Griffiths et al.'s comments on the international consensus statement of internet gaming disorder: furthering consensus or hindering progress?

Expert appraisal of criteria for assessing gaming disorder: an international Delphi study

BACKGROUND AND AIMS

Following the recognition of 'internet gaming disorder' (IGD) as a condition requiring further study by the DSM-5, 'gaming disorder' (GD) was officially included as a diagnostic entity by the World Health Organization (WHO) in the 11th revision of the International Classification of Diseases (ICD-11). However, the proposed diagnostic criteria for gaming disorder remain the subject of debate, and there has been no systematic attempt to integrate the views of different groups of experts. To achieve a more systematic agreement on this new disorder, this study employed the Delphi expert consensus method to obtain expert agreement on the diagnostic validity, clinical utility and prognostic value of the DSM-5 criteria and ICD-11 clinical guidelines for GD.

METHODS

A total of 29 international experts with clinical and/or research experience in GD completed three iterative rounds of a Delphi survey. Experts rated proposed criteria in progressive rounds until a pre-determined level of agreement was achieved.

RESULTS

For DSM-5 IGD criteria, there was an agreement both that a subset had high diagnostic validity, clinical utility and prognostic value and that some (e.g. tolerance, deception) had low diagnostic validity, clinical utility and prognostic value. Crucially, some DSM-5 criteria (e.g. escapism/mood regulation, tolerance) were regarded as incapable of distinguishing between problematic and non-problematic gaming. In contrast, ICD-11 diagnostic guidelines for GD (except for the criterion relating to diminished non-gaming interests) were judged as presenting high diagnostic validity, clinical utility and prognostic value.

CONCLUSIONS

This Delphi survey provides a foundation for identifying the most diagnostically valid and clinically useful criteria for GD. There was expert agreement that some DSM-5 criteria were not clinically relevant and may pathologize non-problematic patterns of gaming, whereas ICD-11 diagnostic guidelines are likely to diagnose GD adequately and avoid pathologizing.

Techniques of Neutralization in Narratives of Addicted Gamers: A Social Science Approach on Gaming Disorder

Due to a hegemony of psychology, the phenomenon of addicted gaming tends to be conceptualized as a chronic illness. Taking a sociological perspective requires reframing the phenomenon: As deviant behavior, and therefore as a behavior, that goes against behavioral expectations of social groups. Such change of perspective raises new questions and sheds light on aspects of the phenomenon that have been unstudied so far. The article takes one step in this direction and applies the concept of neutralization as a heuristic to study how gamers classified as addicted make sense of their deviant gaming practices. Analyses of biographical-narrative interviews with addicted gamers indicate that they use five neutralization techniques in order to carry out their deviant practices without generally questioning social norms, these are rejection of individual responsibility, trivializing revaluation, positive revaluation, revaluation of deviance as self-determined choice and condemnation of instances of social control.

More stringent criteria are needed for diagnosing internet gaming disorder: Evidence from regional brain features and whole-brain functional connectivity multivariate pattern analyses

BACKGROUND

Internet gaming disorder (IGD) is included in the DSM-5 as a provisional diagnosis. Whether IGD should be regarded as a disorder and, if so, how it should be defined and thresholded have generated considerable debate.

METHODS

In the current study, machine learning was used, based on regional and interregional brain features. Resting-state data from 374 subjects (including 148 IGD subjects with DSM-5 scores ≥5 and 93 IGD subjects with DSM-5 scores ≥6) were collected, and multivariate pattern analysis (MVPA) was employed to classify IGD from recreational game use (RGU) subjects based on regional brain features (ReHo) and communication between brain regions (functional connectivity; FC). Permutation tests were used to assess classifier performance.

RESULTS

The results demonstrated that when using DSM-5 scores ≥5 as the inclusion criteria for IGD subjects, MVPA could not differentiate IGD subjects from RGU, whether based on ReHo or FC features or by using different templates. MVPA could differentiate IGD subjects from RGU better than expected by chance when using DSM-5 scores ≥6 with both ReHo and FC features. The brain regions involved in the default mode network and executive control network and the cerebellum exhibited high discriminative power during classification.

DISCUSSION

The current findings challenge the current IGD diagnostic criteria thresholding proposed in the DSM-5, suggesting that more stringent criteria may be needed for diagnosing IGD. The findings suggest that brain regions involved in the default mode network and executive control network relate importantly to the core criteria for IGD.

