COVID-19 Pandemic,Social Isolation,and Online Gaming Addiction: Evidence From Two Case Reports

Abstract

In the background of COVID-19 restrictions, online games have positioned themselves as activities which promote adherence to precautionary measures, while allowing users to socially interact and entertain themselves. Emerging evidence suggest increase in viewership as well as gaming activity throughout the world. However, such rapid increase in initiation of gaming activities also puts vulnerable population at risk of developing problematic use and addiction. We provide 2 real world examples of how pandemic-related changes can contribute toward gaming disorder in those with previously recreational or minimal Internet gaming. Public health policymakers need to be mindful of potential fallout of gaming addiction secondary to increased changes brought by the pandemic.

Introduction

COVID-19 pandemic has led to school and work place closures, limited physical activity, and social interaction, leading to significant disruptions of routine activities. ¹ Significant rise in online gaming activity, streaming, and viewership was observed during the early periods of quarantine. ² Further, gaming industry has been quick to utilize World Health Organization’s coronavirus prevention guidelines to its advantage by presenting online gaming as a means of engaging with friends while adhering to social distancing. ³

While gaming does provide a sources of enjoyment, social connectedness, and effective coping for some, there remains a risk that unhealthy lifestyle patterns forced due to COVID-19 may intensify gaming-related behaviors and in some cases may lead to problematic use.^1,3,4 Emerging evidence suggest increased gaming during the COVID-19 period, however clinical reports are missing. ⁵ We, through our 2 case reports, present a real world example of COVID-19 pandemic and related social isolation contributing significantly to the development of gaming disorder.

Case Report 1

A 14-year-old was brought to our clinic by parents with complaints of excessive online gaming for the last 6 months. Detailed evaluation revealed that prior to March 2020, he was a bright student with regular involvement in outdoor tasks and minimal exposure to online gaming and activities. Due to the lockdown placed in March 2020, school academics were shifted to online mode, providing him regular access to mobile phone and laptop, unlike normal circumstances. As outdoor activities were restricted, he was invited by other friends to engage in multiplayer online games. Within a month, he started spending 3 to 4 h/day playing mobile games to overcome his boredom and maintain social connections. His preoccupation further increased resulting in long playing hours during night and skipping of online classes. The salience with gaming was so marked that he would often miss his meals, or take them while playing. Significant deterioration was noticed in personal hygiene and studies. He started avoiding interaction with his friends and family members. On being pointed out, he would respond angrily and break household items. Although he would be often reprimanded physically for these outburst, his desire to play online games would persist. The parents grew extremely worried with such rapid behavioral change but could only seek medical help after COVID-19-related restrictions were lifted.

The patient met 6 (preoccupation, tolerance, inability to reduce playing, giving up other activities, continuing despite problems, and deceiving family members about time spent on gaming) out of 9 DSM-5 criteria and scored 40 on a 9-item Internet gaming disorder scale-short form (IGDS9-SF). Considering the significant impairment caused due to Internet gaming over past 6 months, a diagnosis of Internet gaming disorder was considered. Our multidisciplinary team (consisting of psychiatrist, psychologist, and social worker) adopted an eclectic approach, focusing on enhancing motivation, activity scheduling, and engagement in physical activities on outpatient basis. Parents were psychoeducated about the digital hygiene practices as well as taught to manage expressed emotions. At 12 weeks and after 8 in-person sessions, he had returned to his previous self, showing significant improvement in academic and personal activities, spending less than 2 h/week in online gaming. He maintained well for further 2 months after which he dropped out of the treatment.

Case Report 2

Our second case is 24-year-old who started playing multiplayer online battle arena and massively multiplayer online role-playing game while pursuing his postgraduation degree in design. The knowledge of games and its characteristics (costume, story, character, and planning graphic) helped him design games projects for his course. This interest helped him in getting good project grades and recognition in the course. Thus, he continued to play 2 to 3 h a day for browsing videos or playing games. Although he altered his sleep pattern to remain involved in gaming, there were no significant psychosocial and occupational dysfunctions secondary to gaming. This pattern persisted till pre-COVID-19 lockdown (March 2020).

He shifted to work from home due to COVID-19 restrictions, affording more spare time which he invested in playing. Soon, his playing time increased to around 10 h/day. On a typical day, he would start gaming from 6 PM and continue till 4 AM. This led to significant disruptions in sleep, work, physical activities, and social interactions. His family members would object his online gaming and this would often lead to arguments and as a result he began avoiding them. His preoccupation reached to such degrees that he invested his savings in-gaming related activities. He reported that gaming helped him overcome the boredom and stay connected with peers. Further, it provided for some structure and overcome negative mood states due to the pandemic. His parents made multiple attempts to motivate him to seek help for gaming behavior, eventually convincing him. He was diagnosed with Internet gaming disorder based on a clinical interview which revealed emotional dyscontrol, need for novelty, loss of control, preoccupation with gaming, and continued engagement despite dysfunctions in the past 12 months.

He received 10 in-person multimodal psychotherapy sessions (motivation enhancement therapy, cognitive restructuring, behavioral activation, contingency contracting, relapse prevention, digital hygiene, yoga, and family therapy) from October 20 to April 21 on outpatient basis, after which he dropped out. He showed reduction in duration of play from 8 to 10 h a day to 2 to 3 h a day and increased engagement in other offline leisure activities.

Discussion

Internet gaming can provide a safe alternative platform for individuals to engage and socialize while adhering to COVID-19 safety precautions.^6,7 However, as exposure to online gaming increases, a small proportion remains vulnerable to developing problematic patterns. Reports are emerging that COVID-19 pandemic has led to increase in time spent in online gaming among regular ⁸ as well as problematic users. ⁹ As more people are exposed to online gaming, this can act as gateway for gaming dependence in new or regular users as evidenced in 2 cases. While it is possible that only a minority of online gamers will develop dependence, the absolute number can be overwhelming. Further, pandemic may make it difficult for online gamers to reach out for help. The results of this fallout maybe visible in next few months to years. We believe that the cases we report are not one-off example but few who could access services at an early stage. Therefore, it is essential that governments and stakeholders across the globe take pre-emptive steps in managing problematic online gaming. Preventive measures like adequate sleep, proper nutrition, activity scheduling, engagement in physical activities, and maintaining social contact need to be emphasized for general well-being of young adults. Further, specific measures like monitoring one’s own and children’s screentime, utilizing digital well-being tools, and early help seeking for problematic gaming need to be promoted to ensure that regular gaming doesn’t progress to problematic or dependent pattern.^4,10

Conclusion

Due to conditions forced by COVID-19, exposure to Internet and online gaming has seen a rise among youth. Further limited social and physical interaction can contribute toward social isolation. Combination of these 2 phenomenon can precipitate online gaming addiction, as exhibited by 2 cases reported. Public health specialist and policymakers around the world must recognize this brewing challenge and ensure that awareness and preventive actions are put in place to address the rise of problematic gaming post pandemic.