Background: There is a growing interest in understanding the impact of video games in the clinical field, given that their excessive use could be associated with health issues. Particularly, gaming disorder (GD) is considered as an addictive behavioral disorder. Clinicians widely recognize the comorbidity of gaming and psychotic disorders (PDs). Furthermore, association between addictive (i.e., substance use disorders) and PDs are well recognized by clinicians. It seems of high interest to explore GD among people with PDs. To this day, little is known about the consequences of GD in vulnerable populations. Objectives: The aim of this scoping review was to summarize the available research on the comorbidity between GD and PD and to identify the knowledge gaps in this field. Methods: We used Levac’s six-stage methodology for scoping review. Two-hundred and forty-two articles from seven databases were identified. Eight articles respected our inclusion and exclusion criteria. Results: No available study has assessed the prevalence or incidence of GD among patients with PDs. The cases reported highlight the possibility that excessive video gameplay or abrupt gaming disruption could trigger psychosis in some patients. Conclusion: The results highlight a significant lack of knowledge concerning PDs associated with GD as only a few reported cases and one empirical study exposed the potential association between those conditions.

© 2022 S. Karger AG, Basel

Introduction

There is a growing interest in understanding the impact of video games on mental health as their excessive use is associated with health problems and severe addiction [1, 2]. The estimated global prevalence of gaming addiction has been reported to be 3.05% [3]. However, a recent literature review presented substantial variability ranging from 0.21% to 57.5% in the general population and from 3.2% to 91% in various clinical populations [4]. This significant variability results from differences regarding the demographic characteristics of the studied populations as it is well known that the prevalence of gaming-related problems is higher in the young male population [3-5] and from broad differences concerning the definition of gaming addiction in the scientific community.

For many years, Internet addiction and gaming addiction were considered as undifferentiated conditions. Since then, many authors supported the idea that patients with so-called Internet addiction used the Internet as a vehicle for more specific addictions rather than being addicted to the Internet itself [6-8]. In a study published before the recognition of gaming disorder (GD) in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as “Conditions for Further Study,” Kim and Kim [9] claimed that “Internet users are no more addicted to the Internet than alcoholics are addicted to bottles.” This view was also supported by EEG studies, suggesting that gaming addiction results from distinct neurophysiological consequences than other possible Internet addictions (e.g., online gambling and pornography) [6, 10]. Also, poor impulse control and high anxiety both seem to specifically predispose specifically to excessive gaming habits [11-13].

As a first step to differentiate gaming addiction from other forms of excessive Internet use, Internet GD (IGD) was introduced in 2013 in the DSM-5 as a condition requiring further studies. The term IGD unfortunately failed to fully clarify the ambiguities as this term would suggest that only Internet gaming should be taken into account, whereas excessive gaming may include offline gaming as well. Gaming addiction was finally recognized as an official diagnosis during the World Health Assembly in May 2019 and is now part of the 11th edition of the Classification of Diseases (ICD-11) under the term gaming disorder. This condition is defined as a pattern of gaming behavior (“digital gaming” or “video gaming”) characterized by impaired control over gaming, increased priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences [14]. Despite this refinement of GD definition over the years, consensus is still lacking in the literature, and terms like IGD, Internet addiction disorder, problematic Internet use, Internet use disorder, and cyberdependance are misused to describe GD. We consider all those terms in our search strategy to be as exhaustive as possible. However, as this scoping review is centered on GD, we will refer to this term to ensure uniformity; however, some studies cited here did not make the difference between those concepts.

Even if the recognition of this diagnosis is fairly recent, GD was found to be related to multiple conditions like attention-deficit/hyperactivity disorder, depression, anxiety, social phobia, impaired interpersonal relationships, academic difficulties, and suicidal ideation, although the direction of the causality is uncertain in some instances [15-25]. Since research on GD has mainly focused on children and adolescents thus far, it is difficult to extrapolate these results to the adult population. Furthermore, little is known about the prevalence of GD and its consequences in vulnerable groups, such as patients suffering from a psychotic disorder (PD).

