The Psychology of Internet Gaming Disorder

Since 2016, internet discourse has been consumed by discussion on Gaming Disorder. Gaming Disorder is the proposed diagnosis for gaming addiction put forth by the World Health Organisation (WHO). The WHO has approved of the Gaming Disorder diagnosis and will feature in the International Classification of Diseases 11 (ICD-11) diagnostic manual when it releases.

While many of us are familiar with Gaming Disorder due to this discourse, some may not be aware of Gaming Disorder’s less controversial older sibling – Internet Gaming Disorder (IGD). If IGD is still a gaming addiction diagnosis, what makes it less controversial than Gaming Disorder? What does IGD actually involve?

In this article, I aim to create the most comprehensive explanation and exploration of IGD on the internet that is not behind an academic barrier or paywall. I will explain the history behind IGD, what IGD actually is, and explain a plethora of research on IGD.

Thank you and please enjoy!

(Lack of) Controversy

Before I begin my explanation of IGD, I would like to start with the history of IGD and why it is not as controversial as Gaming Disorder.

When it comes to health diagnostics, there are two primary diagnostic manuals: the ICD and the Diagnostic and Statistical Manual (DSM). While the ICD covers both physical and mental health diagnoses, the DSM focuses on mental health diagnoses. The ICD and DSM are created by the WHO and American Psychological Association (APA) respectively, and each have different protocols for how to introduce new diagnoses.

The ICD handles new diagnoses in a more rigid manner than the DSM. To use Gaming Disorder as an example, Gaming Disorder was added to a beta draft of the ICD-11 on September 2016 and then approved on June 2018. This timeframe left very little time to explore how valid Gaming Disorder is as a diagnosis. Instead, researchers only had time to publish opinion pieces on whether they felt the inclusion of the diagnosis was a good idea. However, even papers approving of Gaming Disorder criticised how rushed its inclusion was (Shadloo et al., 2017).

On the other hand, the DSM is more flexible. Once a diagnosis is published in the ICD, it can be diagnosed. In contrast, the DSM includes a section called ‘Conditions for Further Study’. In this section, diagnoses are proposed and researchers are invited to explore the validity of the proposed diagnosis. This ensures that there is a strong body of research that has evaluated the diagnosis before anything is made concrete and diagnosable.

This is the case for IGD. As a ‘Condition for Further Study’, IGD cannot officially be diagnosed, and researchers are currently exploring and investigating IGD as a diagnosis. As a result of its position, academics have had time to research IGD, resulting in a sizeable body of research that Gaming Disorder lacks. In this article, I will be dissecting and explaining this research for you all.

What is Internet Gaming Disorder?

The proposed diagnostic criteria for IGD is as follows:

Preoccupation with gaming, be it frequently playing games or frequently thinking about playing games.
Experiencing withdrawals when not gaming, such as becoming irritable, anxious or sad.
Feeling the need to increase amount of time spent playing games.
Previous unsuccessful attempts to control or reduce time spent gaming.
Loss of interest in offline hobbies and activities not related to gaming.
Continuing to play games excessively despite causing problems in life.
Deceiving others (e.g. friends and family) regarding the amount of time spent gaming.
Using games as a method of escape, distraction or relief from negative emotions.
Excessive gaming resulting in relationship loss or jeopardising employment/education opportunities.

An individual is identified as at risk of IGD if they meet at least 5/9 of the criteria within a time span of 12 months.

Contrary to what the name suggests, IGD does not deal exclusively in online games. The diagnosis has been named Internet Gaming Disorder to acknowledge that online gaming appears to be associated with the most serious problems when it comes to gaming (Rehbein et al., 2010). For example, we are sadly familiar with stories of people dying at internet gaming cafés due to excessive gaming (Hunt & Ng, 2015). PlayerUnknown’s Battleground Mobile (PUBG Mobile) recently introduced a ‘Gameplay Management’ system for minors after being cited as the cause for both accidental and deliberate death in young people (Mamum & Griffiths, 2019).

IGD’s position as a ‘Condition for Further Study’ allows researchers to test the validity of the criteria before it is made an official diagnosis. When you see the word ‘validity’, think of ‘truth’. Does the criteria truthfully represent what a gaming addiction looks like? In order to do this, researchers develop their own questionnaires adapted from the criteria and conduct research into IGD. How common is IGD? Who is more likely to have IGD? What are the consequences of IGD?

