CASE STUDIES OF INTERNET-GAMING DISORDER

Internet gaming disorder (IGD) has been recognized as a temporary disorder by the
American Psychiatric Association (APA) in the latest fifth revision of the
Diagnostic and Statistical Manual of Mental Disorders (APA) DSM5.

CASE -1

A 22yearold first generation South Korean male with past psychiatric history of
major depression with anxious features presented to the mental health clinic at
restart because his compulsive video game use had progressively interfered with
his interpersonal relationships and motivation to work. He began playing video
games at age 6 in the context of physically and verbally abusive parenting. Initially
he played an hour on weekdays and up to 5 hours on the weekends, with strict time
limitations set by his parents. He was the only son in the household, and he was
expected to earn placement at a prestigious university by achieving high academic
marks throughout grade school. As a result of these circumstances, his social
interactions with peers were exceptionally limited, and time spent outside of the
home was strongly discouraged. Except for secretly dating a woman for a short
time and running in a cross-country team, he spent most of his time indoors,
increasingly turning to video games, pornography and anime for entertainment and
sexual reimbursement. Within a week of graduating from college, he was
immersed in internet gaming culture and played online video games 10 hours a
day, maintaining the lowest grades to pass a class. He spent the next two and a half
years retiring from lessons that he couldn't complete due to gambling habits.
During his sophomore year, he moved to an apartment with other game buddies
and played online video games such as first-person shooters and role-playing
games 14 hours a day. The patient said: "Even when his hands hurt and he didn't
want to play for fun anymore, he started practicing his gaming skills at Counter
Strike. This is when I first began failing classes and started withdrawing from
school midway through the quarter to avoid being dropped from enrollment.” He
created false transcripts in order to receive financial support from his parents, but
after 3 years he was expelled from the university. His family became aware of his
actions and stopped assisting him, so he moved into a small room in a low-income
apartment complex where he depleted his savings playing video games, paying
rent, and subsisting on Chinese food and pizza takeout. During this time, the
patient was playing primarily the online roleplaying game The World of Warcraft
16 to 17 hours daily. The patient shared with us: “This was undoubtedly the worst
my gaming addiction has ever been and was also the darkest time in my entire life.
I recall an ever-present fear and oppressive weight on me during those days, that if
I peeled back from the haze of those 16 to 17 hours of gaming, my thoughts would
immediately turn toward the ruined life I had made for myself, the contempt of my
peers, my dwindling finances, and the rats. The fragile old house was poorly
maintained and was heavily infested with mice. I remember they climbing the
monitor cord from time to time while I was playing, and I got used to muting the
squeaks and barks of my trash can as I was drifting to sleep at night. However, this
lifestyle was not economically feasible, at which point he was admitted to a mental
hospital, suicidal ideation, and expressed his desire to use video games. He was
able to get a job. During his session, he suddenly refused to stop using video games
altogether, and the concept of doing so caused immense anxiety and frustration.
Instead, he chose to phase out his involvement in video games by reducing the
number of hours of games he plays each day. His therapeutic goal was to reduce
the use of video games to find a job, but his social anxiety was worse than before
due to years of social isolation during play. Using the criteria proposed by the
Gentiles, he met the IGD criteria by answering "yes" to all 11 questions. After two
years of cognitive-behavioral therapy (CBT) and psychotherapy, he was finally
able to admit video game addiction, quit the game, and manage depression without
medication. He was able to establish a more regular diet and sleep schedule. He
returned to college, where his social life and academic performance satisfied him.
After several experiences of playing video games and seeing how they interfered
with his ability to perform academically, he resisted his gaming urges by keeping
his computer at his parents` home. Despite developing new friendships, he never
dated again. Pornography had become his primary source of psychosexual
stimulation. Though his use of pornography never interfered with his occupation or
other activities of daily living, his lack of engaging in a romantic relationship with
another person was a mild to moderately distressing matter to him. Due to the
personal nature of the issue, he was less willing to discuss it in therapy, which
became an unexpected obstacle in his case management over time.

DISSCUSSION

The American Psychiatric Association’s nine proposed criteria for IGD were based
on preliminary research, which compared video game use to gambling addiction.
These criteria include the following:

 pre-occupation with video games;

 tolerance manifested by increasing amounts of time invested in video game
use;
 escape of adverse moods through video game use;
 loss of relationships/opportunities as a result of video game use;
 reduced participation in other activities as a result of video game use;
 deceit in order to continue video game use;
 continued video game use despite adverse consequences;
  difficulty reducing video game use;
 withdrawal (manifested as restlessness and irritability) upon discontinuation
of video game use.
Clinically significant impairment is determined by the manifestation of daily living
dysfunction resulting in severe social, emotional, or work-related problems. His
use of video games began as an escape from the pressure of family expectations
and increased over time (from 1 to 2 hours of daily play before college and
increasing to 16 to 17 hours of daily play before seeking treatment). However, it is
important to note that patients have a history of anxiety and it is difficult to
determine the level of anxiety associated with IGD. This limitation in time may
prevent individuals from escalating video game use in the same way patients might
gamble larger amounts of money or take larger doses of a substance.