PDs are characterized by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking, abnormal motor behavior, and negative symptoms. These conditions include several subtypes that share similar psychopathologies and are considered here as one entity [26]. Some characteristics of patients with PDs, particularly those with a first-episode psychosis (FEP), may suggest that these individuals would be particularly liable to develop a GD. Indeed, both conditions mainly present themselves in adolescence and young adulthood and are more frequent in the male population. Furthermore, both PD and GD have been associated with substance use, social isolation, social anxiety disorders [27, 28]. Also, we can speculate that the FEP population is at greater risk for GD due to pharmacological treatment. Indeed, recent results have suggested that partial dopamine agonist antipsychotics may increase the risk of developing a gambling addiction [29, 30], a condition possibly sharing pathophysiological pathways with GD [31]. On the other hand, it is known that excessive gaming may lead to neurobiological alterations typically observed in other addictions (e.g., activation of brain region associated with rewards, reduced activation in areas involved in impulse control, cognitive control, executive function, motivation) [32, 33] and an increase in dopamine release similar in magnitude than that induced by psychostimulants [34, 35]. Those modifications in brain functions in addition to behavioral disturbances associated with GD like sleep deprivation [36], comorbid substance use [37], and other factors increasing liability to psychosis in given individuals (e.g., genetic vulnerability) [38-40] could possibly contribute to the onset of psychotic episodes in vulnerable individuals. The identification of GD comorbid to PD could lead to a better understanding of the mechanisms leading to a disability in PD and, thereby, to novel strategies to support recovery in the PD population. To date, there are no available reviews addressing this comorbidity.

Aims of the Study

The aim of this scoping review was to summarize the available research on the comorbidity between GD and PD and to identify the knowledge gaps in this field regarding the prevalence, incidence, risk factors, and consequences of GD in patients with PD. The secondary objective was to describe the prevalence and incidence of GD in patients with PD and psychotic symptoms.

Methods

We used Levac’s six-stage methodology [41] and reported the scoping review following the PRISMA Extension for Scoping Reviews guidelines [42].

Identifying the Research Questions

The research questions guiding the realization of this scoping review were developed in collaboration with clinicians specialized in both the fields of PD (M.A.R. and M.F.D.) and GD (I.G. and Y.K.). The main question was as follows: What is the state of knowledge regarding the comorbidity between GD and PD? To this was added one sub-question: What is the prevalence, incidence, and consequences of GD among psychotics with PDs?

Identifying Relevant Studies

The following databases specialized in medicine and psychology were searched for relevant studies: MEDLINE, Embase, PsychINFO, CINAHL, Cochrane, Web of Science, and Proquest Dissertation & theses. The search strategy, built by a librarian from Laval University in collaboration with our research team, was translated into the different databases (see online suppl. material 1 at www.karger.com/doi/10.1159/000527143 for details). We also examined the reference lists of the included articles to check if we could find other eligible studies for the review. Considering the scarcity of research on the subject, we have developed a very broad-spectrum research strategy that allowed us to identify all the literature that conjointly examined GD and PD.

Study Selection

Relevant studies were selected in two steps using Covidence Systematic Review Software (Verital Health Innovation, Melbourne, VIC, Australia). Reviewers (M.G.C., C.M., and M.H.L.) independently screened abstracts and titles based on inclusion and exclusion criteria (Table 1). To ensure consistency in the criteria’s application, training sessions were conducted for a set of 20 citations before the reviewers started their independent work. The article had to be approved by two reviewers to be included in the following steps, and disagreements were solved through discussion between them.

Table 1.

Inclusion and exclusion criteria

After this first step, pairs of reviewers performed a second round of screening using the same inclusion and exclusion criteria. They read the full text to determine if the article matched the criteria (see Fig. 1 PRISMA flowchart below for details).

Fig. 1.Data Charting Process

Team members carefully read all studies included during the full-text screening to extract relevant information using an extraction chart.

Collating, Summarizing, and Reporting the Results

The results were reported following the PRISMA Extension for Scoping Reviews guidelines [42]. A PRISMA flowchart details the results of our research strategy, the removal of duplicates, the addition of articles from the reference’s list, the number of articles excluded at each screening step, and the total number of publications included for the extraction.