These are some questions that I hope to shed some light on.

How is it Measured?

As the diagnostic criteria for IGD is one set of nine symptoms, you may assume that there is one questionnaire of nine questions to test for IGD. However, Király et al. (2015) points out that there are currently at least ten questionnaires that can be used to measure IGD.

In a review of IGD research, Gentile et al. (2017) found that prevalence rates for IGD in research could vary pretty wildly – from 1% to 9%. Other reviews found that IGD rates could vary even more wildly – from 0.7% to 27.5% (Saunders et al., 2017). While this could be attributed to factors such as age and country, it could also be attributed to how exactly video game addiction was measured.

To provide greater insight into IGD questionnaires and their findings, I will discuss the findings of a few research papers individually.

The Internet Gaming Disorder Scale Short Form (IGDS9-SF) is a nine question questionnaire that mirrors the nine diagnostic symptoms for IGD. One study tested this questionnaire in multiple locations: Albania, the USA, the UK, and Italy (de Palo et al., 2018). Without getting too technical, it found through something known as Factor Analysis that all questions corresponded to one distinct factor, supporting the idea that the IGD criteria is representative of a single criteria for gaming addiction.

Using the IGDS9-SF, Pontes et al. (2018) set out to explore which parts of the diagnostic criteria were most associated with meeting the criteria for IGD. In a sample of 3,377 gamers, it was found that experiencing withdrawals when not gaming and a loss of control when gaming increased the likelihood of meeting the IGD criteria by 78%. These factors, combined with experiencing negative consequences from excessive gaming, increased the likelihood by another 27%. This study suggests that not all IGD criteria is weighted equally – some parts of the criteria may be more important than others.

However, this finding is not always consistent across research. Stavropoulos et al. (2019) wished to evaluate the IGDS9-SF using MMO players to understand how IGD symptoms can change over time. This study was conducted with both an Australian and American sample over a three-month period. They found that in the Australian sample, loss of control and gaming consequences weren’t good predictors of reaching the IGD diagnosis score, and factors such as preoccupation with gaming and gaming withdrawal differed over time. Not only do IGD symptoms seem to differ over time, but the importance of certain parts of the criteria seem to differ between research samples.

Moving away from the IGDS9-SF, a 20-question questionnaire called the Internet Gaming Disorder Test (IGD-20) was tested alongside a video gaming motivation questionnaire (Sprong et al., 2019). This study aimed to explore why those who experience IGD symptoms play video games.

It was found that high IGD-20 scores correlated with gaming for social interaction and escapism, with escapism resulting in the highest IGD-20 scores. The authors argue that this supports the idea of using games “as a coping strategy to forget about the negative experiences in their life” (Wood et al., 2007; Griffiths, 2010).

This finding was supported in research by Ramoz-Diaz et al. (2018). Using the Ten-Item Internet Gaming Disorder Test (IGDT-10), they found that IGD scores were most predicted by using gaming as a method of escapism and immersing oneself in a fantasy setting.

Internet Gaming Disorder Research

Back in my article on The Psychology of Gaming Disorder, I detailed how and why there is a lack of research for Gaming Disorder. In comparison, IGD has a more expansive body of research. When exploring IGD research, it may be fruitful to divide it into two sections: ‘Who Suffers From IGD?’, and ‘IGD and Mental Health’.

While the former will explore factors that relate to high IGD scores, the latter will attempt to shed some light on the question of ‘Isn’t addictive gaming just a symptom of depression/anxiety/another mental health problem?’.

Who Suffers from Internet Gaming Disorder?

Players who score highly on IGD questionnaires gain the most enjoyment from time-consuming tasks such as grinding (repeating actions for the chance of a reward), completionism, and interacting with other players (King et al., 2011; Hull et al., 2013).

It is argued that due to the relationship between IGD scores and grinding/completionism, gaming in large quantities may be due to players chasing the thrill of a reward (Griffiths & Wood, 2000; Király et al.; Liu & Peng, 2009). It is possible that if someone is currently living an unsatisfactory life, they may use gaming as a method of obtaining rewards and achievements (Stavropoulos et al., 2017; Mills et al., 2018). The relationship between IGD scores and seeking player interactions could be due to those experiencing loneliness wishing to seek a social outlet (Anderson et al., 2016).

