Author’s Accepted Manuscript

Clinical predictors of gaming abstinence in help-

seeking adult problematic gamers

Daniel L. King, Cam Adair, John B. Saunders,

Paul H. Delfabbro

www.elsevier.com/locate/psychres

PII: S0165-1781(17)31037-5
DOI: https://doi.org/10.1016/j.psychres.2018.01.008
Reference: PSY11135
To appear in: Psychiatry Research
Received date: 7 June 2017
Revised date: 5 January 2018
Accepted date: 7 January 2018
Cite this article as: Daniel L. King, Cam Adair, John B. Saunders and Paul H.
Delfabbro, Clinical predictors of gaming abstinence in help-seeking adult
problematic gamers, Psychiatry Research,
https://doi.org/10.1016/j.psychres.2018.01.008
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 Clinical predictors of gaming abstinence in help-seeking adult problematic
gamers
Daniel L. King , Cam Adair , John B. Saunders3, Paul H. Delfabbro1
1* 2

1
School of Psychology, The University of Adelaide
2
Gamequitters, Canada
3
Centre for Youth Substance Abuse Research, University of Queensland, Brisbane,
Queensland, Australia
*Corresponding author. School of Psychology, Level 5, Hughes Building, The

University of Adelaide, Adelaide, SA 5005, Australia. Tel: +61 8 8313 3740; fax: +61

8 8303 3770.

Abstract

Research into the effectiveness of interventions for problematic gaming has been

limited by a lack of data concerning the clinical characteristics of voluntary treatment-

seekers; the nature and history of their gaming problems; and, their reasons for

seeking help. The study aimed to identify variables predictive of short-term

commitment to gaming abstinence following initial voluntary contact with an online

help service. A total of 186 adult gamers with gaming-related problems were recruited

online. Participants completed the DSM-5 Internet gaming disorder (IGD) checklist,

Depression Anxiety Stress Scales-21, Internet Gaming Cognition Scale, Gaming

Craving Scale, and Gaming Quality of Life Scale. A one-week follow up survey

assessed adherence with intended gaming abstinence. Abstainers were less likely to

have withdrawal symptoms and less likely to play action shooting games. Participants

with mood symptoms (40% of the total) reported significantly more IGD symptoms,

stronger maladaptive gaming cognitions (e.g., overvaluing game rewards), more

previous occurrences of gaming problems, and poorer quality of life. However, mood

symptoms not predict abstinence from or continuation of gaming. Adults with gaming

disorder seeking help to reduce their gaming may benefit initially from strategies that

manage withdrawal and psychoeducation about riskier gaming activities.

1
Keywords: Internet gaming disorder; Addiction; Depression; Anxiety; Abstinence;

DSM-5

1. Introduction

Excessive and disordered gaming are increasing recognized as topics of relevance

to psychiatry due to their negative impact on general psychological functioning (Petry

et al., 2014a; van Rooij et al., 2011; Weinstein and Lejoyeux, 2010), as well as their

association with other mental disorders (Ferguson et al., 2011; King et al., 2013). In

the DSM-5, Internet gaming disorder (IGD) refers to persistent and recurrent gaming

associated with clinical impairment or distress (APA, 2013), with a set of criteria

similar to other addictions, including gambling disorder. The beta draft ICD-11 also

recognizes ‘Gaming disorder’ as a type of addictive disorder (WHO, 2017). To date,

more than 60 epidemiological studies of problem gaming in general populations and

subgroups have been reported in the international literature (WHO, 2015). Many

studies have examined Internet use problems including online gaming and others

more specifically online gaming, reporting rates of prevalence from 0.7% up to 21%

(Kim et al., 2016; Mak et al., 2014; Porter et al., 2010; Przybylski et al., 2016;

Rehbein et al., 2015), suggesting that there may be an increasing demand for

interventions that target IGD or problematic gaming issues.

Services offering interventions for gaming disorder are currently most developed

in East Asia, particularly in South Korea, China, and Japan (King et al., 2017a;

Nakayama et al., 2016). However, a common challenge facing clinicians in the

treatment of IGD across all nations is client non-engagement, or lack of adherence to

therapy goals, particularly in adolescents. While some treatment studies have reported

2
that participant dropout or attrition tends to be quite low (see Winkler et al., 2013),

this observed adherence to treatment may occur because studies tend to eliminate

participants unlikely to engage prior to the main trial phase. In practice, clinicians

who treat IGD may encounter uncertainties in relation to predicting what types of

clients, or which client characteristics, are likely to be associated with treatment

success or other positive outcomes. Higuchi et al. (2017) reported, for example, that

40% of individuals referred for IGD treatment at a specialist clinic in Japan refused to

enter treatment and were unwilling to modify their gaming behavior despite the

presence of significant harms. One potential way for researchers to gain empirical

insights into the characteristics that may predict treatment engagement is to assess

differences in the clinical profile of individuals wishing to modify their gaming

behavior and their association with successful outcomes. Therefore, the aim of the

present study was to identify variables predictive of short-term commitment to

gaming abstinence in adult gamers following initial voluntary contact with an online

help service, to help identify the factors that may inform treatment considerations for

IGD.