Development and psychometric validation of Internet Gaming Disorder Scale-Short-Form (IGDS9-SF) in a Brazilian sample

OBJECTIVES

The aim of this study was to develop and examine the psychometric properties of the IGDS9-SF in a sample of Brazilian gamers and to find the best cut-off point for this instrument using a normative and clinically diagnosed sample of gamers.

METHODS

A total of 610 participants were recruited to the present study. Construct validity was assessed through Exploratory and Confirmatory Factor Analysis (EFA, CFA). Criterion-related validity was established through the associations with Game Addiction Scale (GAS) and weekly gameplay. Reliability analysis was performed using the Cronbach's alpha (α) as the indicator of internal consistency. A cut-off point was estimated using the Receiver Operating Characteristics Curve (ROC curve) where the results of a clinical assessment was used as the gold standard.

RESULTS

EFA and CFA findings confirmed the single-factor structure of the IGDS9-SF. Positive correlations indicated adequate criterion-related validity, and the scale was shown to be reliable (α=0.82). Finally, the optimal cut-off point for risky gaming was found to be >16 points and for diagnosis to be >21 points.

CONCLUSIONS

This study provides validity and reliability evidence for the use of the Brazilian version of the IGDS9-SF in the assessment of Internet Gaming Disorder, further supporting its usefulness as a robust psychometric tool that can be employed in clinical and research settings in Brazil.

A cohort study of patients seeking Internet gaming disorder treatment

BACKGROUND AND AIMS

Although Internet gaming disorder (IGD) is included as a condition in the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, little is known about its nature or treatment response. This study is a follow-up of 755 patients who received professional treatment for IGD over a 5-year period.

METHODS

The initial recommended treatment course lasted for 8 weeks, with additional care provided as needed. Treatment completion rates in the complete sample, as well as baseline predictors of treatment completion and long-term recovery among the 367 patients who completed the follow-up, are reported.

RESULTS

Nearly two thirds of patients who initiated treatment for IGD completed the 8-week psychotherapy. Of these, about two thirds who had not recovered completely by the end were offered additional care. Independent predictors of extended treatment were higher baseline scores on the Young Internet Addiction Scale, Beck Depression Inventory (BDI), and Korean-Attention Deficit Hyperactivity Disorder-Rating Scale (K-ADHD-RS). Between 1 and 5 years later, 33.5% of the complete sample was considered as recovered from IGD. Significant predictors of recovery from IGD were older age, earlier admission to the clinic, lower baseline scores on the BDI and K-ADHD-RS, and no offer of extended treatment.

DISCUSSION AND CONCLUSIONS

The majority of the patients seeking treatment for IGD continued experiencing difficulties and randomized controlled trials of interventions, which are needed to be conducted to improve outcomes. Age, family, social factors, and psychological symptoms should be considered, while designing and evaluating interventions, because they impact initial and sustained response to treatment for IGD.

Thinking more broadly about policy responses to problematic video game use: A response to Király et al. (2018)

Király et al. (2018) did an excellent job of reviewing policies that are undertaken to prevent and respond to problematic video game use. I argue that there has been a failure of imagination when considering public policy - generally, we only think of governmental or legislative policies. This paper identifies several other ways we could consider public policy, providing examples of some that have already been enacted and suggesting others that could be, all without governmental intervention. These types of policies may not only be more practical, but also be more effective.

Behavioral Addictions as Mental Disorders: To Be or Not To Be?

Should excessive and problematic engagement in nonsubstance use behaviors be mental disorders? The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) repositioned gambling disorder in the substance use disorders section and introduced Internet gaming disorder in the research appendix; the International Classification of Diseases (ICD-11) is also considering it. This article outlines pros and cons of considering behavioral addictions as mental disorders and also reviews the DSM-5 decision-making processes. It focuses on three conditions: gambling disorder, Internet gaming disorder (IGD), and Internet addiction (IA). We detail assessment methods and prevalence rates for these conditions and outline psychiatric comorbidities, demographic and biological risk factors, and promising treatment approaches. We also briefly discuss other putative behavioral addictions: eating/food, sex, exercise, shopping, and tanning "addictions." Overall, data are inconclusive, and consistent terminology and methodology are needed to define and evaluate these conditions more fully prior to considering them mental disorders.

