Proposed DSM Criteria

Repetitive use of Internet-based games, often with other players, that leads to significant issues
with functioning. Five of the following criteria must be met within one year:
1. Preoccupation or obsession with Internet games.
2. Withdrawal symptoms when not playing Internet games
3. A build-up of tolerancemore time needs to be spent
playing the games.
4. The person has tried to stop or curb playing Internet
games, but has failed to do so.
5. The person has had a loss of interest in other life activities,
such as hobbies.
6. A person has had continued overuse of Internet games
even with the knowledge of how much they impact a
persons life.
7. The person lied to others about his or her Internet game usage.
8. The person uses Internet games to relieveanxietyor guiltits a way to escape.
9. The person has lost or put at risk and opportunity or relationship because of Internet games.
severity modifiers : mild, moderate, or severe. based on how much time is spent playing the
games, and how much they impact a persons overall functioning.
Ko CH, Yen JY, Yen CF, Chen CS, Chen CC: The association between Internet addiction
and psychiatric disorder: a review of the literature. Eur Psychiatry 2012, 27(1):18.

Proposed Criteria continued

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.
sexual Internet sites are excluded.
Ko CH, Yen JY, Yen CF, Chen CS, Chen CC: The association between Internet addiction and
psychiatric disorder: a review of the literature. Eur Psychiatry 2012, 27(1):18.

Diagnostic Features
Internet gaming disorder is 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
withdrawal symptoms

engage in gaming activities despite neglect of other activities.

school or work, or family obligations are neglected.

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
separate from gambling disorder involving the Internet because
money is not at risk.
Ko CH, Yen JY, Yen CF, Chen CS, Chen CC: The association between Internet addiction and
psychiatric disorder: a review of the literature. Eur Psychiatry 2012, 27(1):18.

biopsychosocial processes
1. behavior is salient (the individual is preoccupied with gaming).
2. the individual uses the behavior in order to modify their mood (ie,
gaming is used to escape reality or create the feeling of euphoria).
3. tolerance develops (the individual needs increasingly more time to
feel the same effect).
4. withdrawal symptoms occur upon
discontinuation of the behavior (the
individual feels anxious, depressed, and
irritable if they are prevented
from playing).
5. interpersonal and intrapersonal conflict develops as a consequence
of the behavior (the individual has problems with their relationship,
job, and hobbies, and lack of success in abstinence).
6. Upon discontinuation of the behavior, the individual experiences
relapse (they reinitiate gaming).
Kuss, D. J. (2013). Internet gaming addiction: Current
perspectives.Psychology Research And Behavior Management,6

negative consequences
Sacrificing:
real-life relationships
other pastime activities
sleep
work
education

lack of attention
aggression and hostility
stress
dysfunctional coping
poor academic achievement
problems with verbal memory
low well-being and high loneliness
problems with:
sleeping
Seizures
psychosomatic challenges

Kim EJ, Namkoong K, Ku T, Kim SJ. The relationship between online game addiction and aggression, self-control
and narcissistic
personality

Prevalence Rate and Risk Factors for

Internet Addiction
male adolescents 12 to 20 years of age.
more prevalent in Asian countries
than in North America and Europe
prevalence estimates which vary
significantly and range from
0.2% in Germany to 50% of
Korean teenagers
In South Korea, Internet gaming addiction is viewed as a
significant concern for public health, and up to 24% of
children who have been diagnosed with Internet addiction
are hospitalized.
Internet cessation camps
Kuss, D. J. (2013). Internet gaming addiction: Current perspectives.Psychology Research And Behavior
Management,6

Etiology - Environmental
It has been stated that the higher
the Internet penetration and social
acceptance of gaming, the higher the
prevalence of gaming problems,
partially explaining the higher
prevalence rates
reported in
South-East Asian countries.

Kuss DJ, van Rooij A, Shorter GW, Griffiths MD, van de Mheen D.; Internet addiction in
adolescents: prevalence and risk factors. Computer Human Behav. 2013;29:19871996.

