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CPE3100 ABNORMAL BEHAVIOUR

INTERNET GAMING DISORDER


IN DSM-5

MUHAMMAD HASNAN BIN MOHD SALIM


NURUL ASYIKIN BINTI JAAFAR

DR. MAZNAH BINTI BABA

173656
172343

INTRODUCTION
Video game addiction is a known issue around the world. Incidence and severity grew
in the 2000s, with the advent of broadband technology, games allowing for the creation of
avatars, 'second life' games, and MMORPGs (massive multiplayer online role playing
games). World of Warcraft has the largest MMORPG community on-line and there have been
a number of studies about the addictive qualities of the game. Addicts of the game range from
children to mature adults. A well-known example is Ryan van Cleave, a university professor
whose life declined as he became involved in online gaming. Andrew Doan, MD, PhD, a
physician with a research background in neuroscience, battled his own addictions with video
games, investing over 20,000 hours of playing games over a period of nine years.
Online gaming addiction may be considered in terms of B.F. Skinner's theory of
operant conditioning, which claims that the frequency of a given behaviour is directly linked
to rewarding and punishment of that behavior. If a behaviour is rewarded, it is more likely to
be repeated. If it is punished, it becomes suppressed.
Orzack, a clinical psychologist at McLean Hospital in Massachusetts claims that 40
percent of World of Warcraft (WoW) players are addicted. Orzack says that the best way to
optimize the desired behaviour in the subject is to provide rewards for correct behaviour, and
then adjust the number of times the subject is required to exhibit that behaviour before a
reward is provided. For instance, if a rat must press a bar to receive food, then it will press
faster and more often if it doesn't know how many times it needs to press the bar. An
equivalent in World of Warcraft would be purple (epic) loot drops. Players in World of
Warcraft will often spend weeks hunting for a special item which is based on a chance
system, sometimes with only a 0.01% chance of it being dropped by a slain monster. The
rarity of the item and difficulty of acquiring the item gives the player a status amongst their
peers once they obtain the item.
Online Gamers Anonymous, an American non-profit organization formed in 2002, is a
twelve-step, self-help, support and recovery organization for gamers and their loved ones
who are suffering from the adverse effects of addictive computer gaming. It offers resources
such as discussion forums, online chat meetings, Skype meetings and links to other resources.
Jim Rossignol, a finance journalist who reports on Internet gaming has described how
he overcame his own addiction, and channeled his compulsion into a desirable direction as a
reporter of Internet gaming and gaming culture.

INTERNET GAMING DISORDER IN DSM 5


The American Psychiatric Association decided that enough evidence exists to propose
the potential disorder of video game addiction as a "condition requiring further study" in the
Diagnostic and Statistical Manual of Mental Disorders as Internet Gaming Disorder. Video
game addiction is a broader concept than internet gaming addiction, but most video game
addiction is associated with internet gaming. APA suggests, like Kahn, the effects (or
symptoms) of video game addiction may be similar to those of other proposed psychological
addictions. Video game addiction may be like compulsive gambling, an impulse control
disorder. APA explains why internet gaming disorder has been proposed as a disorder:
This decision was based upon the large number of studies of this condition and the
severity of its consequences. .... Because of the distinguishing features and increased
risks of clinically significant problems associated with gaming in particular, the
Workgroup recommended the inclusion of only internet gaming disorder in Section 3 of
the DSM-5.
Excessive use of video games may have some or all of the symptoms of drug
addiction or other proposed psychological addictions. Some players become more concerned
with their interactions in the game than in their broader lives. Players may play many hours
per day, neglect personal hygiene, gain or lose significant weight due to playing, disrupt sleep
patterns to play resulting in sleep deprivation, play at work, avoid phone calls from friends, or
lie about how much time they spend playing video games. In one extreme instance, it was
reported that a seventeen-year-old boy would play for periods of up to 15 hours, skipping
meals and only stopping when he blacked out.
Proposed Criteria
Persistent and recurrent use of the Internet to engage in games, often with other players,
leading to clinically significant impairment or distress as indicated by five (or more) of the
following in a 12 month period:
1. Preoccupation with Internet games. (The individual thinks about previous gaming
activity or anticipates playing the next game; Internet gaming becomes the dominant
activity in daily life.)
Note: This disorder is distinct from Internet gambling, which is included under gambling
disorder.
2. Withdrawal symptoms when internet gaming is taken away. (These symptoms are
typically described as irritability, anxiety, or sadness, but there are no physical signs of
pharmacological withdrawal.)
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 interest in previous hobbies and 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, therapist, or others regarding the amount of internet
gaming.
8. Use of internet games to escape or relieve a negative mood (e.g., feelings of helplessness,
guilt, anxiety).
9. Has jeopardized or lost a significant relationship, job, or educational or career
opportunity because of participation in internet games.
NOTE: Only non-gambling internet games are included in this disorder. Use of the internet
for required activities in a business or profession is not included; nor is the disorder intended
to include other recreational or social internet use. Similarly, sexual internet sites are
excluded.
Specify current severity
Internet gaming disorder can be mild, moderate, or severe depending on the degree of
disruption of normal activities. Individual with less severe internet gaming disorder may
exhibit fewer symptoms and less disruption of their lives. Those with severe internet gaming
disorder will have more hours spent on the computer and more severe loss of relationships or
career or school opportunities.