Current knowledge of the predictors of treatment retention and outcomes in adults

with gaming disorder who voluntarily seek treatment is very limited (King and

Delfabbro, 2014). A recent international review by King et al. (2017b) reported that

only 11 out of 30 studies conducted in the past decade had included a follow up

assessment, making it difficult to ascertain which individual-level variables may be

associated with longer term changes. Additionally, none of the 30 studies had

examined the demographic and clinical predictors associated with treatment

compliance or study retention, and therefore these issues represent a significant gap in

knowledge. Most of the research on longitudinal changes in IGD symptoms and

3
gaming behavior has focussed on adolescent populations (Hastings et al., 2009; Han

et al., 2011; Wan and Chiou, 2006). For example, a study of 517 adolescents in

Taiwan by Ko et al. (2007) examined the 1-year incidence and remission rates for

Internet addiction. The authors reported that 49% of the subgroup of 83 individuals

with IA had remitted at follow up, with low hostility and low interpersonal sensitivity

identified as the best predictors of remission. However, these data are unlikely to

generalise to more complex cases of adults with gaming disorder.

Identifying clinical predictors of individuals’ ability to abstain from gaming may

help to make accurate prognostic judgments and risk assessments of individuals at

risk of or impacted by IGD. Comorbidities are an important consideration, as mood

symptoms such as depression and anxiety are likely to negatively affect the ability of

an individual with IGD to manage stress and therefore abstain from or reduce gaming.

A meta-analysis by Ho et al. (2014) of 8 studies, comprising 1641 adolescent and

adult patients and 11210 controls, reported that there was a significant and positive

association between Internet addiction and alcohol abuse, attention deficit and

hyperactivity, depression, and anxiety. Some authors have proposed subtypes of IGD

including ‘emotionally vulnerable’, ‘socially conditioned’ and ‘impulsive/aggressive’,

but it is not clear whether any of these subtypes tend to do better than others in

treatment (Lee et al., 2016). Another possibility yet to be explored is whether

individuals with IGD may have greater difficulty in regulating their gaming use

according to whether they play certain types (e.g., genres) of games (James and

Tunney, 2017). It is may be speculated based on research findings that massively

multiplayer online (MMO) games and popular competitive action shooting games

(Charlton and Danforth, 2007; Smyth, 2007) may be more difficult for users to reduce

their use and maintain at safe levels.

4
 The severity of a mental disorder is likely to impact recovery and maintenance of

treatment gains. To date, there has been limited research on whether certain IGD

symptoms, such as withdrawal, may negatively impact on treatment adherence

(Kaptsis et al., 2016). Withdrawal is known to influence the progression of symptoms

and outcomes in substance use disorders (Edwards, 1990) but its role in behavioural

addictions is less understood. It is likely that individuals who experience more intense

and frequent symptoms of withdrawal related to gaming may experience greater

difficulty in reducing their gaming compared to those who do not regularly experience

withdrawal. Few studies have examined how craving for gaming experiences may

manifest during abstinence, whether symptoms worsen or improve over time, and

their potential role in predicting treatment compliance and outcomes.

In evaluating clinical predictors of gaming abstinence, it should be acknowledged

that many individuals with IGD may not intend to abstain from gaming while in

therapy. Total cessation of use of electronic devices may be quite impractical and

counterproductive to a normal lifestyle. In a review of the long-term benefits of

treatments for gaming disorder, King and Delfabbro (2014a) reported that, in all 8

reviewed studies, the participants’ stated treatment goal was controlled use of games,

rather than quitting games indefinitely. There is nevertheless some research evidence

that suggests a temporary abstinence from gaming may be beneficial for some

individuals with a habitual pattern of use. Brief abstinence from gaming has been

shown to reduce craving (Kaptsis et al., 2016), weaken maladaptive cognitions (King

et al., 2017c), and reduce gaming and direct attention toward other activities (Sakuma

et al., 2017). The ability to abstain for a substantial period may indicate self-

regulation and therefore may be a good indicator of whether a person can achieve the

longer term goal of controlled gaming.

5
1.1 The present study

The present study involved screening adults with clinically defined gaming

problems who voluntarily sought to abstain at least temporarily from gaming. The aim

was to identify variables predictive of short-term (i.e., 1-week) voluntary commitment

to gaming abstinence following initial contact with an online help service. Variables

of primary interest were current level of gaming activity and history of gaming,

preferences for specific game types, symptoms of gaming withdrawal, maladaptive

gaming beliefs and mood symptoms. These data may guide formulation of the

vulnerabilities and protective factors in adults with IGD who commence

psychotherapeutic interventions. Study outcomes may also add to the current lack of

knowledge of predictors in gaming disorder symptoms (King and Delfabbro, 2014a).

