Internet Gaming Disorder: A Real Disorder or a Way of Coping? A Case Series

Abstract

Internet gaming disorder (IGD) is frequently associated with comorbid psychological issues, and apparently, there exists a bidirectional relationship that either of them predisposes the other. It still remains an enigma whether IGD is an individual entity or a coping mechanism. Here, we aim to describe IGD in 4 adolescent males with comorbid psychiatric or psychosocial conditions using a developmental approach and to bring out different interplays between gaming behavior, psychopathology, and environment. This article also aims at exploring how IGD can be understood as a way of coping with another psychological condition, identifying which could be a key factor in the management.

Introduction

Gaming disorder has been recently proposed to be included in the 11th Revision of the International Classification of Diseases (ICD-11), ¹ whereas the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has already incorporated “Internet gaming disorder (IGD)” in the section of proposed disorders for further study. ²

There have been multiple debates because of the conception of IGD. Concerns have been raised about the identification of IGD as a discrete clinical entity, its theoretical construct, and the underlying conceptual and empirical issues. These include the validity of the current diagnostic criteria, broadening of the disorder to include internet nongaming activities (eg, social media), and the risk of over-pathologizing a common activity. ³ IGD is found to be associated with various comorbid psychiatric conditions among different age groups. The psychopathology associated with addictive behaviors can result from a problem or, alternatively, lead to further issues.^4,5 If the association between 2 disorders is higher than expected by chance, there exists a probability of mechanisms contributing to that association. Moreover, some authors have mentioned the need of exploring the link between IGD and such comorbid conditions.^6–7

Further, the possibility of gaming disorder just being a coping mechanism for an underlying psychopathology or a psychiatric illness or a distressing situation has also been raised by many but remains unexplored and unanswered. ⁸

Here, we describe 4 patients who presented with symptomatology suggestive of IGD; however, a detailed assessment revealed an underlying psychological condition, from which the gaming behavior had stemmed. Written informed consents from the parents and assent from the children were taken.

Case Descriptions

Case I

Master A, a 17-year-old male, with an easy temperament, from a joint family set-up, presented to outpatient services with his father, who expressed extreme concern about the boy spending too much time playing online games for 3 years. The games were mostly online multiplayer games involving the assumption of another identity and involved combat, war, and related strategies. Around this time, he became irregular at school and gradually stopped attending completely, even after a lot of persuasion from family. He often remained confined to his room and interacted with family members only when deemed necessary. He remained mostly sad and occasionally expressed his worthlessness that most of his peers have decided something for their life but he has not. He spent 2 to 3 h daily playing games online. Since the last 7 months, he often roamed during the night and slept for only 3 to 4 h per day. His indulgence in gaming increased to around 10 h a day. Whenever his parents told him to cut down or deprive him of his cellphone, he became excessively irritable and on, a few, occasions disruptive. His self-care and appetite were also affected.

The interview with the patient revealed sad affect, expression of anhedonia, amotivation, low self-esteem, and worthlessness. About gaming, he felt that it uplifts his mood and gives him a sense of achievement at least for a while, and had no motivation to discontinue it. On probing the temporality of the 2 problems, depressive symptoms preceded the excessive indulgence in gaming.

Based on available details and using the Diagnostic and Statistical Manual Fifth Edition (DSM-5), diagnosis of major depressive disorder (MDD) with IGD was considered. Hamilton Depression Rating Scale (HDRS) score was 22. In view of self-neglect, he was advised admission, which was refused by both parents and the patient. He was started on capsule fluoxetine 20 mg, which was subsequently increased to 40 mg. In addition, cognitive behavior therapy was initiated with fortnightly sessions. Improvement in depressive symptoms with an HDRS score of 12 along with a reduction in gaming time to 2 h per day was gradually seen within 3 months. He started engaging in other activities with family members. The patient continued follow-up till 10 months when he had already joined back school as well. In this case, the primary diagnosis was MDD, however, the child was using gaming as a way to distract himself from the distressing thoughts and emotions and to get a feeling of accomplishment.