Etiology - Genetic
component
The intricacies of the genetic transmission of IA remains
exploratory.
CC genotype of the rs1044396 polymorphism on gene coding
for the nicotinic acetylcholine receptor subunit alpha 4
(CHRNA4) occurred significantly more frequently in patients
suffering from IA.
homozygous short alleles (SS) of the serotonin transporter
gene promoter region (5HTTLPR) are more prevalent among
excessive internet users, and the genotype was found to be
associated with depressive disorder.
The involvement of the serotonin genotype in IA and
depression suggests that these two conditions may share
similar neurochemical changes thereby warranting further
investigation.
Kim EJ, Namkoong K, Ku T, Kim SJ. The relationship between online game addiction and aggression,
self-control and narcissistic personality.

Personality Traits
traits most commonly associated
with Internet addiction:
neuroticism, aggression and hostility,
and sensation seeking.

Protective factors
Conscientiousness
and extraversion
Kuss DJ, van Rooij A, Shorter GW, Griffiths MD, van de Mheen D. Internet addiction in adolescents: prevalence
and risk factors. Comput Human Behav. 2013;29:19871996.

Internet Addiction Among Elementary

and Middle School Students in China
Internet addiction can cause children and adolescent
physical and psychological health problems, such as:
depression
suicidal ideation,
loneliness
interpersonal problems
time management problems
sleeplessness
destructive lifestyles
poor dietary behaviors

There is a greater likelihood that the adolescent will behave

aggressively and even commit a crime if he or she is addicted
to the Internet.
Kim EJ, Namkoong K, Ku T, Kim SJ. The relationship between online game addiction and aggression, self-control
and narcissistic personality.

Comorbidity Meta analysis

The prevalence of ADHD among IA patients
was 21.7 %
The prevalence of depression
among IA patients
was 26.3 %
The prevalence of anxiety
among IA patients was
23.3 %
The prevalence of alcohol abuse among IA
patients was 13.3 %
Ho, R. C., Zhang, M. W., Tsang, T. Y., Toh, A. H., Pan, F., Lu, Y., & ... Mak, K. (2014). The association between Internet
addiction and psychiatric co-morbidity: A meta-analysis. BMC Psychiatry, 14

Assessment
Proper diagnosis is difficult as no accepted
set of criteria for Internet addiction listed
in the DSM
Using Pathological Gambling
as a model,
Internet addiction can be defined as an
impulse-control
disorder which does not
involve an
intoxicant.
Kim EJ, Namkoong K, Ku T, Kim SJ. The relationship between online game addiction and aggression, selfcontrol and narcissistic personality.

Assessment - questionnaire
1. Do you feel preoccupied with the Internet (think about previous on-line
activity or anticipate next on-line session)?
2. Do you feel the need to use the Internet with increasing amounts of
time in order to achieve satisfaction?
3. Have you repeatedly made unsuccessful efforts to control, cut back, or
stop Internet use?
4. Do you feel restless, moody, depressed, or irritable when attempting to
cut down or stop Internet use?
5. Do you stay on-line longer than originally intended?
6. Have you jeopardized or risked the loss of significant relationship, job,
educational or career opportunity because of the Internet?
7. Have you lied to family members, therapist, or others to conceal the
extent of involvement with the Internet?
8. Do you uses the Internet as a way of escaping from problems or of
relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety,
depression)?
Kuss, D. J. (2013). Internet gaming addiction: Current perspectives.Psychology Research
And Behavior Management,6

Treatment
abstinence of internet usage, activity scheduling to supplant
online activity with face-to-face interpersonal activity, and
motivational interviewing.
The reduction of internet usage
may lead to a corresponding
reduction of the severity of
comorbid psychiatric symptoms.
Pharmacotherapy involving the
opioid receptor antagonist,
naltrexone may diminish the rewarding
experience associated with IA
SSRIs may attenuate the impulsivity that is associated with
internet use, depression and anxiety.
Ho, R. C., Zhang, M. W., Tsang, T. Y., Toh, A. H., Pan, F., Lu, Y., & ... Mak, K. (2014). The association
between Internet addiction and psychiatric co-morbidity: A meta-analysis. BMC Psychiatry, 14

Treatment implications
patients who present with IA should be
screened for alcohol abuse, ADHD,
depression and anxiety.
IA may not present as a singular diagnostic
entity, but co-occur with alcohol abuse,
ADHD, depression and anxiety
it is recommended that patients who
present with the above-mentioned
psychiatric condition be interviewed about
their internet usage
Ho, R. C., Zhang, M. W., Tsang, T. Y., Toh, A. H., Pan, F., Lu, Y., & ... Mak, K. (2014). The association
between Internet addiction and psychiatric co-morbidity: A meta-analysis. BMC Psychiatry, 14