This study was guided by the assumption that the greater presence and severity of risk

factors may reduce the ability to meet abstinence goals. It was hypothesized that those

participants with more complex disordered gaming profiles and histories would be

unable to achieve short-term (i.e., 7-day) gaming abstinence. It was also hypothesized

that non-abstainers would report more severe IGD symptomatology, stronger gaming-

related cognitions and intense craving symptoms, and more severe mood symptoms

than successful abstainers.

2. Method

The target population of this study were adults with clinically defined gaming-

related problems voluntarily seeking to reduce their level of gaming activity or abstain

indefinitely from gaming. Potential participants were individuals who visited the

website Game Quitters, a dedicated problem gaming community support site that
6
provides resources, social forums, and practical strategies to quit or reduce gaming.

An anonymous online survey was hosted and promoted on the Game Quitters

homepage. The survey consisted of psychometric instruments combined with open-

ended follow up questions. The survey was developed as part of an international

project on Internet gaming psychopathology, with coverage of the following subjects:

(1) current and historical use of games, (2) gaming preferences, (3) structural

characteristics, (4) gaming-related cognitions, (5) craving and withdrawal, (6)

disordered gaming, (7) mood symptoms, and (8) treatment-seeking histories.

A one-week follow up survey was administered to assess the degree of adherence

with intended abstinence. A one-week period was chosen because some past research

had identified significant changes in gaming-related cognitions after this period of

time (King et al., 2017c). A one-week follow-up was also reasoned to maximise the

likelihood of participant retention, which was supported by the fact that study attrition

exceeded 30% after one week. Total participation time required 30-60 minutes and

those who completed surveys entered a draw to win a share of gift vouchers.

Participants entered the draw regardless of whether they had abstained from games at

follow up. Data collection occurred from February 2016 to March 2017. This study

was approved by the University of Adelaide Human Research Ethics subcommittee.

All participants provided informed consent and were free to withdraw from the study

at any time.

2.1 Measures

A questionnaire assessed demographic information (i.e., age, gender, ethnicity,

education, and employment status). Internet gaming activity was examined using a

tabular week diary format, measuring hours of gaming in a typical week in the past 3
7
months, types of games played, among other questions on gaming context and reward

preferences.

2.1.1 Internet gaming disorder (IGD) criteria checklist.

The IGD checklist is a 9-item self-report measure to assess the DSM-5 IGD

classification (APA, 2013). Items were drawn from Petry et al.’s (2014) international

consensus statement on measurement of IGD symptomatology. Items assess

symptoms including: preoccupation, tolerance, withdrawal, unsuccessful attempts to

limit gaming, deception or lies about gaming, loss of interest in other activities, use

despite knowledge of harm, use for escape or relief of negative mood, and harm.

Response options are dichotomous (Yes/No). The internal consistency was sound

(Cronbach’s alpha=0.69). Additional questions assessed insight into gaming-related

problems, the onset of current problems and past occurrences of problems, treatment

history, and current intentions to change.

2.1.2 Internet Gaming Withdrawal Scale (IGWS).

The IGWS is a modified version of the six-item Penn Alcohol Craving Scale

(PACS; Flannery et al., 1999), a measure of alcohol withdrawal. The IGWS assesses

frequency and duration of thoughts about gaming, intensity of gaming craving at its

strongest point, ability to resist gaming, and overall strength of craving. The scale has

been employed previously in studies of abstaining adult gamers (Kaptsis et al., 2016).

A total IGWS score was calculated by summing all individual item responses, with

higher scores indicating more intense and frequent symptoms. The IGWS

demonstrated excellent internal consistency (Cronbach’s alpha=.90).

2.1.3 Internet Gaming Cognition Scale (IGCS).

The IGCS is a 24-item measure that assesses maladaptive gaming cognitions

associated with problematic Internet gaming. The scale has demonstrated strong
8
convergent validity with excessive time spent gaming and IGD symptomatology

(Forrest et al., 2017; King and Delfabbro, 2016a). The IGCS employs self-referent

belief statements to assess four types of gaming cognition, including: (a) overvaluing

of game reward, (b) inflexible rules about gaming, (c) gaming for self-esteem, and (d)

gaming for social identity and acceptance. Total IGCS scores range from 0 to 48. The

internal reliability of the measure was excellent in this study (Cronbach’s alpha=.87).

2.1.4 Depression Anxiety Stress Scales–Short Form (DASS-21).

The DASS-21 is a standardized measure of psychological distress suitable for use

in normal and clinical populations. The measure assesses symptoms of depression,

anxiety, and stress across three seven-item subscales (Lovibond and Lovibond, 1995).

Total subscale scores range from zero to 21 and have established clinical cut-off

scores for severity. The internal consistency was good for each subscale: depression

(=0.83), anxiety (=0.75), stress (=.82).