Consultation

The main knowledge users are the clinicians from the Clinique Notre-Dame des Victoires. A team of clinicians was implicated throughout the process, mainly in the development of the conclusions that can be dawned from this study. This knowledge transfer to clinicians will ensure better practice and will help to identify future needs. In addition, the results from this scoping review will contribute to the recognition of a major comorbidity among patients admitted to a FEP program around the world.

Results

As presented in the PRISMA flowchart, the search strategy identified 242 articles from 7 databases, and 40 additional articles were retrieved from the references list of the included articles. Following the title and abstract screening, 34 studies were eligible and submitted to the full-text screening. After confronting each of these articles with the inclusion and exclusion criteria presented above, a total of 8 articles meeting our selection criteria were selected. These articles included 6 case reports of patients presenting a GD and a psychotic episode and two empirical studies exploring the link between PD and GD; these two groups of articles are reviewed in two separate categories.

Cases Description

As summarized in Table 2, 6 case reports were identified by the search strategy, including 4 articles reporting 1 patient, 1 article reporting 3 patients, and one conference abstract reporting 2 patients. Since there is no available description of the population affected by those disorders, the patients’ age and gender were extracted for each case. Patients were male between 15 and 26 years old. Additionally, the presumed psychosis-triggering event and the patients’ symptoms were presented to get a better understanding of the manifestations of these disorders when they are comorbid. The cases of 9 patients presented in this review show clinical associations of GD and PD symptoms in a number of patients, suggesting possible concomitant conditions. Two main patterns leading to a psychotic episode in patients with excessive gaming habits can be observed in those cases. First, for 4 patients, the prodromal phase of the psychotic episode consisted of a significant increase in the gaming time. For some of these patients, the increased playtime followed the exposure to a new type of game that allows massive multiplayer gameplay (MMORPG). For 2 other patients, the psychotic episode followed an abrupt gaming disruption. This change in gaming habits was done voluntarily in one case and imposed by the family in the other. To compare the importance of the use of video games for each patient, the information about gaming and the scales used to assess the GD were included in this table as well, and most patients played MMORPGs. Finally, the treatment and recovery time is presented to get a glimpse of what has and has not worked to stabilize the patients.

Table 2.Other Studies (Non-Case Report)

Only two empirical articles addressed the comorbidity between GD and PD. First, Chang et al. [43] recruited 104 participants diagnosed with schizophrenia from the Jianan Psychiatric Center (Taiwan). The main goal of the study was to investigate the potential role of GD as a mediator in the association between self-stigma and psychological distress (depression, anxiety, stress). Using multiple psychometric scales (Personal and Social Performance Scale, Internet Gaming Disorder Scale-Short Form [IGDS9-SF], Self-Stigma Scale [SSS], and Depression, Anxiety, Stress Scale [DASS]), they found that IGDS9-SF scores were correlated with anxiety (r = 0.220), stress (r = 0.244), DASS-21 total score (r = 0.576), and SSS (r = 0.163). Moreover, they found that self-stigma alone was associated with depression (r = 0.226), anxiety (r = 0.205), stress (r = 0.262), and a DASS-21 (r = 0.693) total score. Furthermore, introducing IGDS9-SF score as a covariable reduced the strength of the association between self-stigma and anxiety (r = 0.058), stress (r = 0.064), and DASS-21 (r = 0.152), suggesting a mediating effect of IGDS9-SF score on the relationship between these variables and SSS. In other words, online gaming might be a coping strategy for schizophrenic patients who experience self-stigma. Based on these results, the authors speculated that patients could use video games to help them connecting to others through the perceived anonymity that the Internet provides [43].

In another study, Gauthier et al. [44] led a single-visit, multicenter study involving 235 patients aged from 12 to 17 years who were hospitalized in four psychiatric units (France). The aim of their study was to determine the validity between two GD scales: the IGDT-10, a self-reported scale, and the IDGT-P-10, an adapted scale developed to allow the patient’s parents to take part in the GD screening by identifying different symptoms presented by their child [44]. The prevalence of GD in the adolescent psychiatric population (n = 104) was 6% (self-reported) and 12.79% (reported by the parents). In this study, none of the 11 patients with PDs had a GD when using the IGDT-10, and only 1 patient had a GD when using the IGDT-10-P [44]. No further analysis was conducted by this research group to explore the comorbidity between GD and PD.