Treatment complications
Patients suffering from IA are more likely to be
non-compliant with psychotropic medication
and psychotherapy because they are
preoccupied with internet usage.
Depression and anxiety often occur as part of
the internet withdrawal syndrome
Excessive internet usage may serve as a
maintaining factor for anxiety by reinforcing
the avoidance of anticipatory anxiety stemming
from stressful situations and life events.
Kim EJ, Namkoong K, Ku T, Kim SJ. The relationship between online game addiction and
aggression, self-control and narcissistic personality.

Case Study
case study evidence of two young
men who spent an average of 14
hours a day playing MMORPGs
Dave & Jeremy
context of the individuals life is an
important factor demarcating gaming
excess from gaming addiction.

Griffiths MD. The role of context in online gaming excess and

addiction: some case study evidence. Int J Ment Health Addict. 2010;8:
119125.

Should Internet addiction be

included in the DSM V?
encourage individuals who suffer from associated
symptoms to ask for professional help,
decreasing morbidity rates, hospitalizations, and
potential legal and medical problems.
decrease barriers to care and stigmata with
regards to public perception of problematic
Internet and gaming use
support research efforts
provide the necessary incentive for health care
and insurance providers to develop, test, and
finance adequate treatment
Kim EJ, Namkoong K, Ku T, Kim SJ.
The relationship between online
game addiction and aggression,
self-control and narcissistic

12 Steps to Quit WoW

1. We admitted we were powerless over video game addiction -that our lives had
become unmanageable.
2. Came to believe that these 12 Steps, as a means to improving ourselves, could help
us toward normal living.
3. Made a decision to turn our will and our lives over to the care these 12 steps and to
the loving care of this group.
4. Made a searching and fearless inventory of our character for ourselves.
5. Admitted to our group, to ourselves and to another human being the exact nature of
our faults and misdeeds.
6. Were entirely ready to practice the program in order to remove our defects of
character.
7. Humbly asked the help of others in the removal of our short comings and resolved
to work to remove these faults ourselves.
8. Made a list of all persons we harmed, and became willing to make amends to them
all.

 In a sample of 696 MMORPG players,

achievement, socializing, and escapism
motivations were found to be predictive
of addictive play.
Similarly, in a sample of 175 primarily
Dutch MMORPG players escapism and
game mechanics predicted excessive
gaming over and above the contribution
of the time spent gaming with others
Kuss DJ, van Rooij A, Shorter GW,
Griffiths MD, van de Mheen D.;
Internet addiction in adolescents:
prevalence and risk factors.

References
Griffiths MD. The role of context in online gaming excess and addiction: some case study
evidence. Int J Ment Health Addict. 2010;8: 119125.
Ho, R. C., Zhang, M. W., Tsang, T. Y., Toh, A. H., Pan, F., Lu, Y., & Mak, K. (2014). The
association between Internet addiction and psychiatric co-morbidity: A meta-analysis.BMC
Psychiatry,14
Kim EJ, Namkoong K, Ku T, Kim SJ. The relationship between online game addiction and
aggression, self-control and narcissistic personality.
Ko CH, Yen JY, Yen CF, Chen CS, Chen CC: The association between Internet addiction
and psychiatric disorder: a review of the literature. Eur Psychiatry 2012, 27(1):18.
Kuss, D. J. (2013). Internet gaming addiction: Current perspectives.Psychology Research
And Behavior Management,6
Kuss DJ, van Rooij A, Shorter GW, Griffiths MD, van de Mheen D.; Internet addiction in
adolescents: prevalence and risk factors. Computer Human Behav. 2013;29:19871996.
Li, Y., Zhang, X., Lu, F., Zhang, Q., & Wang, Y. (2014). Internet addiction among elementary
and middle school students in China: A nationally representative sample
study.Cyberpsychology, Behavior, And Social Networking,17(2), 111-116.
Wang, E. S., & Wang, M. C. (2013). Social support and social interaction ties on internet
addiction: Integrating online and offline contexts.Cyberpsychology, Behavior, And Social
Networking,16(11), 843-849. doi:10.1089/cyber.2012.0557