2.1.5 Gaming Quality of Life (QoL) Scale.

This 40-item measure was an adapted version of the Eating Disorder Quality of

Life Scale (EDQLS; Adair et al., 2007), which is a validated measure based on the

World Health Organization’s definition of quality of life. Fourteen items were

modified slightly to refer specifically to gaming instead of eating (e.g., item 16 “I

have fights with my family about gaming”), and six items were modified to be more

gaming-specific (e.g., item 25 “I’m constantly trying to change my body” changed to

“I'm constantly trying to progress or do new things in games”). The measures

captures broad aspects of life affected by gaming but avoids overlap in content with

instruments that measure gaming disorder symptoms (e.g., withdrawal). Scale

domains includes cognitive, education/vocation, family and close relationships, other

relationships, future outlook, leisure, psychological, emotional, values and beliefs,

9
physical, and gaming behaviours. Total scores range from 40 to 200. The scale

demonstrated excellent internal consistency (Cronbach’s alpha=.91).

2.2 Procedure

Participants were recruited via an advertisement posted on the homepage of the

Game Quitters website. The second author (CA) was the site administrator and he

promoted the study and facilitated data collection. Follow up surveys were

administered using a timed automated emailing service that included reminders. A

total of 342 participants were initially recruited. After excluding cases with

incomplete surveys, there were 220 participants (64.3%). Excluding cases who denied

that their gaming was problematic and/or did not meet five or more IGD criteria

(N=34), there were 186 eligible participants. Inclusion criteria were: (1) being 18

years or older, (2) meeting five or more DSM-5 IGD criteria and personal

acknowledgement of gaming problems, and (3) willingness to attempt to abstain from

games for at least 7 days. Completed survey responses were compiled and analysed

using SPSS for Windows, version 24.0 (IBM Corporation, Armonk, New York,

USA).

2.3 Data analysis

Descriptive analyses, Mann-Whitney U tests and Chi-square tests were performed

to determine broad demographic and gaming-related differences in relation to

adherence with abstinence (i.e., Group 1: ‘abstainers’ who reported successful 7-day

abstinence; Group 2: ‘non-abstainers’ who reported non-adherence or study dropout).

Abstinence was indicated by responses to two items (i.e., “Since the previous survey,
10
have you played video games?” and “In the past week, how many days have you

spent gaming?”). A series of Mann-Whitney U tests and Chi-square tests were

conducted to evaluate potential differences in clinical features and mood symptom

rates between groups. Non-parametric tests were employed because they rely on

fewer assumptions and may be more appropriate for studies with non-normal

distributions. A linear regression model was planned to identify the strongest clinical

predictors of successful abstinence.

3. Results

Table 1 presents a summary of the demographic and gaming-related

characteristics of the overall sample (N=186). The age range was 18 to 48 years, with

a mean of 23.4 years (SD=5.2). The sample was predominantly male (95%), with the

most typical demographic attributes of being single (63%), unemployed (44%) and

Caucasian (70%). There were no significant demographic differences (i.e., age, sex,

education, relationship status, or employment status) between abstainers and non-

abstainers. Similarly, groups did not differ significantly in terms of age of first use of

games (the typical age was about 8 years), the weekly amount of time spent gaming

(M=31 hours per week, SD=18 hours), and weekly use of other online activities (e.g.,

gaming news, forums, Youtube videos) related to gaming (M=18 hours, SD=28

hours). Participants reported a mix of solo and multiplayer gaming (63%) or playing

solo games only (23%), and tended to play with friends known in real life (70%). The

typical history of gaming in general was between 10 to 20 years (M=14, SD=6 years).

The only significant group difference indicated that abstainers were significantly less

likely to play action shooting games (e.g., first-person shooters) than non-abstainers

11
(38% vs 61%). A follow-up analysis found no significant differences in craving scores

according to game genre (i.e., action games, adventure games, etc.).

Table 2 presents a comparison of DASS subscales and disordered gaming

characteristics for abstainers and non-abstainers. The purpose of this analysis was to

identify the characteristics of individuals who experience more difficulty in

committing to a plan to regulate their gaming and/or managing their gaming activity

in general. These individuals may have a poorer prognosis for treatment completion

and outcomes. There were no significant differences between abstainers and non-

abstainers in relation to total IGD criteria, the onset of current gaming-related

problems, or number of separate occurrences of these problems. There were no

significant group differences in total gaming cognition scores, craving and withdrawal

symptoms, mood symptoms, or overall quality of life. There were no group

differences in relation to intentions to abstain from or reduce gaming, with

approximately half of each group (54% and 48%) reporting an intention to quit

gaming indefinitely, and an additional subgroup (36% and 45%) reporting the

intention to abstain temporarily and then engage in controlled use of games.

Table 3 presents a comparison of the IGD symptom profiles of the abstainers and

non-abstainers. Of the 9 DSM-5 criteria, successful abstainers tended to report

significantly lower endorsement of criterion 2 (withdrawal) than non-abstainers (65%

versus 45%). The two groups did not differ significantly in relation to other criteria.