DIAGNOSTIC FEATURES
Gambling disorder is currently the only non-substance-related disorder proposed for
inclusion with DSM-5 substance-related and addictive disorders. However, there are aother
behavioural disorders that show some similarities to substance use disorders and gambling
disorder for which the word addiction is commonly used in nonmedical settings, the one
condition with a considerable literature is the compulsive playing of internet games. Internet
gaming has been reportedly defined as an addiction 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.
The DSM-5 work group reviewed more than 240 articles and found some behavioural
similarities of internet gaming to gambling disorder and to substance use disorders. The
literature suffers, however, from lack of standard definition from which to derive prevalence
data. An understanding of natural histories of cases, with or without treatment, is also
missing. The literature does describe many underlying similarities to substance addictions,
including aspects of tolerance , withdrawal, repeated unsuccessful attempts to cut back or
quit, and impairment in normal functioning. Further, the seemingly high prevalence rates,
both in Asian countries and, to a lesse extent, in the West, justified inclusion of this disorder
in Section III of DSM-5.
Internet gaming disorder has significant public health importance, and additional
research may eventually lead to evidence that Internet gaming disorder (also commonly
referred to as Internet use disorder, Internet addiction, or gaming addiction) has merit an
independent disorder. As with gambling disorder, there should be epidemiological studies to
determine prevalence, clinical course, possible genetic influence, and potential biological
factors, based on, for example, brain imaging data.
Internet gaming disorder is a pattern of excessive and prolonged Internet gaming that
results in a cluster of cognitive and behavioural symptoms, including progressive loss of
control over gaming, tolerance, and withdrawal symptoms =, analogous to the symptoms of
substance use disorder. As with substance-related disorder, individuals with Internet gaming
disorder continue to sit at a computer and engage in gaming activities despite neglect of other
activities. They typically devote 8-10 hours or more per day to this activity and at least 30
hours per week. If they are prevented from using a computer and returning to the game, they
become agitated and angry. They often go for long periods without food or sleep. Normal
obligations, such as school or work, or family obligations are neglected. This condition is
separate from gambling disorder involving the Internet because money is not at risk.
The essential feature of internet gaming disorder is persistent and recurrent
participation in computer gaming, typically group games, for many hours. These games
involve competition between 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. Team
aspects appear to be a key motivation. Attempts to direct the individual toward school work
interpersonal activities are neglected. When individual are asked, the major reasons given
using the computer are more likely to be avoiding boredom rather than communicating or
searching for information.

The description of criteria related to this condition is adapted from a study in China. Until the
optimal criteria and threshold for diagnosis are determined empirically, conservative
definitions ought to be used, such that diagnosis are considered for endorsement of five or
more of nine criteria.
Associated Features Supporting Diagnosis
No consistent personality types associated with Internet gaming disorder have been
identified. Some authors describe associated diagnoses, such as depressive disorder,
attention-deficit/ hyperactivity disorder (ADHD), or obsessive-compulsive disorder (OCD).
Individuals with compulsive internet gaming have demonstrated brain activation in specific
regions triggered by exposure to the Internet game but not limited to reward system
structures.

