This document discusses diagnostic considerations and theories regarding internet gaming addiction. It begins by outlining the debate around whether video games or the internet is the primary platform. It then summarizes Griffiths' video game addiction theory and criteria. Several models and issues with the research are discussed. International prevalence rates are reviewed, with problematic gaming estimated around 3% generally. The DSM-5 criteria for internet gaming disorder is outlined. Etiology, risk factors, differential diagnosis, and comorbidity are explored. Structural characteristics of online games that may contribute to addiction are also summarized.

1. Diagnostic Considerations
Internet Gaming Addiction
Leigh Holman, Ph.D., LPCS, RPTS, NCC, SCS
Amhca Diplomate and CMHC
President-Elect International Association of Addiction & Offender
Counselors

2. Conflict Over what constitutes Problematic Online
Gaming?
 Video games as the starting point for examining the characteristics of a specific
pathology (Charlton & Danforth, 2007; Griffiths, 2005; Griffiths & Meredith, 2009;
Peters & Malesky, 2008).
VS.
 Internet is the main platform that unites different addictive activities, including online
games (Van Rooij, Schoemakers, Vermulst, Van den Eijnden, & Van de Mheen, 2011;
Young, 2009).

3. Griffiths, 2010) Video Game Addiction Theory
Indicators of High Engagement (Charlton & Danforth, 2007,
2008)
1. Salience
• Gaming becomes the most important activity in the person’s life and
dominates his/her thinking, feelings (i.e. cravings), & behavior
• Preoccupation & Cognitive Distortions
• Deterioration of Socialized Behavior
1. Mood Modification
 Gamers report both an arousing ‘buzz or high” and
 Distressing tranquilizing feeling of “escape or numbing”
1. Tolerance
• Increasing amounts of time are required to achieve the former
effects

4. Griffiths, 2010) Video Game Addiction
Theory
Central Role in Addiction (Charlton & Danforth, 2007, 2008)
4. Withdrawal Symptoms
 Unpleasant feeling states or physical effects when not gaming or reduced
time gaming
 Shakes, moodiness, irritability
5. Conflict
• Interpersonal conflict with important relationships
• Conflict with time spent on other activities (hobbies, work, school, social
life)
• Intra-psychic conflict – feelings of loss of control
6. Relapse
 Tendency for repeated reversions to earlier patterns of gaming after
abstinence or control has been established

5. Other models
Porter et al. (2010)
Excessive use of one/more video games resulting in a preoccupation
with and a loss of control over playing video games, and resulting
negative psychosocial and/or physical consequences
Integrated Models
Problematic Online Game Use Model (Kim & Kim, 2010)
5 dimensions: euphoria, health problems, conflict, failure of self-control, and
preference of virtual relationship
Demetrovics et al. (2012) Integrative Approach
6 Dimensions: preoccupation, overuse, immersion, social isolation, interpersonal
conflicts, and withdrawal

6. Issues with Research
No consistency in literature on gaming addiction:
Theory
Conceptualization
Screening and Assessment Measures
Methodology
Population
Sampling

7. International Prevalence
Rates

8. Prevalence
Meta-analysis: About 3% of the general population meet addiction criteria
Limited evidence suggests that most addicts (about 80%) stay addicts for at least
2 years in the absence of treatment
Prevalence rates vary according to: Type of digital technology activity
How addiction is assessed (measurement)
Demographic factors
Cultural context (Far East Asian > Western)
Country
 Recruitment and sampling method psychiatric sample vs. community sample;
 self-selection vs. random selection
 Type of video game typically played
 ↑among online video games, especially MMORPGs

9. DSM-5
“Internet gaming has been reportedly defined as an “addiciton” by
the Chinese government, and a treatment system has been set up.
Reports of treatment of this condition have appeared in medical
journals, mostly from Asian countries and some in the United
States” (APA, p. 796).
DSM-5 Workgroup:
Reviewed more than 240 articles
Some behavioral similarities were found between SUDs and Internet
Gaming Disorder including: tolerance, withdrawal, repeated
unsuccessful attempts to cut back or quit, and functional impairment
Literature doesn’t use a standard definition
Need epidemiologic studies to determine prevalence, clinical course,
possible genetic influence, and potential biological factors base don
fMRI data