The most frequently endorsed items in both groups were ‘use despite harm’ and

‘unsuccessful attempts to reduce gaming’. The tolerance (54% and 61%) and

deception of others (65% and 55%) criteria were the least frequently endorsed items
12
in each group, which may be consistent with the notion that these criteria occur more

commonly in the earlier stages of problem gaming and the majority of participants

(85%) reported that their gaming had been problematic for longer than 12 months. For

example, the ‘need to increase time spent gaming’ (criterion 3) may not apply in cases

where almost all available time is devoted to gaming, and ‘deception of others’

(criterion 7) may not be relevant to cases who do not interact socially with non-

gamers or for whom it has become impractical to hide gaming activities from others.

Table 4 presents a comparison of the overall sample in relation to DASS-21

scores. Although these variables (i.e., mood symptoms) were not related to the

likelihood of successful abstinence (see Table 2), it was reasoned that depression and

anxiety may nevertheless be associated with the clinical features and severity of

disordered gaming. A score in the moderate or more severe range on either the DASS-

21 anxiety or depression subscales was the cut-off used to indicate potentially

significant mood symptoms. Participants with mood symptoms tended to report

significantly more IGD symptoms, scored higher on the Gaming Cognition scale, had

significantly worse overall quality of life, and more previous occurrences of

disordered gaming. However, there were no significant group differences in the

weekly amount of time spent gaming (29 versus 33 hours) and intentions to abstain

from or reduce gaming activity.

A linear regression analysis was planned to assess whether certain clinical

characteristics might be predictive of the number of days spent abstinent from gaming

between baseline and follow up surveys. However, there were no significant

correlations between the intended outcome variable (i.e., number of days spent

abstinent) and key variables of interest (i.e., age, weekly hours spent gaming, total
13
IGD symptoms, craving for games, and mood symptoms) required to perform this

analysis. As a supplementary analysis, Table 5 presents a linear regression model of

these predictors with the outcome variable being total IGD symptoms. The model

explained 38% of the variance in IGD symptoms, with age, gaming cognition, and

DASS-21 depression being the only significant predictors in the model.

4. Discussion

The present study investigated the clinical features and mood symptoms of adults

with self-identified IGD who voluntarily sought to abstain from gaming. Contrary to

expectations, it was found that successful short-term abstainers did not differ

significantly from non-abstainers in terms of demographic, gaming-related history, or

clinical characteristics. Although the presence of mood symptoms was not

significantly related to participants’ capability to abstain, mood symptoms were

significantly related to more severe profiles of gaming disorder and having more

previous occurrences of problem gaming. Non-abstainers reported a greater tendency

to play action shooting games, and were more inclined to endorse the withdrawal

criterion of IGD. Overall, these findings suggest that it may be difficult to predict the

likelihood of successful voluntarily initiated abstinence from gaming activities based

on demographic, gaming-related, and clinical background information. The notion

that specific types of games and/or certain structural features of games (i.e., shooting

and fast-paced action) may be more problematic for some users to abstain from than

other games deserves more attention in the psychiatric and treatment literature.

Further research is needed to better understand the risk and protective factors for IGD,

and to identify variables more amenable to change and responsive to practical support

in the earlier stages of treatment.

14
 Successful abstainers were generally less likely to endorse the IGD withdrawal

criterion at baseline than non-abstainers and dropouts. The DSM-5 IGD classification

refers to gaming withdrawal as ‘irritability’, ‘anxiety’, and ‘sadness’ following

cessation or reduction of gaming, rather than being a pharmacological withdrawal

experience. Additionally, there were no significant group differences in relation to

subjective rating of craving for games (e.g., general desire to play, the ability to resist

games, and urges to play). These two findings indicate that abstainers reported similar

‘craving’ (urge/desire) but less ‘withdrawal’ (negative emotions) than non-abstainers

prior to abstaining from games. It is possible that abstainers may be more capable of

managing negative emotional states that arise when not gaming (or following a

sudden reduction or cessation of gaming) than non-abstainers. This would be

consistent, for example, with research on substance use disorder that reports distress

tolerance (Daughters, 2005) and emotional support (Dobkin et al., 2001) are

significant predictors of treatment compliance. Another explanation is that this group

was genetically predisposed to cope better with negative emotions and withdrawal, as

found in genetic research on problem gambling (see Slutske et al., 2000; Zoratto et al.,

2017). A practical implication is that individuals seeking to reduce gaming may

benefit from strategies that target withdrawal-like experiences, including relaxation or

other negative mood-relieving exercises, scheduling alternative activities for mental

stimulation and socialization, and changes in routine and environment to reduce

exposure to gaming-related cues.

An under-examined aspect of problem gaming in the psychiatric literature is the

diversity of gaming types and features and their role in maintaining IGD symptoms.