Case II

Master S was a 16-year-old boy, studying in class 9, the only child in a nuclear family, and both parents working. He had a history of meningomyelocoele, for which surgical repair was done within the first week after birth. Following surgery, he developed weakness in both lower limbs and neurogenic bladder. This led to restrictions in his movements and outdoor activities. During early childhood, his parents would often give cellphone to him for keeping him engaged (because of their busy schedule). He would often watch videos or play games on the cellphone. However, since he was 1 year old, his parents observed that the duration of his online gaming has increased to 4 to 5 h per day, even to the extent that he did not complete his school assignments and showed a decline in scholastic performance, which was the primary concern of the parents. On being asked to curtail, he would act stubborn and denied going to school. The child earlier had an easy temperament, but was not comfortable around people and preferred his own company.

During the interview, the child was initially hesitant to converse. He expressed having low self-esteem, frustration about his restricted movements, and being different from other children. He also gave a history of getting bullied at school. About the parent’s concerns, he mentioned that playing online games gives him a sense of being connected; plus remaining alone and indoors reduces his chances of getting bullied. He had a fair understanding of his condition and expressed a willingness for change.

A provisional diagnosis of IGD was entertained as per the DSM-5 criterion. Management included sessions with the child as well as the parents. The child was encouraged to reduce gaming time gradually and identify other areas of interest/indoor activities. He was given the opportunity to express his feelings in a safe environment. Simultaneously, parents were psychoeducated about the child’s condition and the need and ways to improvise their interaction with the child. School teachers were also reached out to seek help in order to monitor and prevent the incidences of bullying. Weekly sessions were taken for a month, and every 15 days thereafter. On follow-up, he showed a reduction in gaming duration and improved interaction with parents over 3 to 4 months. Though the provisional diagnosis here was IGD, the triggering event seemed to be bullying and lack of connection with the peer, because of which the child was finding comfort and connectedness in the virtual world, which reinforced his behavior and showed improvement when provided with alternative reinforcement.

Case III

Master H, a 15-year-old male, studying in class 10, was brought by his mother, with complaints of spending excessive time on video games and online games for the last 3 years. His duration of gaming had gradually increased to around 4 h per day and he would start immediately after returning from school. There was a gradual decline in scholastic performance. He also had trouble sleeping and would get easily irritable when asked to avoid gaming and even otherwise as well. However, no behavioral issues were reported at school.

On detailed inquiry, it was found that his father passed away 4 years back, his mother got remarried a few months later, and the boy with his mother shifted to his stepfather’s place. There were frequent altercations between the parents. The patient was finding it difficult to adjust and occasionally received punitive remarks from the stepfather. Whenever he would try to bond with his stepfather, he would feel guilty about betraying his father’s memory and giving the place of his father to someone else, and he would take his step back.

The patient took some time to become comfortable with the clinician. He was stressed about his situation, missed his father a lot, felt lonely, and wanted to find a way out. He said he would get engrossed in games and forget about himself while playing. He was finding it difficult to focus on his studies. The diagnosis of IGD with relational problems and MDD was considered as per the DSM-5 criterion as the symptoms were persistent. The management plan included intervention with the child along with the parents. The patient was started on capsule fluoxetine (20 mg) in view of his depressive symptoms. Regarding cutting down the gaming time, he expressed his inability to reduce it on his own, but agreed on installing a mobile app to restrict the duration of playing. Psychiatric social worker intervention with parents was initiated simultaneously. They were psychoeducated about the patient’s conditions and underlying factors. Relationship issues and the communication pattern of the family were explored and accordingly dealt with. The stepfather showed reluctance initially, but started participating in sessions gradually. Mild change in gaming duration and other symptoms started appearing after around 6 months. In this case, the primary problem emerged to be the loss of a loved one, difficulty reconciling the memories of the past, and the relational problems to which the child responded with avoidant distraction and isolation as a coping mechanism.

Case IV

Master R, a 12-year-old male, studying in class 7 had been spending excessive time on his cellphone, playing games both online and offline for 1 year, which significantly increased in the last 7 months. He played for 2 to 3 h after school, even during his scheduled study time. His grades started falling at school. He did not even interact much with his parents and sibling. He otherwise had an easy temperament and cordial relations with family and friends.

