteria than subjects diagnosed with ADHD and depression (P = 0.005 and P = 0.007, respectively). Subjects diagnosed with ODD have significantly higher scores for “displacement” criteria (P = 0.0494) than subjects diagnosed with dissociative disorder.
The IGDS scores of “escape” (P = 0.0318) and “deception” (P = 0.0318) criteria were significantly more in females than in males. “Displacement” criterion was significantly higher for urban subjects (P = 0.0005) involved with online gaming (P = 0.0023). “Persistence” criterion was significantly higher for subjects playing games on personal devices (P = 0.031) and MMORPGs (P = 0.0342).
| Discussion|| |
The present study explored the phenomenology of DSM-5 internet gaming disorders (IGD-DSM-5) and its associated psychiatric comorbidities among adolescents (13–16 years) attending the child and adolescent psychiatry outpatient department (OPD), KGMU, Lucknow, Uttar Pradesh, for other psychiatric disorders.
In the present study, the most commonly reported symptoms were conflict, preoccupation, and withdrawal. The least common criteria were escape and tolerance. This result is different from the previous study of 824 adolescents conducted by King and Delfabbro, 2016, which reported escape (96%), preoccupation (92%), tolerance (77%), and continued use despite harm (77%) as the most common symptoms. This difference may be due to the sampling effect and inclusion of subjects with comorbid psychiatric disorders. Moreover, clinical cases of the above-mentioned study predominantly played shooting action games (96%) and massively multiplayer online gamers (81%) and had a gaming device in their bedroom. These findings are more in line with the present study. A study by Ko et al., 2014 reported variability in the proportion of symptoms and discussed the validity or diagnostic accuracy of IGD criteria. They reported that the criterion “continued excessive use of internet gaming despite knowledge of psychosocial problems” and the criterion “jeopardized or lost a significant relationship, job, or educational or career opportunity” had the best diagnostic accuracy in differentiating the IGD group from the control group, followed by unsuccessful control, tolerance, preoccupation, withdrawal, escape, and loss of interest. The criterion “deceiving” was the only criterion with a diagnostic accuracy of less than 75%. The role of various criteria in IGD should be further investigated in clinically diagnosed larger samples of IGD to ascertain to what extent these criteria are useful indicators of disordered gaming or whether these criteria may be best operationalized as a motivational factor for playing videogames. There may be a few potential explanations for these varied findings that merit consideration. These studies relied on different assessment tools to evaluate IGD. On the other hand, the samples recruited for these studies differed systematically in their basic demographic features and the different sampling techniques utilized across these studies.
The present study shows that the mean IGDS scores as a measure of symptom severity were highest for conflict, persistence, and withdrawal. In contrast, the scores were lowest for displacement. The study conducted by Király et al. concluded that “continuation” (problem), “preoccupation,” “negative consequences” (conflict), and “escape” were more associated with lower levels of IGD while “tolerance,” “loss of control” (persistence), “give up other activities” (displacement), and “deception” were more informative at higher levels of IGD. The present study shows a pattern toward higher severity of IGD in the study sample when we compare the average scores of different criteria's of IGDS to see the severity of symptoms.
Association of IGD with psychiatric disorders has been well established in the literature.,,,,,,,, Depression seems to be the most common comorbidity in all age groups. In the present study, ODD remained the most common associated psychiatric disorder, followed by dissociative disorder, ADHD, and depressive disorder. In the present study, subjects diagnosed with dissociative disorder having significantly higher IGDS scores for “escape” criteria as compared to those with ADHD and depression each. Online gamers get a more pleasant experience than offline gamers, and this might lead to a gradual and unconscious disconnection from reality. The phenomenon eventually leads to more brittle control over the individual's life and her self-awareness. A study by De Pasquale et al. shows a positive correlation between IGD risk and some dissociative experiences such as depersonalization, derealization, absorption and imaginative involvement, and passive influence. According to this study, these people are presenting with disorders of affective and emotional regulation and may be more exposed to the risk of IGD, similarly as they are having a higher risk of other addictive disorders. These subjects are more prone to crave for “increasing levels of pleasure and involvement experienced within the gaming environment.” Subjects having dissociative disorder engaged with gaming activity to escape the difficulty from psychosocial factors decreased social interaction, frustration, and life dissatisfaction. Association of female gender and dissociative disorder may also explain the higher scores for “escape” in the present study. It has been well documented that there are gender differences found in the use of games and pathological gaming.,, In the present study, significantly higher IGDS scores found in females as compared to males in the “escape” and the “deception” criteria.