Successful abstainers were significantly less likely than non-abstainers to report that

they played action shooting games. Although there has been scholarly examination of
15
massively multiplayer online (MMO) games for their so-called addictive potential

(Ng and Weimer-Hastings, 2005; Smyth, 2007), highlighting in these games the social

pressures on players to maintain a regular schedule of play and the delivery of game

rewards on variable reinforcement schedules (Charlton and Danforth, 2007; King and

Delfabbro, 2014b), abstainers and non-abstainers did not differ in terms of their

preference for MMO games. The DSM-5 Internet gaming disorder category states “it

is unclear if behaviors and consequence associated with Internet gaming disorder vary

by game type” (APA, 2013; p. 796). The present study suggests that players may have

particular difficulty in reducing involvement in action shooting games compared to

other game types because they are generally fast-paced (i.e., rapid events, high reward

frequency), highly stimulating (audio-visual effects, violent imagery), require minimal

time commitment for a ‘complete’ experience (i.e., a game ‘round’ may require less

than 15 minutes), and player feedback is often contextualised by competitive social

ranking systems (King et al., 2010; Wood et al., 2004).

The finding that IGD symptoms of ‘tolerance’ and ‘deception of others’ were

endorsed by only 55% and 65% of the sample, respectively, adds to the current debate

on the utility of IGD criteria. Starcevic (2016, 2017) and Snodgrass et al. (2017) have

argued, for example, that symptoms such as tolerance and withdrawal may be flawed

when applied to behavioural addictions, and there is an urgent need to ascertain

factors that provide the most valid account of disordered gaming. This study confirms

some recent thinking that the concept of tolerance when applied to gaming, or the

‘need for increasing time spent gaming’ (Petry et al., 2014), may fail to capture many

other factors that motivate and maintain excessive behaviour (King and Delfabbro,

2016b; King, Herd, and Delfabbro, 2018). A related possibility is that tolerance, in its

current DSM-5 description, may tend to manifest more commonly in the early stages
16
of IGD. Most participants (84%) reported that their gaming problems had been

present for over 12 months, therefore their gaming behaviours and routines were

likely to be much more established and habitual, occurring at all available times of the

day. Consequently, the need to ‘increase time’ may have been perceived as non-

applicable. For some players, persistent play may involve specific goal motivations,

with gaming activities having to meet certain requirements for the player to achieve

satisfaction (e.g., beat the top score, or completing difficult game levels). Along

similar reasoning, the criterion ‘deception of others’ may be non-applicable to chronic

problem gaming cases, who may also be highly anxious or socially withdrawn, who

rarely engage with others or belong in social circles restricted to other gamers

(Caplan, 2006; Lo, Wang, and Fang, 2007; Yen, Ko, Yen, Wu, and Yang, 2007).

Mood symptoms as measured by the DASS-21 were a feature of 40% of help-

seeking disordered gamers, but were not related to the short-term capability to abstain

from gaming. A recent international review on treatment of gaming disorder (King et

al., 2017b) reported that 15 out of 30 clinical trials published in the last decade have

excluded participants with comorbidities, with remaining studies often unclear on how

comorbid conditions are addressed in therapy. The present study found that mood

symptoms were associated with worse IGD symptoms and stronger gaming-related

beliefs, suggesting that mood symptoms may lessen the effectiveness of cognitive-

behavioural therapies. This potential interaction of mood symptoms and problematic

Internet use symptoms is evident in Davis’ (2001) cognitive-behavioural model of

generalised problematic Internet use. The model posits that pathological Internet use

results from problematic cognitions including self-doubt, low self-efficacy, and

negative self-appraisal that promote Internet use to achieve positive social interaction

and feedback from others. The depressogenic nature of these cognitions (e.g., “I am
17
only good on the Internet” or “I am worthless offline, but online I am someone”)

suggests, in line with the present study, that depressive mood is particularly likely to

exacerbate maladaptive gaming-related beliefs. Future studies should investigate these

cognitive features of gaming disorder and their association with mood disorders to

develop more effective psychotherapeutic strategies for complex clients.

The strengths of the study included: (1) the use of psychometric instruments

including a broad range of measures on gaming-related variables (e.g., usage, context,

craving, beliefs); (2) a relatively large sample of adults who met the DSM-5 IGD

criteria and admitted to have a gaming problem; and (3) the inclusion of a follow-up

survey. However, there were several limitations that warrant acknowledgement. First,

the study relied on information gathered using an anonymous online survey, which

may have increased honest and reflective self-disclosure but was unable to capture

nonverbal information and did not include independent verification of responses.

Second, while the study recruited individuals with gaming problems with the intention

to quit games, it would not be appropriate to consider the abstinence period as

equivalent to an intervention. Relatedly, participants’ adherence to the 7-day

abstinence may not be comparable to a commitment to treatment, which tends to

involve a therapeutic alliance. It is possible that variables assessed in this study may

be more predictive of gains and treatment adherence in the context of a continuing

client-therapist arrangement. This study was also concerned with adherence with brief

abstinence, whereas abstinence may not be the goal intention of many individuals

entering treatment. The study employed a sample of individuals visiting a help site to

quit gaming, which was likely to have favoured individuals with more insight and

readiness to change. Also, given that adherence to abstinence was measured by self-

report, there may have been some recall bias; for example, participants who reported
18
they were abstinent when in fact they were playing a game on another device that they

did not consider ‘problematic’. Finally, this study examined intentions to change

gaming behaviour but did not assess participants’ capabilities and resources to commit

to this change, which may have identified subgroups on which certain clinical

variables may exert greater influence.