Problematic gaming behaviour and health-related outcomes: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to investigate the interplay between problematic gaming behaviour and health-related outcomes at different developmental stages. A total of 50 empirical studies met the specified inclusion criteria, and a meta-analysis using correlation coefficients was used for the studies that reported adverse health implications regarding the impact of problematic gaming behaviour on depression, anxiety, obsessive–compulsive disorder and somatisation. Overall, the results suggested that problematic gaming behaviour is significantly associated with a wide range of detrimental health-related outcomes. Finally, the limitations of this review alongside its implications were discussed and considered for future research.

Treatments for Internet gaming disorder and Internet addiction: A systematic review

Problems related to excessive use of the Internet and video games have recently captured the interests of both researchers and clinicians. The goals of this review are to summarize the literature on treatment effectiveness for these problems and to determine whether any treatments meet the minimum requirement of an evidence-based treatment as defined by Chambless et al. (1998). Studies of treatments for Internet gaming disorder (IGD) and Internet addiction were examined separately, as past studies have linked IGD to more severe outcomes. The systematic review identified 26 studies meeting predefined criteria; 13 focused on treatments for IGD and 13 on Internet addiction. The results highlighted a paucity of well-designed treatment outcome studies and limited evidence for the effectiveness of any treatment modality. Studies were limited by methodological flaws, including small sample sizes, lack of control groups, and little information on treatment adherence, among other problems. In addition, the field is beset by a lack of consistent definitions of and established instruments to measure IGD and Internet addiction. The results of this review highlight the need for additional work in the area of treatment development and evaluation for IGD and Internet addiction. Attention to methodological concerns identified within this review should improve subsequent research related to treating these conditions, and ultimately outcomes of patients suffering from them. (PsycINFO Database Record

Investigating the differential effects of social networking site addiction and Internet gaming disorder on psychological health

Background and aims Previous studies focused on examining the interrelationships between social networking site (SNS) addiction and Internet gaming disorder (IGD) in isolation. Moreover, little is known about the potential simultaneous differential effects of SNS addiction and IGD on psychological health. This study investigated the interplay between these two technological addictions and ascertained how they can uniquely and distinctively contribute to increasing psychiatric distress when accounting for potential effects stemming from sociodemographic and technology-related variables. Methods A sample of 509 adolescents (53.5% males) aged 10-18 years (mean = 13.02, SD = 1.64) were recruited. Results It was found that key demographic variables can play a distinct role in explaining SNS addiction and IGD. Furthermore, it was found that SNS addiction and IGD can augment the symptoms of each other, and simultaneously contribute to deterioration of overall psychological health in a similar fashion, further highlighting potentially common etiological and clinical course between these two phenomena. Finally, the detrimental effects of IGD on psychological health were found to be slightly more pronounced than those produced by SNS addiction, a finding that warrants additional scientific scrutiny. Discussion and conclusion The implications of these results are further discussed in light of the existing evidence and debates regarding the status of technological addictions as primary and secondary disorders.

Established risk factors for addiction fail to discriminate between healthy gamers and gamers endorsing DSM-5 Internet gaming disorder

Background and aims The DSM-5 includes criteria for diagnosing Internet gaming disorder (IGD) that are adapted from substance abuse and widely used in research and clinical contexts, although evidence supporting their validity remains scarce. This study compared online gamers who do or do not endorse IGD criteria regarding self-control-related abilities (impulsivity, inhibitory control, and decision-making), considered the hallmarks of addictive behaviors. Method A double approach was adopted to distinguish pathological from recreational gamers: The first is the classic DSM-5 approach (≥5 criteria required to endorse the IGD diagnosis), and the second consists in using latent class analysis (LCA) for IGD criteria to distinguish gamers' subgroups. We computed comparisons separately for each approach. Ninety-seven volunteer gamers from the community were recruited. Self-reported questionnaires were used to measure demographic- and game-related characteristics, problematic online gaming (with the Problematic Online Gaming Questionnaire), impulsivity (with the UPPS-P Impulsive Behavior Scale), and depression (with the Beck Depression Inventory-II). Experimental tasks were used to measure inhibitory control (Hybrid-Stop Task) and decision-making abilities (Game of Dice Task). Results Thirty-two participants met IGD criteria (33% of the sample), whereas LCA identified two groups of gamers [pathological (35%) and recreational]. Comparisons that used both approaches (DSM-5 and LCA) failed to identify significant differences regarding all constructs except for variables related to actual or problematic gaming behaviors. Discussion The validity of IGD criteria is questioned, mostly with respect to their relevance in distinguishing high engagement from pathological involvement in video games.

