Internet Gaming Addiction / Disorder (IGD)– A Review of Aetiology, Diagnosis and Management

EPIDEMIOLOGY OF INTERNET GAMING DISORDER (IGD)

The global prevalence of internet gaming disorder (IGD) stands at around 1­ – 1.6%, though methodological inconsistencies have hindered accurate study appraisal. [King and Delfabbro 2018]

In a multination evaluation of internet gaming in more than 20 countries, the disorder was more prevalent among teenage boys. [Cheng 2018]

The prevalence of DSM-5 internet gaming disorder in a national sample of (mean age of 13.5) Slovenian school-age children was around 2.5%. [Pontes et al., 2016]

In another European study, including Germany, Greece, Iceland, The Netherlands, Poland, Romania and Spain, an additional 5.1% of adolescents were deemed at risk of developing the disorder and in China and Taiwan, rates of pathological gaming were 10% and 7.5% respectively, possibly due to gaming’s acceptance as a high-value competitive sport. [Muller et al., 2015]

East Asian male children and younger adolescents are globally considered at the highest risk. [Gupta et al., 2021]

EVOLUTION OF INTERNET GAMING DISORDER (IGD)

Videogame-related distress was first reported in 1983 by two school counsellors who noticed compulsive behaviour, withdrawal and lack of motivation when their teenage pupils were asked to stop playing video games. [Soper and Miller 1983]

Although successful treatments led to improved credibility in recognising gaming disorder as a treatable condition, research focused on gaming preoccupation rather than gaming addiction. Studies were often anecdotal or observational. [Griffiths 2016]

In the 1990s, research on gaming addiction widened to include personal computers, consoles, and arcade machines due to the increasing availability of home computers. [Przyblski et al., 2017]

Researchers adapted the existing DSM-III and DSM-IV gambling criteria as they believed that the psychopathology of internet addiction closely matched that of substance addiction.

In 2013 the American Psychiatric Association (APA) identified Internet gaming disorder as a condition warranting further investigation. [APA 2013]

The 11th version of the International Classification of Diseases (ICD-11) has officially included gaming disorder as a mental disorder. [World Health Organization 2018]

Despite growing interest in IGD as a treatable disorder, there is an ongoing debate about whether IGD can be considered an addiction. Past studies have been criticised for relying on the perception that gaming disorder is an addiction rather than a coping mechanism. [Gupta et al., 2021]

One school of thought is that IGD is a non-substance addiction, and the other is that it is simply a coping technique, a good stress reliever which shouldn’t be pathologised [Gupta et al., 2021], or a transient phase. [Kuss et al., 2017]

A systematic review indicated that symptoms most typically associated with people experiencing IGD-like behaviours include: [Paulus et al., 2018].

• Increased screen time
• Preoccupation with gaming
• Increased tolerance for long gaming hours
• Impaired control over gaming behaviour
• Internal conflicts related to gaming behaviour (‘conflictuousness’)
• Increased importance is given to gaming in one’s life (salience)
• Feelings of depression and guilt when faced with the consequences of gaming, and
• Relapse to gaming behaviour after a brief period of abstinence.

People with IGD often report irritability, anger, poor mental health, isolation, interpersonal conflict, loss of friendships, poor functioning at work, financial insecurity, poor diet, sleep disturbance, overconsumption of caffeine, and increased suicide risk. [King and Delfabbro 2018]

Common comorbidities include anxiety, depression and attention deficit hyperactivity disorder (ADHD). In some studies, children with ADHD were found to have high impulsivity scores, which have accurately predicted IGD development. [Gupta et al., 2021]

NEUROBIOLOGY AND GENETICS IN INTERNET GAMING ADDICTION

Neuroimaging:

A range of neuroimaging methods has been used to identify IGD, including functional magnetic resonance imaging (MRI), resting-state functional (rsfMRI), voxel-based morphometry (VBM), and positron emission tomography (PET) and electroencephalography (EEG).

• Gamers with IGD were found to have impaired visual and auditory capacity – recognised through lower activity in the bilateral and inferior temporal gyri. [Ding et al., 2014]
• Impaired cognition, decision-making and response-inhibition were also observed in those with IGD. [Xing et al., 2014]
• Deficiencies identified in the neuronal reward system suggest that IGD could be an addiction syndrome. [Spechler et al., 2016]
• Neuroimaging studies of those addicted to gaming show comparable brain activity to individuals with substance abuse disorders. [Kuss et al., 2017]
• However, criticism of the DSM-5 criteria calls out its lack of specificity: The time spent on video games varies among individuals and not every increase can be attributed to poor tolerance. [King and Delfabbro 2016]

Genetics:

Genetic studies have also identified a higher prevalence of two specific polymorphisms in those with IGD. [Han et al., 2007]

• Taq1A1 allele of the dopamine D2 receptor
• Val158Met in the catecholamine-O-methyltransferase gene.

As comparable levels have been seen in individuals with substance addiction, there may be a genetic component to IGD, warranting further research as new genetic techniques become available.

RISK FACTORS FOR INTERNET GAMING DISORDER

Familial factors such as high access to internet devices, poor interfamilial relationships, and lower socioeconomic status all increase the risk of children and adolescents developing IGD. Parental internet usage control is therefore critical in preventing or reducing problematic gaming. [King and Delfabbro 2018]

DIAGNOSTIC ASPECTS OF INTERNET GAMING DISORDER

Internet Gaming Disorder (IGD) is defined in the ICD-11 as: [World Health Organization 2018]

A pattern of gaming behaviour (“digital-gaming” or “videogaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.