These arguments are supported in research by Stavropoulos et al. (2019). Using a sample of Australian and American MMO players, they found that those who could be defined as the Japanese term ‘Hikkikomori’ (e.g. stays at home with parents, does not socialise, does not study or work) were significantly more likely to score highly on an IGD questionnaire.

This study is interesting for two reasons: it uses a sample of young adults, and it uses a sample of MMO players. Young adults have been identified as a risk group for developing IGD (APA, 2013). Young adulthood (or ‘emerging adulthood’) is a time of challenge as it presents a lot of change and upheaval in the transition to adulthood (Arnett, 2000; 2007). In addition, MMO players report the longest playtime of any game genre and have been identified as a risk group for excessive gaming (Stetina et al., 2011).

When examining young adult MMO players, it was found that identifying more with your character/avatar was a risk factor for high IGD scores (Liew et al., 2018; Stavropoulos et al., 2018). However, this relationship was weakened by engaging in offline activities such as exercising.

The previous few findings paint an interesting picture for young adults and online gaming. During a time period as difficult as emerging adulthood, game genres such as MMOs could be considered a form of escapism, self-medication, or a combination of both (Kuss et al., 2012; Kwon et al., 2011; Yee, 2006; Király et al.). When the leap to further education or employment proves to be challenging or unsuccessful, throwing yourself into an MMO could serve as a method of escaping real-life problems, talking with others, or obtaining the thrill of a reward after a long period of grinding (Yee; Kuss).

Throughout my time writing articles, I’ve noticed that readers have enjoyed learning about neurological and biological research for a topic. With this in mind, I set out to find some IGD studies that used neurological or biological measures.

How does 27 studies sound?

27 studies of neurobiological correlates of IGD were reviewed by Kuss et al. (2018). By reviewing these 27 studies, some interesting findings emerged. It was found that those with high gaming addiction scores: had poorer impulse control, had a poorer ability to control their emotions, were poorer decision-makers, and had a deficiency in their neuronal reward system. This deficiency implies that they have a reduced capacity for feeling joy and rewards from activities.

In the same way that someone could repeatedly gamble for pleasure, someone may be more likely to play games to an addictive extent as they chase more rewards and satisfaction from things like loot drops. However, a potential issue with this finding is the cause-effect nature of the relationship. Was someone born with a reduced capacity for rewards, or did they play games so often that it has diminished their ability to feel rewards?

Moving away from neurobiological research, Salvarli & Griffiths (2019) conducted a review of research that explored 24 different personality traits and their relationship with IGD. As this is quite a large review paper, I’ll be sticking to key personality traits that have the most evidence to support their argument.

Those with high IGD scores were more likely to be introverted (Braun et al., 2016, Charton & Danforth, 2010, Muller et al., 2014). It was argued that introverted people may use online games to compensate for a lack of a social network that extroverted people may readily enjoy (McCrae & Costa, 1997, Muller et al., Barker, 2009). It may also be difficult for these people to go out and meet new people as IGD scores were also related to low openness to experience (Kayis et al., 2016). When the choice is between going to an event where they could meet new people and staying at home playing a safe and comfortable online game, the online game may win.

In many studies, high IGD scores were related to high scores for what is known as neuroticism (Charlton et al.; Li et al., 2016; Mehroof & Griffiths, 2010; Muller et al.; Wittek et al., 2016). Those who are highly neurotic are considered to lack emotional stability and confidence. It is argued that these overly anxious and stressed individuals may use gaming as an escape from their problems (Mehroof et al.).

High IGD scores also related to individual factors such as being shy, being anxious, and being depressive (Lee et al., 2017). This finding leads us into the next section – what is the relationship between IGD and mental health?

Internet Gaming Disorder and Mental Health

A common criticism of Gaming Disorder is that it is possible that ‘Gaming Disorder’ is simply self-medication for other mental health disorders such as depression. In essence, you would be treating the self-medication for depression rather than the depression. Due to the lack of research on Gaming Disorder, it is difficult to explore the relationship between Gaming Disorder and mental health.

Using IGD rather than Gaming Disorder, it’s possible to uncover a few findings regarding addictive gaming and mental health, but they do have their limitations.

Király et al. (2018) explored the relationship between psychiatric symptoms and prolonged gaming in 11,465 participants across Europe and Korea. They found that experiencing symptoms of a psychiatric condition significantly related to levels of prolonged gaming, and factors such as escaping problems and immersing oneself in a fantasy setting further related to these symptoms. These findings may indicate that prolonged gaming is used as a method of trying to escape from and forget about problems when suffering from mental health difficulties.