4.1 Conclusions

This study presents data that indicate successful short-term gaming abstainers

may not differ significantly from non-abstainers in terms of many demographic,

gaming-related, or clinical characteristics. Successful 7-day abstinence among gamers

with self-identified problems was associated with significantly lower likelihood of

endorsement of IGD withdrawal and preference for action shooting games. This

relatively large sample of help-seekers were generally psychologically complex, had

extensive histories of gaming behaviour, a high current commitment to gaming

activities, strong gaming-related beliefs, and mood symptoms. In Australia and many

other countries, there is an increasing need to address problematic gaming and offer

specialized service options to adults with gaming-related problems (King et al.,

2017a). While universal prevention initiatives to reduce screen time among at-risk

populations such as adolescents are beneficial, at the other end of the spectrum there

is a need for interventions tailored to gaming-related problems in adults. Further work

is needed to identify clinical predictors of treatment outcomes among adults with

IGD, with an emphasis on the individual and gaming-related variables that may

influence longer term recovery.

Role of Funding Sources

19
This work received financial support from a Discovery Early Career Researcher
Award (DECRA) DE170101198 funded by the Australian Research Council (ARC).
Funding
This work received financial support from a Discovery Early Career Researcher
Award (DECRA) DE170101198 funded by the Australian Research Council (ARC).

Conflict of Interest Statement

The authors report no conflicts of interest. The authors alone are responsible for the
content and writing of the paper.

Authors’ disclosures
None of the authors have anything to disclose.

Authors’ contribution
All authors contributed substantially and meaningfully to this study and the final
manuscript. DK and CA designed the study and wrote the protocol. DK and CA led
the recruitment and the data collection phase. DK conducted statistical analysis. DK
wrote the first draft of the manuscript and all authors have approved the final
manuscript.

Ethics
This study was approved by the local Research Ethics Committee and all subjects
provided written informed consent in accordance with the Helsinki declaration.

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Table 1 Baseline demographic and gaming-related characteristics of gaming abstainers versus non-
abstainers/dropouts

Non-abstainers/dropouts Effect
Abstainers (N=31) Group differences
(N=155) size
n (%) M (SD) n (%) M (SD) U or χ2 Sig. d/Φ
DEMOGRAPHIC
25.3
Age - 23.1 (4.8) - 1929 0.082 0.02
(6.5)
Sex: Male 147 (94.8) - 30 (96.8) - 0.210 0.647 0.03
Employed1 89 (57.4) - 14 (45.2) - 1.57 0.210 0.09
Relationship status:
101 (65.2) - 19 (61.3) - 0.169 0.681 0.03
Single
Educational attainment
High School or TAFE 47 (30.3) - 12 (38.7) - 0.060 0.496 0.02
University 89 (57.4) - 19 (61.3) - - - -
GAMING-RELATED
Age of first gaming - 8.8 (4.2) - 8.7 (7.7) 2045.0 0.190 0.01
Past year gaming hours 26.8
- 32.6 (19.5) - 1779.0 0.270 <0.01
p/w2 (10.4)
Other online activities 25.6
- 28.5 (24.5) - 2348.0 0.842 <0.01
p/w2 (17.6)
Gaming preferences
Action/shooting 94 (60.6) - 12 (38.7) - 5.07 0.029 0.17
MMO 83 (53.5) - 15 (48.4) - 0.276 0.599 0.03
Context of gaming
Usually alone 36 (23.2) - 8 (25.8) - 0.100 0.951 0.02
Usually in a group 20 (12.9) - 4 (12.9) - - - -
1
Refers to paid employment on any basis. 2Refers to a typical week in the past 12 months.
P/W: per week. MMO: Massively Multiplayer Online (Game), including role-playing (MMORPG) and battle arena (MOBA)
games. TAFE: Vocational education and training.