Discussion

The main result from this scoping review is the demonstration of the paucity of the literature on the comorbidity between GD and PD. Indeed, it is limited to only 6 case reports and two cross-sectional studies. Hence, we do not have any reliable data on the prevalence of GD among patients with PD or on the relationship of GD with the main symptoms of PD or on the functional consequences of GD in this population.

Two main patterns leading to a psychotic episode in patients with excessive gaming habits have been identified in previously described case reports. Regarding those observations, it seems that psychotic symptoms could be triggered by an increase in gaming time or a sudden gaming withdrawal. To our knowledge, there is no available explanation for those phenomena. However, some authors from the reported literature have proposed hypotheses that are aligned with the observations made in the cases reported in the present review. Frist, Rizzo et al. [45] proposed a theory in which excessive gaming could directly trigger a psychotic episode. Another theory brought up by some authors is that GD could be a consequence of a PD. They proposed that patients with PDs are more prone to use video games to escape their reality, and it could serve as a coping strategy for their symptoms. Research by Chang et al. [43] is in favor of this theory. They exposed that patients with schizophrenia experiencing self-stigma could use video games as a coping strategy to decrease their depressive and anxiety symptoms, and it helped them connect with others. These observations suggest that video game use may be beneficial for some patients. Some studies on gaming motivations show that escapism via video game can have multiple positive outcomes such as enjoyment, fun, and wishful thinking. However, it can also lead to negative outcomes, such as depression, time wastage, negative mood, social anxiety, loneliness, and self-discrepancy. Individual variables such as cultural context appear to act as moderators in this dual outcome. A better understanding of the gamer’s motivations of patients who use video games as a coping strategy could lead to targeted interventions to promote positive outcomes [46, 47]. In other cases, presented by Angane et al. [48], patients turned to gaming for reality substitution because of the distressing symptoms that they experienced, and progressively increased their gaming time, leading to a GD. These observations also suggest that gaming could be beneficial for patients facing psychological distress. However, it is difficult to establish the actual consequences of gaming habits on patients’ health since gaming could potentiate social isolation observe in patients with FEP.

In addition, the types of games played in the case reports were similar, and most patients played MMORPGs. Two patients even mentioned that they increased their playing time when they switched to this type of game. Thus, the practice of MMORPG is a risk factor for the development of GD and could even be associated with the onset of psychotic episodes. The type of game could therefore be a contributing factor to both GD and PD. It is not clear whether GD can be caused by PD or vice versa. In fact, only two cross-sectional studies examined this comorbidity, but such a cross-sectional study design does not allow to conclude on the causality of the link between the different observations and can only consider them to be correlated, which might result from different relationships. For instance, those conditions share multiple consequences that might be exacerbated by their simultaneous presence. Also, psychosis and GD could share underlying biological, sociodemographic, or psychological mechanisms that make individuals vulnerable to both pathologies. However, empirical evidence is to date insufficient to identify the nature of the relationship between the two disorders.

Clinical Perspective and Knowledge Gaps

Clinical experience with patients leads to further questioning of the results and to suggestions for future research. Indeed, the current review highlights the lack of high-quality data about PDs combined with GDs. Beyond the data collected in this review, additional clinical factors must be considered. Indeed, patients suffering from FEP in our setting often mentioned video games as a frequent hobby. While occupational and functional recovery is an important focus of early psychosis interventions, many individuals spend a considerable amount of time on gaming consoles, cell phones, or computers playing video games, and these time-consuming gaming habits seem to persist even in patients with a formal diagnosis of schizophrenia [49]. Some of these patients seem to have appropriate use, and some others have problematic use; it has been proposed that video games can be used as a coping strategy to improve the quality of life of patients with PDs experiencing self-stigma. It is possible that patients also use video games to avoid other psychotic symptoms (e.g., lack of concentration, delusion, alogia). It would be beneficial to investigate the patient’s motivations for gaming and the causal link between different psychotic symptoms and the development of a GD. The reasons for playing video games were not reported by all patients in the previous cases. However, playing to reach personal satisfaction, to increase self-esteem, and to avoid hostile environment at home were expressed by 2 patients. Interestingly, those reasons were associated with GD in previous studies.