The patient in this case report began playing video games at a young age, which is
a vulnerable time for both social development and addiction. Furthermore, given
the immersive nature of modern gaming, the patient was likely reinforced by the
escape video games provided from his rigid parenting structure, in addition to the
satisfaction players feel when they advance levels or complete tasks. Pleasure and
excitement associated with video games involve physiological arousal and
stimulation of the HPA axis, resulting in increased heart rate, blood pressure, and
sympathetic tone. In addition, video games built on the principles of social
interactivity, increased immersiveness, and seemingly endless outcomes are
hypothesized to be neurologically and physiologically stimulating.

Competitive play of the game Tetris® with other human players results in higher
testosterone levels when males have lower cortisol levels. In our patients, he was
fascinated by internet games and the culture of playing with others, and perhaps
the excitement associated with playing with others contributed to his dependence
on internet video games. In addition, it is important to note that the patient`s social
anxiety and dysfunction may have contributed to the patient`s excessive use of
video gaming and development of IGD. When a young child spends too much
time in Internet gaming or pornography, there can be significant problems
associated with excessive use. Additional research exploring the co-occurrence of
IGD and problematic use of pornography would be interesting. Either way, from a
management perspective, it is important to identify the potential comorbidities of
IGD, including social anxiety, depression, and pornography use. Patients are less
likely to be forthcoming about pornography use due to the sensitive and personal
nature of the subject, and if not addressed with potentially co-occurring social
anxiety, this issue may become insidious and difficult to treat.

CASE - 2

A 20year old university student was referred by his family physician for
psychiatric evaluation. he has no past or family history of psychiatric illness. His
mother said that he is very bright and good student of computer programming. His
parent had high expectation from him regarding his academic performance and
they have always praised and encouraged him, as he is a computer perfectionist.
His mother also complaining about his behavior like: decreasing in academic
performance, decreasing the time which is given him for studying and doing home
works, spending more time playing video games, decreasing in work performance,
inability to quit playing, staying up too late night in order to play, neglecting the
important responsibilities while playing, aggression toward family member and
changes in sleeping patterns, decreasing in personal hygiene, irregular or poor
eating habits, headaches, red or dryness in eyes, and weight gain. When they
confuse the game, they lie and blame others. During the psychological evaluation,
he was informed that he started spending hours on a computer and started playing
video games at the age of seven. At first, I played for 1 hour every day, then slowly
3-4 hours a day and 5-6 hours or more on weekends. It increases even more during
his college vacation because he was at home alone while his parents were working.
He claims that the internet is the most important thing in his life. He said the
internet could change his mood, he enjoyed being on a computer before, and felt
the urge to play video games to relieve the stress of academic research. Whenever
he doesn't have the opportunity to sit in front of a computer, he begins to get very
frustrated and shivering. But he also said he didn't consider himself an "addict", he
couldn't work or live without them, and my social and intellectual life was directly
related to it. He has no friends outside, but he has made many internet friends
through online chat. He also feels that the internet has improved his level of
knowledge. As a result of this situation, he began to suffer from self-confidence,
which made him very sad when his peers, school teachers and social interactions
with his family were restricted. This condition worsened day by day, and his
academic performance deteriorated. Whenever his parents didn't let him sit in front
of the computer, he was frustrated, yelling at them, insisting, not listening, and
angry. He spent most of his time playing video games indoors, slowly increasing
his play.

DISSCUSION

This case report showed behavioral patterns that were very similar to those of
substance and play.Tolerance is a process in which the amount of a particular
activity needs to be increased in order to produce an initial effect. Here, the patient
was playing a video game for joy and euphoric effects to relieve stress. Withdrawal
symptoms are unpleasant emotional or physical effects that occur when activity
ceases or suddenly diminishes. At this point, the patient begins to get frustrated and
trembles if he is not given the opportunity to sit in front of the computer. Social
and occupational disabilities, where the patient distances away from his family and
friends, his academic performance deteriorates, he leaves college members and has
high expectations for his academic excellence. I was there. He seems to be using
this machine as an "electronic friend". This is the behavior reported in other
technical products such as video games. His preoccupation with video games
resulted in his poor academic performance and his attempt to conceal his gaming
use and its consequences ultimately resulted in loss of family ties, but he still
continues gaming. At last, he gave up study. Finally, he sought help because he
could not reduce gaming use on his own, due to this he struggled with anxiety,
irritability, and mild depressed features. After which we referred him to our
clinical psychologist for cognitive behavioral therapy, RT and family therapy, and
psychoeducation. During session he opted to gradually discontinue his
involvement with video games. There are several case reports of serotonin
treatment. The data supporting drug use is very limited.

CONCLUSION

Mental health pr at college and universities should be aware of the sign and
symptoms of IGD in order to identify students suffering from the problematic use
of video games. The supporting data for use of drugs is very limited.