PREVALENCE
The prevalence of Internet gaming disorder is unclear because of the varying
questionnaires, criteria and thresholds employed, but it seems to be highest in Asian countries
and in male adolescents 12-20 years of age. There is an abundance reports from Asian
countries, especially China and South Korea, but fewer from Europe and North America,
from which prevalence estimates are highly variable. The point prevalence in adolescents
(age 15-19 years) in one Asian study using a threshold of five criteria was 8.4% for males and
4.5% for females.
Risk and Prognostic Factors
a) ENVIRONMENTAL. Computer availability with Internet connection allow access to the
types of games with which Internet gaming disorder is most often associated.
b) GENETIC AND PHYSIOLOGICAL. Adolescent males seem to be at greatest risk of
developing Internet gaming disorder, and it has been speculated that Asian environmental
and/ or genetic background is another risk factor, but this remains unclear.
Functional Consequences of Internet Gaming Disorder
Internet gaming disorder may lead to school failure, job loss, or marriage failure. The
compulsive gaming behaviour tends to crowd out normal social, scholastic, and family
activities. Students may show declining grades and eventually failure in school. Family
responsibilities maybe neglected.
Differential Diagnosis
Excessive use of the Internet not involving playing of online games (e.g., excessive
use of social media, such as Facebook, viewing pornography online) is not considered
analogous to internet gaming disorder, and future research on other excessive uses of the
internet would need to follow similar guidelines as suggested herein. Excessive gambling
online may qualify for a separate diagnosis of gambling disorder.
Comorbidity
Health maybe neglected due to compulsive gaming. Other diagnoses that may be
associated with Internet gaming disorder include major depressive disorder, ADHD, and
OCD.

PREVENTION
Some countries, such as South Korea, China, the Netherlands, Canada, and the United
States, have responded to the perceived threat of video game addiction by opening treatment
centers. Because few clinical trials and no meta-analyses have been completed, research is
still in the preliminary stages for excessive gaming treatment. The most effective treatments
seem to be, as with other addictions and dependencies, a combination of
psychopharmacology, psychotherapy and twelve-step programs.
China
The Chinese government operates several clinics to treat those suffering from overuse
of online games, chatting and web surfing. Treatment for the patients, most of whom have
been forced to attend by parents or government officials, include various forms of pain or
uneasiness. In August 2009, Deng Sanshan was reportedly beaten to death in a correctional
facility for video game and Web addiction.
Netherlands
In June 2006, the Smith and Jones clinic in Amsterdam which has now gone
bankrupt became the first treatment facility in Europe to offer a residential treatment
program for compulsive gamers. Keith Bakker, founder and former head of the clinic, has
stated that 90% of the young people who seek treatment for compulsive computer gaming are
not addicted.
United States
Computer gaming addicts anonymous cgaa.info, formed in 2014, is a recovery
fellowship offering twelve-step support and fully following the Twelve Traditions. They have
daily chat meetings at stepchat.com for support and recovery from computer gaming
addiction of all kinds: video, console, PC, online, tablet, phone, arcade, etc.
McLean Hospital in Belmont, Massachusetts has set up Computer Addiction Services.
Elsewhere, gamers may seek services at generalized addiction support centres. Online
Gamers Anonymous, an American non-profit organization formed in 2002, is a twelve-step,
self-help, support and recovery organization for gamers and their loved ones who are
suffering from the adverse effects of excessive computer gaming. The organization provides a
variety of message boards, daily on-line chat meetings, a Saturday and Wednesday Skype
meeting, and other tools for healing and support. In July 2009, ReSTART, a residential
treatment centre for "pathological computer use", opened in Fall City, near Seattle,
Washington.Gaming Addiction 2012 promotes responsible gaming including internet games,
online gambling, and fantasy sports. They offer surveys for gamers and people that care about
gamers. They advocate a simple three pronged approach to responsible gaming: Understand
what gaming is; Solve problems that are created by excessive gaming; act out the solution
and live a healthier life free of gaming addiction.
Canada
At a Computer Addiction Services center in Richmond, British Columbia, excessive
gaming accounts for 80% of one youth counselor's caseload.

Australia
In 2012, Emil Hodzic formally launched the Video Game Addiction Treatment Clinic
(www.videogameaddictiontreatment.com.au) in response to the growing need for individual
and family based assistance. He is the first Psychologist in Australia to provide specialist
psychological support, consultation and talks on this issue.