During the interview with the child, he expressed having scholastic difficulties, specifically in Arithmetic and Social Sciences. He said, “no one understands me and my problems,” and that he feels sad and left out most of the time. Because of academic difficulties, he was not interested in his studies. Parents frequently scolded him for not studying and compared him with his sibling, which immensely affected his self-esteem. He had gradually withdrawn and limited himself to gaming. The child was assessed for learning issues and found to have a specific learning disorder (SLD). The diagnosis of SLD with IGD was considered as per the DSM-5 criterion. The patient also showed depressive symptoms, however, did not fulfill the diagnostic criterion for MDD. The management included a brief psychological intervention. Parents were psychoeducated regarding SLD. Efforts were made to improve communication in the family. In view of SLD, he was started on remediation specific to his problems, and a discussion regarding subject change at school was done. One month after the change in subject, gaming reduced to a satisfactory level for the child and the parents. Here again, the primary clinical condition seemed to be SLD which the child was unable to express and used coping strategies like isolation and distraction, and management of one improved the other.

Discussion

Because of the very inception of gaming disorder, multiple researchers have questioned the scientific basis and clinical utility of formalizing it as a disorder. It has also been argued extensively whether it is actually a stand-alone entity or just a manifestation of another primary cause. ⁹ Various studies claim to have validated gaming disorder as an addiction. However, these are contradicted by the notion that behavioral addictions are justified just by endorsing concepts and models, which were validated for other disorders. ⁸

Another concern is that many existing diagnoses in psychiatry occur together and, this has sparked extensive debate about the generally overlapping nature of mental health diagnoses. ¹⁰ Various psychiatric and psychological comorbidities have been identified in association with gaming disorder, especially, depression, attention deficit hyperactivity disorder, anxiety, obsessive-compulsive symptoms, hostility, or aggression. Depression is the most common comorbidity in all age groups (adolescents, adults, and the general population). ¹¹ However, we wish to highlight that the issue here is not whether gaming disorder co-occurs with other diagnoses, but whether it reflects a patient’s response to those disorders, which is still not a well-explored territory. Instead, the targeted behavior is considered an addiction; screening tools are developed according to traditional substance-use criteria; and risk factors or comorbidities are explored. ⁸ There could be a different approach, ie, to identify if gaming disorder is co-occurring with another disorder or has some relations with it. A systematic review studying bio-psychosocial factors in IGD identified that children with problematic internet gaming showed more severe depression, conduct disorder, emotional symptoms, hyperactivity, peer problems, and perceived stress. In addition, they had poor quality of family relationships and more family conflicts. ¹² On a similar note, Lemmens et al found low psychosocial well-being including diminished social competence, increased loneliness, and lower self-esteem as the antecedents of gaming disorder, and could be a symptom of another primary psychological condition or pre-existing psychosocial vulnerabilities. ¹³

Research on IGD, although establishing it as “addiction,” found a number of psychosocial and environmental correlates; however, intricate relation of these seems yet to be established. IGD has been looked at predominantly through the frame of addiction. But a person can get excessively indulged in gaming to avoid unpleasant thoughts or situations, or to cope with an existential crisis in one’s life, or to deal with a major loss in one’s life. Such issues are not very simplistic in nature, and comparing coping to a mental disorder might create a moral panic in society and further expand the flexible boundaries of psychiatric diagnosis, ¹⁴ potentially resulting in a dismissive view of the diagnosis.

Conclusion

Thus, to summarize, IGD seems to occur frequently as a comorbidity to another clinical condition like, in our cases, depressive disorder or SLD or as a way to deal with other conditions requiring clinical attention like relational problems, bullying, and loss of a parent at an early age. All 4 patients described in this draft presented with clear features of gaming disorder as a way of coping with the primary clinical condition, which itself became a separate disorder later.

It appears that the presence of IGD should warrant detailed assessment along with exploration for any comorbid conditions or presence of a primary cause. This understanding can help parents, teachers, as well as clinicians in the early identification, prevention, or management of IGD.