10. DSM-5
“a pattern of excessive and prolonged Internet gaming that
results in a cluster of cognitive and behavioral symptoms,
including progressive loss of control over gaming, tolerance,
and withdrawal symptoms, analogous to the symptoms of
substance use disorders.
Typically play for 8-10 hours per day and at least 30 hours
per week.
Experience agitation and anger if they cannot play
Neglect norlmal work/school/relationship obligations
Separate from gambling disorder involving the Internet

11. DSM-5
Essential Feature: “persistent and recurrent participation in
computer gaming, typically group games, for many hours. . .
Involve competition etween groups of players (often in
different global regions, so that duration of play is
encouraged by the time-zone independence) participating in
complex structured activities that include a significant aspect
of social interactions during play” (APA, p. 797)
Team or social aspects are a key motivation
Criteria is adapted from studies published in China

12. DSM 5 Section III: Internet Gaming
Disorder
Proposed Criteria:
Persistent and recurrent use of Internet to engage in games, often with other players, leading to
clinically significant impairment or distress as indicated by 5 or more of the following
in a 12 month period:
1.Preoccupation with Internet games.
2.Withdrawal symptoms when Internet gaming is taken away.
3.Tolerance: the need to spend increasing amounts of time engaged in internet games.
4.Unsuccessful attempts to control the participation in Internet games.
5.Loss of interests in previous hobbies & entertainment as a result of, and with the exception of,
Internet games.
6.Continued excessive use of Internet games despite knowledge of psychosocial problems.
7.Has deceived family members, therapists, or others regarding the amount of Internet gaming.
8.Use of Internet games to escape or relieve a negative mood.
9.Has jeopardized or lost a significant relationship, job, or educational or career opportunity
because of participation in Internet games.

13. DSM 5 Section III: Internet Gaming
Disorder
Specify Severity:
Mild
Moderate
Severe
Depends on how much the disorder is causing distress or
functional impairment in normal activities the client should
be involved in.
Mild: exhibit fewer symptoms and less disruption
Severe: generally more time spent on the computer and
more severe impact on functioning at work or school and in
disruption in significant relationships

14. Diagnostic Considerations
The criteria in Section III should be used to determine if the
client fits within these diagnostic criteria first.
Since Section III diagnosis cannot be used as a diagnosis,
consider using: Other Specified Obsessive Compulsive
Disorder, Internet Gaming

15. Risk & Prognostic Factors
Environmental:
Computer availability
Internet connection
Speculation that helicopter parenting or very controlled home
environments might generate higher risk situations
Genetic & Physiological:
Adolescent males at higher risk
Asian environmental and/or genetic background is a risk factor
suggested by literature, but clear evidence isn’t available

16. Differential Diagnosis
Internet use that is excessive but doesn’t involve playing
online games is not the same.
Gambling using the Internet is not the same.
Depression
Social Phobia or other Anxiety
Aspergers or Autism Spectrum Disorder

17. Comorbidity
2x more likely to be diagnosed with ADD/ADHD than gamers who
play recreationally (Batthyany, Muller, Benker, & Wolfling, 2009;
Bioulac, Arfi, & Bouvard, 2008; Chan & Rabinowitz, 2006; Gentile et
al., 2011; Han et al., 2009).
Depression (Gentile et al., 2011; Peng & Liu, 2010).
 MMORPG depressive symptoms (sadness, hopelessness, crying spells,
insomnia, concentration problems) are related to habitual computer gaming
at night b/t 10-6 (Lemola et al., 2011)
Anxiety & Social Phobia – longitudinal data suggest pathological
gamers exhibit higher levels of depression, anxiety & social phobia
during follow-up than normal gamers (Gentile et al., 2011), but the
relationship may be reciprocal.