CASES OF INTERNET GAMING DISORDER


Globally, there have been deaths caused directly by exhaustion from playing games
for excessive periods of time. There have also been deaths of gamers and/or others related to
playing of video games.
China
In 2007, it was reported that a Mr Zhang died in Jinzhou after playing online games
persistently during the week-long Lunar New Year holiday as a result of a heart attack,
brought on by a lack of physical activity. During the same year, reports indicated that a 30year-old man died in Guangzhou after playing video games continuously for three day.
In 2012, two men in Taiwan died while playing computer games. The police
"speculated that long hours in a sedentary position created cardiovascular problems" for the
second, an 18 year old.
The suicide of a young Chinese boy in the Tianjin municipality has highlighted once
more the growing dangers of game addiction, when those responsible do not understand or
notice the risks of unhealthy play. Xiao Yi was thirteen when he threw himself from the top
of a twenty-four story tower block in his home town, leaving notes that spoke of his addiction
and his hope of being reunited with fellow cyber-players in heaven. The suicide notes were
written through the eyes of a gaming character, so reports the China Daily, and stated that he
hoped to meet three gaming friends in the after life. His parents, who had noticed with
growing concern his affliction, weren't mentioned in the letters.
In March 2005, the BBC reported a murder in Shanghai, when Qiu Chengwei fatally
stabbed fellow player Zhu Caoyuan, who had sold on eBay a dragon saber sword he had been
lent in a Legend of Mir 3 game, and was given a suspended death sentence.
South Korea
In 2005, Seungseob Lee, visited an Internet cafe in the city of Taegu and played
StarCraft almost continuously for fifty hours. He went into cardiac arrest and died at a local
hospital. A friend reported: "...he was a game addict. We all knew about it. He couldn't stop
himself." About six weeks before his death, his girlfriend, also an avid gamer, broke up with
him, in addition to his being fired from his job.
In 2009, Kim Sa-rang, a 3-month-old Korean child, died from malnutrition after both her
parents spent hours each day in an internet cafe, rearing a virtual child in an online game,
Prius Online.
Vietnam
An Earthtimes.org article reported in 2007 that police arrested a 13-year-old boy
accused of murdering and robbing an 81-year-old woman. A local policeman was quoted as
saying that the boy "...confessed that he needed money to play online games and decided to
kill and rob..." the victim. The article further related a police report that the murder by
strangling netted the thief 100,000 Vietnamese dong (US$6.20).

United States
In November 2001 Shawn Woolley committed suicide, it has been inferred that his
death was related to the popular computer game Everquest. Shawns mother said the suicide
was due to a rejection or betrayal in the game from a character Shawn called "iluvyou".
In February 2002, a Louisiana woman sued Nintendo because her son died after
suffering seizures caused by playing Nintendo 64 for eight hours a day, six days a week.
Nintendo denied any responsibility.
18-year-old Devin Moore was addicted and obsessed with Grand Theft Auto: Vice
City. He suddenly snapped and went on a crime spree on June the 7th, 2003. He was caught
trying to steal a car and was brought in to the police station where he then managed to steal
one officer's gun, and shot him and two other officers dead before stealing a police car and
escaping. He was eventually caught and sentenced to death by lethal injection. After he was
recaptured he said, "Life is a video game. Everybody's got to die sometime."
Press reports in November 2005 state that Gregg J. Kleinmark, 24, pleaded "guilty to
two counts of involuntary manslaughter". He "left fraternal twins Drew and Bryn Kleinmark
unattended in a bathtub for 30 minutes, in order to go three rooms away and play on his
Game Boy Advance" while "in the mean time, the two ten-months old kids drowned".
Ohio teen Daniel Petric shot his parents, killing his mother, after they took away his
copy of Halo 3 in October 2007. In a sentencing hearing after the teen was found guilty of
aggravated murder, the judge said, "I firmly believe that Daniel Petric had no idea at the time
he hatched this plot that if he killed his parents they would be dead forever." On 16 June
2009, Petric was sentenced to 23 years to life in prison.
In Jacksonville, Florida, Alexandra Tobias pleaded guilty to second-degree murder for
shaking her baby to death. She told investigators that the baby boy's crying had interrupted
her while she was playing a Facebook game called FarmVille. She was sentenced to 50 years
in December 2010.
A New Mexico woman named Rebecca Colleen Christie was convicted of second
degree murder and child abandonment, and sentenced to 25 years in prison, for allowing her
3 and a half-year-old daughter to die of malnutrition and dehydration while occupied with
chatting and playing World of Warcraft online.
Brazil
In 2014, in Rio de Janeiro, 16-year-old Gabriel Cavalcante Carneiro Leao was hit by a
bus distracted while playing the Google Alternate reality game Ingress which is played on
cellphone and requires visiting real world locations. After four days in a coma, he died.

CONCLUSION
The present review of current perspectives on Internet gaming addiction has shown
that research has progressed significantly over the last decade, leading to a larger evidence
base which includes important findings from neuroimaging research. Further, it indicates that
contextual factors play an important part in our understanding of Internet gaming addiction as
a holistic phenomenon. It is suggested that an official diagnosis of Internet gaming addiction
must regard embedding of the problematic behavior within the context of the individual, the
game, and gaming practices, as well as the broader sociocultural environment as the meaning
of the gaming behavior derives from its context. The holistic approach adopted here not only
highlights empirical research that confirms neurobiological correlates of Internet gaming
addiction and establishment of a preliminary diagnosis, but also emphasizes the need for an
indepth understanding of meaning, context, and practices associated with gaming. Ultimately,
a holistic understanding will benefit individuals who seek professional help for problematic
online gaming as treatment approaches become more targeted and consequently more
efficacious.

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