In the present study, subjects with ODD were having significantly higher IGDS scores for “displacement” criteria as compared to subjects diagnosed with dissociative disorder. The literature shows that adolescents with high scores in IGD also have negative consequences at the psychosocial level: fewer recreational activities, fewer social activities and contacts, and diminished academic performance., Generally, each online video game has an associated players' community which may lead players to find people online with similar interests and thus replace their “real-life” social network. As these online relationships spend more and more time, “real-world” social relations will tend to deteriorate or disappear, and this lack of “real-life” social support can lead some players to develop IGD. Subjects diagnosed with ODD are more inclined toward violent video games. The highest proportion of ODD subjects can explain most of the present study subjects playing MMORPGs with violent or aggressive contents. Such kind of games gives more satisfaction and pleasure to these subjects. Excess involvement with such games may “displace” the previous hobbies and activities in these subjects. In the present study, the “displacement” criterion was also significantly higher for urban subjects and subjects involved with online gaming. Online video games are never-ending, have global reach,, attract gamers to play incessantly, and are associated with a greater tendency to develop addictive behaviors in contrast to offline video games., Due to faster internet facilities in urban regions, online gaming can also be considered another contributing factor to the “displacement.” In the present study, the “persistence” criterion was significantly higher for video games on personal devices and with the subjects involved with MMORPGs. The individual having personal devices can play video games anytime and anywhere without any interruption and permission. When attempts are made to stop this excessive gaming, they had withdrawal symptoms such as irritability and aggression. MMORPGs are the most preferred type of internet games, in which players often socialize in groups and cooperate to achieve game-relevant goals.
The present study has certain limitations. First, due to nationwide lockdown, outpatient services were closed and we had to stop recruitment of subjects, resulting in a small sample size. As a result, some of the findings might not have reached clinical significance. This study shows that adolescents can be diagnosed with IGD based on DSM-5, but studies having control group comparison are needed to determine its applicability in the Indian population. The study sample is clinic-based; patients were visiting OPD primarily for psychiatric disorders other than IGD. Although a correlation has been found between psychiatric disorders and IGD symptoms, a cause–effect relationship cannot be established with this study design. The strengths include that both the parents and adolescents have been interviewed while the previous studies have used either adolescents or parents' responses by self-rated forms or checklists.,, In this study, the phenomenology of IGD-DSM-5 and associated psychiatric disorders has been discussed in a small clinical population that needs to be examined by large sample prospective, community-based multi-cantered clinical studies.
| Conclusion|| |
The present study is the first Indian study that explored the phenomenology of IGD in terms of using DSM-5 IGD criteria, symptom severity, and its association with psychosocial variables, specifically the variables of game playing behaviors such as the accessibility of device, mode of the game, and type of games. This study suggests that symptoms of IGD have a significant association with factors such as gender, domicile, gaming genre (MMORPGs), accessibility of smartphones, online/offline modes of gaming, and the associated psychiatric comorbidity. These factors can be viewed in terms of modifiable risk factors and have diagnostic as well as treatment implications. The presence of risk factors such as male gender, urban domicile, and MMORPG gaming genre in history may assist in diagnosing IGD and the symptom severity of IGD criteria, and their phenomenological overlap with comorbidities may direct clinicians to treat accordingly.
Dr. Sivangini Singh (Resident of psychiatry) for her help in editing of this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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