Yet, knowledge of video games is essential to today’s psychiatrists since asking questions about this sphere is often associated with a significant amount of information in the assessment of the patient. Indeed, by questioning, for example, the type of video game (multiplayer or solo), we can evaluate the interaction of the patient with other people. In addition, the time spent on the console can lead us to understand not only the impact of the game on the patient’s life but also to learn more about his lifestyle and sleep habits. As well, psychotic symptoms can be questioned during pleasurable activities. For example, is the patient able to overcome auditory hallucinations while playing the console?

Another essential element that should be addressed in future studies is that no GD measurement scale has been validated yet for patients with PDs. The existing screening tools were developed for a general population and consist of self-reported scales based on the DSM-5 and ICD-11 criteria, which can be difficult to interpret even for patients without disabilities [50].

The limited knowledge of the pathophysiology of the comorbid presence of GD is not limited to its comorbidity with PDs. Indeed, the causal link between GD and multiple psychiatric disorders is poorly understood as well, and further studies are needed in this area of research [51].

Limitations

We tried to be inclusive in our search strategy to identify as many studies as possible. However, we had to limit our search to English and French articles due to limited resources. Since GD is a research field of interest in Asian countries, it is possible that some studies were missed.

Finally, the data collected in this scoping review are to be interpreted with caution. Indeed, some case reports were detailed in terms of the symptomatology and pharmacotherapy used, but the others were poorly documented. Furthermore, longitudinal data on the evolution of GD after the treatment of psychosis were missing. Moreover, the doses of antipsychotics used in the case reports were very high, and the evaluation of adverse effects was not specifically studied. In addition, patients’ diagnosis was poorly documented, and diagnostic references such as SCID or ICD were not specifically mentioned. However, many clinical conditions remained clinically unusual. For example, a 15-year-old male who had lost consciousness was associated with a diagnosis of psychosis but is less common in the usual PD presentation. In addition, many authors refer to a prodrome of psychosis but not to clinical high risk per se. In addition, the effect of medication on gaming was not specifically studied. We also decided to include conferences abstracts in this scoping review in order to reflect as closely as possible the knowledge currently available. These abstracts address similar concepts as the other articles included in the present review. However, the lack of detail in these abstracts limits their interpretation and the conclusions that can be drawn from them.

Conclusion

In conclusion, these results highlight a significant lack of knowledge concerning PD associated with GD. Only a few reported cases and a single study exposed the direct association between those conditions. Future studies should focus on (1) the prevalence, incidence, and risk factors of PDs and psychotic symptoms in patients with GD; (2) the incidence of GD in patients with PDs and psychotic symptoms; and (3) the creation of GD screening tools adapted to patients with PDs. These findings will guide the allocation of appropriate resources to support the recovery of these patients.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

MHL was supported by the Frederick Banting and Charles Best Canada Graduate Scholarship Doctoral Awards from the Canadian Institute of Health Research (FID-172598). The funder played no role in this study, and we have no restrictions regarding the submission of this report for publication.

Author Contributions

Maxime Huot-Lavoie: conceptualization, methodology, formal analysis, writing – original draft, and project administration. Mina Gabriel-Courval: formal analysis and writing – original draft. Laurent Béchard, Olivier Corbeil, Sébastien Brodeur, Charles Massé, Émilien Fournier, Anne Marie Essiambre, Elizabeth Anderson, and Audrey Cayouette: writing – review and editing. Charles Massé: formal analysis. Isabelle Giroux and Yasser Khazaal: conceptualization, validation, and writing – review and editing. Marie-France Demers and Marc-André Roy: conceptualization, methodology, resources, writing – review and editing, and supervision.

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