The DSM-5 defines internet gaming disorder as [American Psychiatric Association 2013]

Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress.

Internet gaming disorder is subtly different from internet addiction in that it focuses specifically on gaming rather than wider online activities such as searching the internet or using other online platforms such as chat rooms. [Griffiths 2016]

DSM-5 Criteria: 

IGD is diagnosed if five (or more) of the following nine criteria are present over 12 months: [American Psychiatric Association 2013].

1. Preoccupation with online/offline gaming (preoccupation)
2. Experience of unpleasant symptoms when gaming is taken away (withdrawal)
3. The need to spend increasing amounts of time engaged in games (tolerance)
4. Unsuccessful attempts to control participation in games (loss of control)
5. Loss of interest in previous hobbies and entertainment as a result of, and except games (give up other activities – salience)
6. Continued excessive use of games despite knowledge of psychosocial problems (continuation)
7. Deceiving family members, therapists, or others regarding the amount of gaming (deception)
8. Use of games to escape or relieve negative moods (escape);
9. Jeopardising or losing a significant relationship, job, education, or career opportunity because of participating in games (negative consequences).

ICD-11 Criteria:

The 11th version of the International Classification of Diseases (ICD-11) has officially included gaming disorder as a mental disorder. According to the ICD-11, all criteria must be present.

1. Impaired control over gaming
2. Increasing priority is given to gaming over other activities
3. Continuation of gaming despite the occurrence of negative consequences; and
4. Resulting in clinically significant distress or impairments in important areas of functioning

Because there has been no clear definition of IGD until recently, many studies have used ad-hoc assessment tools and only one study published after 2013 used DSM-5 criteria. [Sakuma 2017]

Assessments in current circulation include:

• The Internet Addiction Test (IAT)
• Young’s Diagnostic Questionnaire (YDQ)
• The Korean Internet Addiction Scale (K-IAS).

TREATMENTS FOR INTERNET GAMING ADDICTION

In the most comprehensive analysis of internet gaming addiction studies to date covering China, South Korea, the USA, Brazil, India, Switzerland, Norway and Germany [King et al., 2017]; [Zajac et al., 2017], the primary treatment approaches studied were psychological (cognitive behavioural therapy (CBT) and counselling.) and pharmacological (Antidepressants or stimulants).

Pharmacological Treatment: 

• Medication trials examined drugs typically used to treat depression (bupropion, escitalopram) or ADHD (methylphenidate, atomoxetine).
• Antidepressant or stimulant medications (bupropion, escitalopram, methylphenidate) were given in combination with talking therapies in 7 out of the 38 included studies.

Methylphenidate (MPH): 

• Treatment with Methylphenidate for 8 weeks was associated with reduced internet usage and reduced scores on the Korean version of Young’s internet addiction scale (YIAS-K). [Han et al., 2009]. 
• The researchers suggest that Internet video game playing might be a means of self-medication for children with ADHD.
• Another study of 86 adolescents with ADHD and IGD showed MPH effectively reduced the severity of IGD, and this reduction correlated with reduced impulsivity. [Park et al., 2016].

Bupropion: 

• Bupropion was superior to placebo in reducing gaming time and IGD symptoms.
• Escitalopram is also effective in treating and managing IGD symptoms
• Bupropion was superior to escitalopram in improving attention and impulsivity in IGD patients. [Song et al., 2016].

Atomoxetine: 

• Atomoxetine effectively reduced the severity of IGD symptoms in 86 adolescents diagnosed with ADHD and Internet gaming disorder. [Park et al., 2016]
• This reduction was also correlated with impulsivity reduction

Psychological Treatment 

• CBT-based psychotherapy has been the most widely studied psychosocial treatment for IGD thus far, with four published randomised controlled trials of such treatments. Only two trials found that the CBT approach was superior to the control.
• Another study showed that CBT plus bupropion was superior to bupropion alone. [Kim et al., 2012]

Limitations of current evidence: [Zajac et al., 2020]

• Over half of the studies included in the review were conducted in South Korea and thus may not generalise to other cultures.
• Sample sizes are small.
• There are methodological differences between the various trials with no consensus definition of IGD, leading to clinical heterogeneity.

Others: [King et al., 2017]; [Zajac et al., 2017] [Zajac et al, 2020]

The following treatments have been trialled in small samples with a minimal evidence base.

• Virtual reality training
• Family therapy
• Daily journal keeping
• Electro-acupuncture.
• Mindfulness-oriented group therapy
• Brief voluntary abstinence
• Transcranial direct current stimulation
• Eclectic psychotherapy (CBT, family, motivational interviewing, solution-focused)
• Self-Discovery Camp
• MMORPG speaking and writing course
• Residential Camp and parent management.

SUMMARY

Internet gaming is an incredibly popular social activity among people of all ages worldwide, and it gives players chances to immerse themselves in alternate worlds for competition or pleasure. [Gupta et al., 2021]

If players lose control over their gaming and it begins to interfere with their daily lives, an internet gaming disorder (IGD) may develop, and further assessment and treatment may be warranted. [World Health Organization 2018]

There is a current lack of professional consensus around valid and reliable methods of assessment, diagnosis and treatment for IGD [Gupta et al., 2021]: The new ICD-11 definition, published in 2022, has been criticised for its weak evidence-base and the DSM-5 identifies internet gaming disorder as a possible clinical condition meaning that it cannot yet be diagnosed in practice.

Clinicians should proceed cautiously and sensitively when working with individuals experiencing mental health and social difficulties around internet gaming. [Gupta et al., 2021]