27
Table 2 Baseline mood symptoms and disordered gaming characteristics of gaming abstainers versus
non-abstainers/dropouts
Non-abstainers Group Effect
Abstainers (N=31)
(N=155) differences size
n (%) M (SD) n (%) M (SD) U or χ2 Sig. d/Φ
DISORDERED
GAMING
6.6
Total IGD criteria (/9) - - 6.1 (2.2) 2069.0 0.216 <0.01
(1.9)
Onset of IGD: 12+ 25
131 (84.5) - - 0.027 0.870 0.01
months ago (80.5)
Previous IGD
occurrences
7
First or second 44 (28.4) - - 0.438 0.508 0.05
(22.6)
24
Three or more 111 (71.6) - - - - -
(77.4)
Gaming Cognition 25.1
- 22.6 (7.9) 2006.5 0.211 <0.01
Score (/48) (9.3)
Gaming Craving
Thoughts about 5.1
- - 5.2 (1.1) 2098.0 0.943 <0.01
gaming (/7) (1.3)
5.8
Desire to play (/7) - - 5.5 (1.2) 1755.0 0.127 0.01
(1.3)
5.0
Ability to resist (/7) - - 4.6 (1.5) 1870.0 0.182 0.01
(1.7)
4.4
Urge to play (/7) - - 4.6 (.9) 2002.5 0.407 <0.01
(1.1)
Treatment intention
15
Quit indefinitely 84 (54.2) - - 1.018 0.601 0.07
(48.4)
14
Controlled use 56 (36.1) - - - - -
(45.2)
Uncertain 15 (9.7) - 2 (6.5) - - - -
MOOD SYMPTOMS
Anxiety – Moderate+ 21 (13.5) - 3 (9.7) - 0.556 0.456 0.05
15
Depression – Moderate+ 56 (36.1) - - 0.842 0.359 0.07
(48.4)
Stress – Moderate+ 18 (11.6) - 3 (9.7) - 0.215 0.643 0.04
107 107.8
Total QOL (/200) - - 2026.5 0.833 <0.01
(22.1) (23.0)
IGD: Internet gaming disorder. Moderate+: Refers to a total score within the moderate or greater severity
categories. QOL: Quality of Life.

Table 3
Symptoms of Internet gaming disorder positively endorsed by gaming abstainers versus non-
abstainers/dropouts
Non-abstainers (N=155) Abstainers (N=31) Group differences Effect size
Criterion1 n % n % U p d
Preoccupation 124 80.0 21 67.7 2108.0 0.134 0.01
Withdrawal 102 65.8 14 45.2 1906.5 0.031 0.03
Tolerance 85 54.8 19 61.3 2247.0 0.510 <0.01
Unsuccessful attempts 131 84.5 25 80.6 2309.5 0.594 <0.01
Loss of interests 122 78.7 24 77.4 2371.5 0.874 <0.01
Use despite harm 142 91.6 27 87.1 2294.0 0.427 <0.01
Deception 102 65.8 17 54.8 2139.0 0.247 0.01

28
Escape 116 74.8 22 71.0 2309.5 0.654 <0.01
Conflict 100 64.5 19 61.3 2325.0 0.733 <0.01

Table 4 Clinical profiles of gamers with and without anxiety and/or depression symptomatology
Effect
No mood (N=94) Mood group1 (N=65) Group differences
size
n (%) M (SD) n (%) M (SD) U or χ2 Sig. d/Φ
29.8 33.0
Total gaming hours p/w - - 2730.0 0.253 0.01
(17.1) (18.5)
5.8 7.3
Total IGD criteria (/9) - - 2125.0 <0.01 0.15
(2.0) (1.5)
Gaming Cognition 21.3 28.5
- - 2004.5 <0.01 0.17
Score (/48) (8.2) (8.2)
Gaming Craving: Urge 6.4 7.5
- - 2911.0 0.014 0.04
(/7) (2.3) (1.9)
118.3 94.8
Total QOL (/200) - - 1281.0 <0.01 0.29
(19.8) (17.9)
Onset of gaming
problem
Past 12 months 14 (14.4) - 10 (13.3) - 0.43 0.836 0.01
More than 12 months
83 (85.6) - 65 (86.7) -
ago
History of gaming
problems
First or second 32 (32.7) - 11 (14.7) - 7.36 <0.01 0.21
Three or more 66 (67.3) - 64 (85.3) -
Treatment Intention
Quit indefinitely 49 (50.0) - 39 (52.0) - 1.01 0.798 0.07
Controlled use 21 (21.4) - 19 (25.3) -
Brief abstinence 18 (18.4) - 10 (13.3) -
Uncertain 10 (10.2) - 7 (9.3) -
1
Refers to a score on either DASS-21 Anxiety or Depression subscale in the moderate or more severe category. IGD: Internet
gaming disorder. QOL: Quality of Life.

Table 5 A hierarchical regression model of age, gaming variables, and mood symptoms
predicting total IGD symptomatology

95% CI
Model B SE β t Sig. Lower Upper
Constant 1.2 0.76
Age 0.07 0.03 0.19 2.96 <0.01 0.02 0.12
Gaming hours per week 0.01 0.01 0.07 1.11 0.27 -0.01 0.02
Craving urge 0.17 0.13 0.10 1.33 0.19 -0.09 0.43
Gaming Cognition 0.08 0.02 0.37 5.02 <0.01 0.05 0.11
DASS-21 Anxiety 0.02 0.05 0.03 0.39 0.69 -0.08 0.12
DASS-21 Depression 0.12 0.04 0.25 3.08 <0.01 0.04 0.20
Model summary: R square=0.38. F(6,152)= 15.8, p<0.01.

29
Highlights:

> Clinical predictors of adherence to brief gaming abstinence were examined.

> Successful abstainers were less likely to report withdrawal symptoms.

> Mood symptoms were not related to adherence to gaming abstinence.

> Mood symptoms were associated with problematic gaming symptoms and beliefs.

> Problem gamers may benefit from withdrawal management and psychoeducation.

30