18. Etiology
Neurobiological Aspects:
Cue induced gaming urge activates the same brain regions activated by
gambling in pathological gamblers and substance use in substance
addicts (Han et al., 2011; Ko et al., 2009).
Working memory may be affected similarly as is in substance
dependence (Kim et al., 2012).
Need more studies

19. Etiology
 Personality Aspects:
 Low Emotional Stability (Charlton & Danforth, 2010; Mehroof & Griffiths, 2010;
Nagygyorgy, Mahalik, & Demetrovics, 2012; Peters & Malesky, 2008).
 Low Agreeableness (Charlton & Danforth, 2010; Peters & Malesky, 2008).
 Low Extroversion (Charlton & Danforth, 2010).
 Neuroticism
 Amount of time playing – Decreased quality of interpersonal relationships and increased social
anxiety (Lo, Want, & Fang, 2005).
 Problematic Gaming is negatively correlated with offline social self-efficacy and positively
correlated with online social self-efficacy (Jeong & Kim, 2011, Porter et al., 2010).
 Inadequate self-regulation (Seay & Kraut, 2007)
 Low Self-Esteem ( Ko, Yen, Chen, Chen, & Yen, 2005); Lemmens et al., 2011)
 Low Emotional Intelligence (Herodotou, Kambouri, & Winters, 2011)
 Above Average State Trait Anxiety (Mehroof & Giffiths, 2010)
 Increased Loneliness (Lemmens et al., 2011; Seay & Kraut, 2007)
 Narcissistic Personality (Kim et al., 2008)
 Aggression (Kim et al., 2008; Mehroof & Griffiths, 2010)
 Lower life satisfaction (Ko et al., 2005; Wang, Chen, Lin, & Want, 2008)
 Decreased Psychosocial Well-being compared to other gamers (Lemmens et al., 2011)

20. Etiology
Motivational Aspects:
 Motives play in important role in the development and maintenance of problematic
online gaming (Demetrovics et al., 2011; Kuss & Griffiths, 2012)
 Bartle (1996) 4 motivational types: achievers, explorers, socializes, & killers of
MUD players
 Yee (2006) tested Bartle’s model with MMORPG players. Using EFA, identified 10
motivational components that belong to 3 main factors:
 Achievement: advancement (desire to gain power, progress rapidly & accumulate in-game
symbols of wealth/status), mechanics, and competition;
 Social Factor & Discovery: socializing, relationship, and teamwork;
 Immersion: role-playing, customization, and escapism (use of online environment to avoid
thinking about real-life problems)
 Demetrovics et al. (2011): Motives for Online Gaming Questionnaire (MOGQ): 7
factors
 Social, escapism, coping, fantasy, skill development, recreation, competition

21. Etiology
Motivation (Cont.) Cyber Junkie by Kevin Roberts
 Achievement – increases self-esteem – good at something
 Escape – emotional escape, interpersonal difficulties
 Role Playing: “Their online persona often possesses attributes that they wish they
had in real life” (p. 14). “Driven to become someone else, to exist in a different
time, or to live lives filled with meaning.” Rely on the game for social interaction.
 Control: often products of strict/helicopter parenting - cyber world as a refuge
where they have a sense of power and purpose
 Aggression: Teabagging – kneeling over an opponent’s on-screen character after
you kill them to show dominance & humiliate them – Aggression and anger
management issues precede online gaming – a way to act out aggression – generally
suffer from emotional avoidance
 Discovery: satisfaction comes from finding new twists to a game or uncovering a
glitch that no one has yet discovered. Often genius level IQ and
underachieving/bored in life/school/job – desire to feel fully alive & game is a
substitute

22. Etiology
Structural Characteristics in Online Gaming:
 High degree of realism (realistic sound, graphics, and setting), a rapid absorption rate,
character development, the ability to customize the game, multiplayer features, winning
and losing features, and ability to save the game at regular intervals viewed as essential by
gamers (Weed et al., 2004).
 King et al. (2010) Theoretical Model of 5 Structural Features:
 Social Features: how players communicate, creation of cooperative & competitive
community of players.
 Manipulation & Control Features: how players interact with and control in-game
properties using a physical control scheme
 Narrative & Identity Features: how players take on another identity in the game –
sense of self
 Reward & Punishment Features: how players are reinforced for skillful play (winning)
and punished for loosing – Problem gamers report significantly higher enjoyment of
management of in-game resources, earning points, getting 100% in the game, and
mastering the game – leveling up (earning meta-game rewards) – fast loading times
 Presentation Features: Aesthetics – Realism of sound and look

23. Etiology
Structure Continued:
Instant but Intermittent Reinforcement (people keep responding in
the absence of reinforcement hoping that another reward is just
around the corner).
Magnitude of the Reinforcement (high points score for doing
something in-game – large rewards lead to fast responding and greater
resistance to extinction
Amount of Time
Excessive game play is not a sufficient condition of addiction
More time = higher risk