Kim et al. (2016) explored IGD and psychiatric symptoms using a sample of 3,041 adults. They found that the ‘at risk of IGD’ group had significantly higher scores in all psychiatric symptoms. These symptoms included factors such as obsession-compulsion, depression, anxiety, hostility, psychoticism, and phobic anxiety. The IGD risk group also experienced significantly more loneliness, insomnia, aggression, and were almost five times more likely to attempt suicide.

These findings paint a scary picture of the mental health of those who spend excessive amounts of time gaming…until you explore the data further. When you examine the ‘IGD risk group’ further, 22% of those identified as being at risk for IGD played games for less than an hour per week, with 85% of them playing games for less than four hours per week.

As the focus of IGD is placed on life impairment, IGD does not require a certain amount of game time per week to constitute a gaming addiction. However, the very low rate of game time in this study not only calls into question the validity of the findings, but also questions the criteria for IGD itself. To me, this is a cause for concern.

Treatment

Returning to Gaming Disorder, a further criticism is a lack of clear treatment plan for those who receive a diagnosis. Perhaps the greatest fear for those experiencing gaming addiction is the possibility of being sent to a military-style boot camp (Király; Griffiths, 2008; Griffiths & Meredith, 2009; Huang et al., 2010). These boot camps can be dangerous: there are documented cases of young people dying at these boot camps covered in injuries (Hersey, 2017).

When exploring IGD, it appears that the most common treatment path is Cognitive Behavioural Therapy (CBT; King et al., 2012; Leahy, 2003; Gentile et al.). For those unfamiliar with CBT, the mental health charity Mind (2017) offers a wonderfully succinct explanation: “CBT is a type of talking treatment which focuses on how your thoughts, beliefs and attitudes affect your feelings and behaviour, and teaches you coping skills for dealing with different problems”.

An example of CBT delivered to those who experience excessive gaming includes challenging beliefs about the game/s being more worthwhile than pursuing offline pursuits such as education or a career. Alongside CBT, people may be taught healthy coping strategies for dealing with difficult times or situations, and receive help with managing their time and how to healthily balance gaming and their offline lives (King et al.).

For those in the US, a treatment program known as reSTART was created with the aim of helping those who experience video game addiction and screen dependency. This program specifically helps those who may also be suffering from mental health difficulties such as depression and ADHD, or whose educations and/or careers have been negatively impacted by gaming or screen addiction. While this is a treatment option available in the US, I was unable to find any evaluation of this program’s success rates.

Medication is not prescribed to those who experience IGD symptoms. Instead, medication is given to those who also suffer from depression, anxiety or ADHD alongside addictive gaming (Huang et al.; King & Delfabbro, 2014). Other treatments for addictive gaming include family therapy and motivational interviews which try to explore why exactly the person engages in gaming to an addictive degree (Gentile et al.).

While a number of treatment options appear to be available for those suffering from addictive gaming, no previous research has explored how effective these treatment options are (King et al.; Sprong et al.). Future research should consider evaluating these options to ensure that people receive the best care possible if experiencing addictive levels of gaming.

Critique

Throughout this article, I have been critical of research and concepts where applicable. However, I would also like to address critiques for IGD in an individual section.

A common criticism for the concept of a gaming addiction is that it turns a regular hobby into an addiction. ‘Why not Netflix Disorder? Why not Shopping Disorder?’ is a common set of questions seen in response to Gaming Disorder and IGD. This criticism has been addressed in the context of IGD, stating that the reason why there is a separate IGD diagnosis is due to having more research into excessive online gaming than things like shopping addiction or work addiction (Petry et al., 2014).

However, it seems that more research may be needed to further refine the diagnostic criteria for IGD. We have seen in this article that prevalence rates for IGD can vary wildly across research (0.7%-27.5%), and that meeting the criteria for IGD isn’t necessarily related to playing a lot of games – sometimes less than an hour per week. There also appears to be a problem in IGD research of researchers arbitrarily defining what ‘excessive gaming’ is. For example, Sprong et al. defines ‘excessive gaming’ as over 24 hours per week. In my own data analysis, I found that playing games from a starting point of 20 hours and above generally wasn’t related to negative life consequences. Future research should consider exploring at what point gaming is related to negative consequences rather than arbitrarily defining this.

