Prevalence of internet gaming disorder and its psychological correlates

ABSTRACT Objective To investigate the prevalence of internet gaming disorder (IGD) symptoms in a sample of Brazilian adults, and its association with personality, psychiatric symptoms and psychosocial measures. Methods We evaluated 219 adults online recruited using questionnaires and psychometric scales. We evaluated the behavior and pattern of internet games using the Game Addiction Scale (GAS). We tested the association of the previous measures with the GAS scores by spearman correlations and multiple regression analysis. Results Of our sample, 74% played games online. We found correlations between IGD symptoms and most symptoms of mental disorders, with small or moderate effect sizes, as well as correlations with the personality traits of agreeableness (r = -0.272; p < 0.001), conscientiousness (r = - 0.314; p < 0.001), and neuroticism (r = 0.299; p < 0.001). Additionally, we found a negative association with psychosocial outcomes such as quality of life (r = -0.339; p < 0.001) and life satisfaction (r = - 0.202; p < 0.003). The multivariate model included the personality traits of conscientiousness and agreeableness and symptoms of dissociation and somatization as predictors. The prevalence of IGD was 9% in those who played online games. Conclusion IGD is correlated with different areas of the individual’s life, such as personality, quality of life, and several common symptoms of mental disorders. The prevalence can be considered high among players (9%). Conscientiousness, agreeability, somatic symptoms, and dissociative symptoms were associated with the symptoms of IGD.


INTRODUCTION
Several new technologies and the increasing online media and games mark the 21st century.Investment in consoles and computers took place in 1980, popularizing these devices and causing more significant investment in creating and developing electronic games 1,2 .Progressive technological development, reduced production costs, and easier access to a smartphone and personal computers allowed a large market expansion and reached virtually everyone with access to the internet 3,4 .
Previous research suggests that moderate use of video games can improve psychological functioning, including working memory, learning, and procedural knowledge 2 .Video games would also enhance social skills in patients with anxiety disorders and introverted personalities or alleviate cognitive symptoms in neurodevelopmental disorders 2,[5][6][7] .However, these potential benefits may be hindered by excessive play, which may sometimes characterize a behavioral addiction.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included internet gaming disorder (IGD) in section III, under "Conditions for Further Studies".The manual refers to IGD as a maladaptive game behavior, with a loss of a sense of control over the time spent on electronic games.In addition, it emphasizes that only non-gambling internet games are included in the disorder.However, microtransactions and random rewards during gameplay make it difficult for this classification.Internet use for work, recreational, social, and pornographic purposes should not be considered 8 .Even with the development of studies that prove several negative consequences of the excessive use of online games, the diagnosis of IGD is still controversial due to the difficulty in classification and incipient research studies.Still, this area is in excellent expansion 9 .According to the DSM-5, the diagnostic criteria 8  8. Use 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.(p.795) Also, according to the manual, there is a need to classify the disorder's severity.Depending on the frequency, intensity, and dysfunctionality symptoms, it can be classified as mild, moderate, or severe.IGD prevalence according to standard criteria is still controversial, although it might be more frequent in males at a young age (under 25 years) and may vary geographically, especially in different cultures 8,9 .
Given the above, we aim to investigate how IGD symptoms present in Brazilian adults, their association with other psychiatric symptoms and psychological factors, and establish their prevalence and comorbidities in an onlinerecruited sample.

Participants
This was a cross-sectional, descriptive study that used quantitative methods.The sample (n = 219) was recruited online using the Google forms app through a link sent in advertisements on social media.The inclusion criteria were playing electronic/video games online on a cell phone, tablet, video game console, computer, or other device and the respondent's age (18 years or older).We removed the selected players from the general population, asking if "they were playing online games" in the last 6 months.We used a structured questionnaire to collect sociodemographic data and psychometric scales for further assessment.Subjects with a self-reported history of mental disorders were not excluded from the sample, and this data was used in the study analysis.This sample size allowed for detecting associations (5% error) of large and medium effect sizes with 99% power but only 31% of small effect sizes.

Ethical considerations
The survey did not present any immediate risks to participants, and they could cancel their participation at any time.The only immediate benefit for the participants was receiving a report of their psychometric scale scores.This study project was submitted and approved by the ethical board of Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (approval number/year: 2.905.499/2018).All participants consented, and all data was anonymized and securely managed following the Brazilian General Law of Data Security (Lei Geral de Proteção de Dados).

Participants' assessment
We used standardized scales to evaluate game addiction, personality, mental health, and psychosocial outcomes (quality of life and life satisfaction).All tests were developed and validated to ensure a valid and precise measure of each phenomenon.They were previously translated and adapted to Brazil, minimizing possible biases in test measurements.
• Game Addiction Scale (GAS): The GAS has 21 items designed to assess game addiction: salience, tolerance, change in mood, setback, relapse, conflict, and problems.The scale is scored on a Likert scale of 5 items.Higher scores are representative of more maladaptive and addicted gaming behavior 10 .Problematic use was defined if at least four of the seven dimensions of the scale were considered pathological, and Addiction was defined if all items were considered pathological 11 .