Internet Gaming Disorder in Children and Adolescents

The American Psychiatric Association recently included Internet gaming disorder (IGD) as a potential diagnosis, recommending that further study be conducted to help illuminate it more clearly. This paper is a summary of the review undertaken by the IGD Working Group as part of the 2015 National Academy of Sciences Sackler Colloquium on Digital Media and Developing Minds. By using measures based on or similar to the IGD definition, we found that prevalence rates range between ∼1% and 9%, depending on age, country, and other sample characteristics. The etiology of IGD is not well-understood at this time, although it appears that impulsiveness and high amounts of time gaming may be risk factors. Estimates for the length of time the disorder can last vary widely, but it is unclear why. Although the authors of several studies have demonstrated that IGD can be treated, no randomized controlled trials have yet been published, making any definitive statements about treatment impossible. IGD does, therefore, appear to be an area in which additional research is clearly needed. We discuss several of the critical questions that future research should address and provide recommendations for clinicians, policy makers, and educators on the basis of what we know at this time.

Internet Gaming Disorder as a formative construct: Implications for conceptualization and measurement

Some people have serious problems controlling their Internet and video game use. The DSM-5 now includes a proposal for 'Internet Gaming Disorder' (IGD) as a condition in need of further study. Various studies aim to validate the proposed diagnostic criteria for IGD and multiple new scales have been introduced that cover the suggested criteria. Using a structured approach, we demonstrate that IGD might be better interpreted as a formative construct, as opposed to the current practice of conceptualizing it as a reflective construct. Incorrectly approaching a formative construct as a reflective one causes serious problems in scale development, including: (i) incorrect reliance on item-to-total scale correlation to exclude items and incorrectly relying on indices of inter-item reliability that do not fit the measurement model (e.g., Cronbach's α); (ii) incorrect interpretation of composite or mean scores that assume all items are equal in contributing value to a sum score; and (iii) biased estimation of model parameters in statistical models. We show that these issues are impacting current validation efforts through two recent examples. A reinterpretation of IGD as a formative construct has broad consequences for current validation efforts and provides opportunities to reanalyze existing data. We discuss three broad implications for current research: (i) composite latent constructs should be defined and used in models; (ii) item exclusion and selection should not rely on item-to-total scale correlations; and (iii) existing definitions of IGD should be enriched further.

Not good enough? Further comments to the wording, meaning, and the conceptualization of Internet Gaming Disorder

In their commentary, Kuss, Griffiths, and Pontes (2016) criticize the use of the term "Internet" in the recently proposed diagnosis for Internet Gaming Disorder (IGD) and its use as one of the included diagnostic criteria. We agree with the exclusion of the term "Internet" in the diagnosis, but have some considerations to the comments regarding the nine criteria for IGD. Specifically, we discuss the meaning, the wording, and the importance of the criteria, as well as the importance of distress or functional impairment in the proposed diagnosis. We also address the possibility of categorizing IGD as a subtype of a general behavioral addiction diagnosis.

Impulsivity in Multiplayer Online Battle Arena Gamers: Preliminary Results on Experimental and Self-Report Measures

Background and aims Multiplayer Online Battle Arena (MOBA) games have become the most popular type of video games played worldwide, superseding the playing of Massively Multiplayer Online Role-Playing Games and First-Person Shooter games. However, empirical studies focusing on the use and abuse of MOBA games are still very limited, particularly regarding impulsivity, which is an indicator of addictive states but has not yet been explored in MOBA games. In this context, the objective of the present study is to explore the associations between impulsivity and symptoms of addictive use of MOBA games in a sample of highly involved League of Legends (LoL, currently the most popular MOBA game) gamers. Methods Thirty-six LoL gamers were recruited and completed both experimental (Single Key Impulsivity Paradigm) and self-reported impulsivity assessments (s-UPPS-P Impulsive Behavior Scale, Barratt Impulsiveness Scale), in addition to an assessment of problematic video game use (Problematic Online Gaming Questionnaire). Results Results showed links between impulsivity-related constructs and signs of excessive MOBA game involvement. Findings indicated that impaired ability to postpone rewards in an experimental laboratory task was strongly related to problematic patterns of MOBA game involvement. Although less consistent, several associations were also found between self-reported impulsivity traits and signs of excessive MOBA game involvement. Conclusions Despite these results are preliminary and based upon a small (self-selected) sample, the present study highlights potential psychological factors related to the addictive use of MOBA games.