This article uncovered multiple questionnaires used to measure and assess IGD. This may not be a good thing as defining IGD using different questions can result in different findings in research. Instead of evaluating many questionnaires once, it would be better for our understanding of IGD if a single questionnaire was evaluated across multiple samples and countries. This seems to be currently happening with the IGDS9-SF though, which I applaud researchers for.

While this review uncovered a number of ways in which IGD can be treated, I was unable to find any research on the effectiveness of these treatments. If IGD has been found to relate to sleep problems, eating problems, backaches, headaches, fatigue, lower work and education performance, and the deterioration of relationships (Király et al; Király et al., 2015), it’s only fair that problems this serious deserve the best and most effective of treatments.

In conclusion, the research base for IGD can be summarised as frustrating. While it produces findings that can be of genuine benefit to those who are suffering (such as IGD being a symptom of despondent youth seeking social support and rewards), limitations of the research make it difficult to address important questions. For example, it is difficult to tell whether IGD is self-medication for pre-existing mental health problems when research exploring this has an IGD group that plays games for less than four hours per week. These limitations, combined with no tested treatment program and wildly differing prevalence rates for IGD in research (0.7%-27.5%), suggests that more work remains to be done on IGD.

Thankfully, the APA is allowing this work to be done before it is recognised as a mental health diagnosis in any official capacity.

Summary

Internet Gaming Disorder (IGD) is the gaming addiction diagnosis proposed by the American Psychological Association (APA). The APA included this diagnosis in the DSM-V mental health diagnostic manual as a ‘Condition for Further Study’. IGD cannot currently be diagnosed, but researchers are invited to explore the validity/truth of IGD as a gaming addiction diagnosis.
IGD has a 9-item diagnostic criteria: preoccupation with gaming; withdrawal symptoms; need to increase game time; difficulties in controlling game time; loss of interest in other hobbies; gaming despite knowledge of consequences; deceiving others about gaming time; using games for coping or escapism; loss of relationships or life prospects due to gaming. An individual is at risk of IGD if they meet 5/9 of the diagnostic criteria within a 12 month period. Despite its namesake, IGD can involve offline gaming as well as online gaming.
Prevalence rates for IGD can vary wildly in research – from 0.7% to 27.5%. Some of the diagnostic criteria appears more important for meeting the criteria than others (e.g. loss of control and experiencing withdrawals), but isn’t found consistently across research.
High IGD scores relate to aspects of gaming such as grinding, completionism, and social support. The evidence base suggests that young people entering adulthood may use genres such as MMOs to connect with others and feel a sense of accomplishment in a challenging and frustrating world. High IGD scores also relate to personal factors such as: low impulse control, low emotional stability, being an introvert, not being open to new experiences, and being shy and anxious.
When examining the relationship between IGD and mental health, IGD scores were related to experiencing psychiatric symptoms, depression, anxiety, insomnia, aggression, and suicide attempts. However, the validity of these findings are questionable as 85% of the ‘IGD risk group’ were found to play games for less than 4 hours per week. The quality of this research base limits our ability to understand whether gaming addiction is self-medication for pre-existing mental health problems.
Treatments for those experiencing IGD symptoms include talking therapies such as cognitive-behavioural therapy (CBT), family therapy, motivational interviews, and retreat-like programs such as reSTART. However, I was unable to find any studies evaluating the effectiveness of these treatments, so we do not currently know how successful they are.
The research base for IGD can be summarised as frustrating. While it produces findings that can be of genuine benefit to those who are suffering (such as IGD being a symptom of despondent youth seeking social support and rewards), limitations of the research make it difficult to address important questions. For example, it is difficult to tell whether IGD is self-medication for pre-existing mental health problems when research exploring this has an IGD group that plays games for less than four hours per week. These limitations, combined with no tested treatment program and wildly differing prevalence rates for IGD in research (0.7%-27.5%), suggests that more work remains to be done on IGD.

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References

Hi there, thank you for looking in the reference section. When I use a lot of sources to write an article, I put the reference section in a separate Google Doc so I don’t scare away potential readers due to a small scroll bar. As I have cited a rather large 53 sources in this article, you can find the reference list for this article here. Thank you for understanding!

The Psychology of Internet Gaming Disorder