• Inventory of the Five Big Personality Factors (IGFP-5):
This relatively short personality assessment comprises 44 items representative of the "Big Five" personality traits (Openness, Conscientiousness, Extroversion, Agreeableness, and Neuroticism).All items are scored on a Likert scale of 5 points.Higher scores represent a higher expression of the personality trait 12 .• Adult Self-Report Scale for Attention Deficit Hyperactivity Disorder (ADHD) using DSM-5 criteria (ASRS): This standardized questionnaire is designed to assess inattention, hyperactivity, and executive dysfunction, which are core symptoms of ADHD.Scores on this scale range from 0 to 24, with higher scores indicating more frequent and intense ADHD symptoms [13][14][15]

Statistical analysis
We used Spearman's correlation to test the association of the study variables.Then, we used a multiple regression analysis (stepwise) to determine which variables related to mental health, personality, and psychosocial factors were associated with GAS scores.We selected the variables significantly correlated with GAS scores as predictors in a stepwise model since multiple predictors might be intercorrelated.The statistical procedures were performed using the SPSS 22.0 software.

RESULTS
Tables 1 and 2 show participants' descriptions.Table 1 stratifies our sample into online gamers and the general population.There were no significant differences between these two groups regarding sociodemographic factors.Our sample was predominantly composed of young adults (age 25 ± 6 years), with a balanced proportion of male and female participants currently enrolled in college/university studies (69%).Most of the participants were single (84%), living with a family (63%), and had an average family income of 3 to 4 minimum wages (31%).About 78% of the participants had a sleep routine between 4 to 8 hours, and almost half of our sample had a history of mental disorders (48%), mainly ADHD (31%), anxiety disorders (15%), and depression (8%).The most common psychiatric treatment was a combination of prescribed psychotropic drugs and psychotherapy (43%).Regarding the subsample of online gamers (74% of the total sample), participants were relatively divided in the amount of time spent playing games daily (27% less than 1 hour, 30% 1 to 2 hours, 16% 2 to 3 hours, and 27% more than 4 hours per day).Most participants predominantly played games using their smartphones (46%) or computers (41%), and a significant proportion mainly played online multiplayer games (40%).According to GAS scores, 74% of the sample showed no evidence of addiction, while 26% showed a problematic pattern of gaming and 10% a pattern of IGD.
Table 3 shows the correlations between the study variables and GAS scores.The largest correlations were moderate and observed with the conscientiousness personality factor (-0.314), quality of life (-0.339),symptoms of depression (0.336), somatic symptoms (0.336), symptoms of personality disorders (0.371), symptoms of dissociation (0.371), and ADHD symptoms of executive dysfunction (0.341).This preliminary analysis suggests that conscientiousness might be a protective factor regarding IGD, several psychiatric symptoms might be associated with this disorder, and its intensity might impact the quality of life.
Table 4 shows the multiple regression model.The final model consisted of two personality factors (Conscientiousness and Agreeability) and two psychiatric symptoms (somatic and dissociation).Both personality factors showed a negative association with GAS scores, suggesting they are protective regarding IGD.At the same time, somatic symptoms and dissociation are positively associated, suggesting they may be risk factors or comorbidities for the disorder.

DISCUSSION
Our results showed that about 25% of the sample exhibited dysfunctional/addictive online gaming behavior.GAS scores were associated with most psychiatric symptoms, personality traits, and a lower quality of life and satisfaction.In the multivariate analysis, Conscientiousness and Agreeableness  personality traits were associated with lower GAS scores, while somatic and dissociation symptoms were associated with higher scores.Most studies regarding IGD tend to focus on children and adolescents 18 .However, the symptoms of IGD may persist into adulthood and cause psychosocial problems, as documented in our results.Despite the similarity of its cognitive, behavioral, and neurobiological characteristics with substance-related disorders 19 , the main correlates of IGD were different from those of addictions.Somatic and Dissociative symptoms can be related to addictive behavior, but they are usually less pronounced than ADHD symptoms, impulsivity, disinhibition, or internalizing symptoms 19 .Although it may still be speculative since this is not a longitudinal study, we can interpret our data as suggesting risk factors (dissociative and somatic symptoms) and protective factors (Conscientiousness and Agreeableness).
Conscientiousness is a personality trait associated with self-directed behavior, representing individuals who are more organized and efficient with high self-control 12 .This trait may help to exert self-regulation while playing online, reducing the risk of excessive time, conflict, or loss of control.
for IGD are 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 12 months: 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).People's 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 no physical signs of pharmacological withdrawal.) 3. Tolerance -the need to spend increasing time engaged in Internet games.4. Unsuccessful attempts to control participation in Internet games. 5. Loss of interest in previous hobbies and entertainment as a result of, and except for, 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.
16ll the subject assesses their quality of life (scores ranging from 1 to 5).Higher scores are indicative of a higher quality of life16.
. • World Health Organization Quality of Life assessment (WHOQOL-BREF): This instrument measures the quality of life.It is scored in four broad domains (physical, psychological, social relations, and environment) using a set of 26 questions scored on how

Table 2 .
Gaming profiles from the subjects who play games (n = 162, 74% of the full sample) GAS: Game Addiction Scale.

Table 3 .
Spearman correlations between personality, psychosocial measures, and psychiatric symptoms with Game Addiction Scale (GAS) scores GAS: Game Addiction Scale; IGFP: Inventory of the Five Big Personality Factors; WHOQOL-Bref: World Health Organization Quality of Life Instrument -abbreviated version; SWLS: Satisfaction with life scale; CCSM: DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure; ASRS: World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5.

Table 4 .
Predictors of Game Addiction Scale (GAS) scores in a stepwise multiple regression model Inventory of the Five Big Personality Factors; CCSM: DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure.*Statistically significant values.