Internet gaming and related psychotic disorder: An emerging phenomenon

Abstract

Internet addiction has recently been suggested as a possible diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and incorporated in the International Classification of Diseases 11^th Revision (ICD-11) as a gaming disorder, predominantly, online or offline. Mostly, psychotic phenomena have been described by either alcohol or opioid withdrawal, but there is a paucity of literature on Internet-related psychosis. We report two cases from Northern India of sudden onset of psychosis due to Internet addiction. The contents of hallucinations and delusions reflected themes of Internet gaming. Psychosis as a specifier for Internet gaming disorder (IGD) is not defined in DSM-5, whereas it should be considered as one of the presentations of Internet addiction.

There is an increasing trend of video games among children and adults. What started as a leisure has now become a major addiction in their lives. The overall prevalence of Internet gaming disorder (IGD) was 3.5% among school children.[1] Point prevalence for ages 15–19 years was 8.4% males and 4.5% females.[2] Its quick rise to prominence has stimulated scientific inquiry and public concern. Some studies have emphasized the positive effects of playing video games by increasing focus on four main domains, that is, cognitive, motivational, emotional, and social.[3] However, harmful physical effects have also been documented. Moreover, the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has included IGD in Section III, “Conditions for Further Study.”[2] It is defined as a preoccupation with Internet games, tolerance, etc., which often leads to significant daily, work, and/or educational disruption.[3] Other psychiatric disorders, such as depression and anxiety, have also been reported.[4] However, we report cases (informed consent obtained) with varied presentations arising from IGD withdrawal and IGD-induced psychosis.

CASE SERIES

Case 1: A 40-year-old married man of middle socioeconomic status was brought to the Department of Psychiatry with complaints of suspiciousness, fearfulness, and decreased sleep for the past 3 months. History revealed that he used to play an Internet game named Vivo Live for the past year. Eventually, when he lost a hefty amount of money (2 lakhs) in these games, he decided to stop playing. He firmly believed that other players were watching him through satellite about his eating, sleeping, and bathing activities. Therefore, he preferred switching off the lights while using the bathroom lest they may spy on him, attributed to the purpose of re-engaging him in playing the game. Later on, he incorporated his family members into his suspiciousness. He stopped watching television and using social media platforms as he believed that his videos were being circulated and shown on these sites. He also stopped doing work from home because he believed that his video conferences were continuously being recorded. On the Mental State Examination (MSE), he was well-built and kept. Eye-to-eye contact was evasive, and responses were guarded. The mood and affect were anxiety. Thought content showed delusion of persecution and reference. Attention and concentration were impaired. He lacked insight, and there was no real contact. Routine investigations or urine screens for drugs were normal. No abnormalities were found on the non-contrast computed tomography (NCCT) brain. His score on the Young Internet Addiction Test (IAT) Scale was 55. The probable diagnosis was IGD with psychosis. He was treated with risperidone 3 mg, which was gradually increased to 6 mg, trihexyphenidyl 2 mg, and lorazepam 2 mg. During follow-up, there was significant improvement within 2 weeks and had an early remission.

Case 2: A 16-year-old school-going male student was brought to the psychiatry outpatient department (OPD) by his parents with complaints of disorganized behavior, suspiciousness, and markedly decreased sleep for the past 3 months. He was acknowledged as a bright student with exceptional abilities in computer skills. On a detailed evaluation, his parents revealed that he started to spend hours on his computer and began playing video games at the age of 10 years. Initially, he used to play for about an hour daily, which gradually increased to 12–14 hours daily. Most of the time, he used to play war games. For the last 3 months, his parents noticed abnormalities in his behavior. He was described as severely irritable and with daily outbursts of uncontrollable anger. He had isolated himself in his room and exhibited disorganized behavior of pacing around the room, smiling, and talking to himself. He was seen shooting with an imaginary gun, hiding in places, and defending himself as if in a war. He was reacting to the enemy soldier in the video game. He was suspicious about neighbors who connived with enemies and were plotting against him to eliminate them. The quantity of sleep was also markedly reduced, and quality was disturbed. MSE revealed distractibility and hallucinatory behavior. The speech was minimal and often irrelevant. He displayed oddities in his behavior as if shooting with a gun (imaginary) and making grunting noises, which were out of context. Thought content showed delusion of persecution and reference. Attention and concentration were impaired. He lacked insight, and reality contact was broken. Routine investigations or urine screens for drugs were normal. The NCCT brain did not show any significant abnormalities. The score on the IAT scale was 68. Thus, the probable diagnosis was IGD with psychosis. He was given olanzapine 5 mg daily, which was gradually increased to 15 mg. He responded to the treatment, and symptoms were remitted within 4 weeks. Other therapies, such as cognitive behavior therapy (CBT), habit reversal therapy (HRT), and reality therapy (RT), were planned. Gradually, he resumed his schooling and is doing well.

Case 3: A 15-year-old school-going female student was brought to the psychiatry OPD by her parents with complaints of fearfulness, suspiciousness, and markedly decreased sleep for the past 2 months. History revealed that she used to play an Internet game for a year, in which the player had to defend and kill the opponents. Due to her examinations, the patient's family members advised her to stop playing it, and gradually, her sleep decreased from 8 hours to 3–4 hours at night. Then, the family members started observing odd and unusual behavior. She used to hide underneath the bed, saying that people were going to kill her. She would ask her family members not to let any stranger come inside. When asked about her behavior, she would say that her opponents in the video games wanted to take revenge on her. On MSE, she was thin-built and kept. Eye-to-eye contact was evasive, and responses were guarded. Affect was anxiety. Thought content showed delusion of persecution. Attention and concentration were impaired. She lacked insight, and her judgment was impaired. Routine investigations or urine screens for drugs were normal. No abnormalities were found on the NCCT brain. Her score on the IAT was 62. The probable diagnosis was IGD with psychosis. She was treated with haloperidol 5 mg, trihexyphenidyl 2 mg, and lorazepam 2 mg. During follow-up, there was a significant improvement in a month.

Case 4: A 16-year-old unmarried man from a lower socioeconomic status was brought to the Department of Psychiatry with complaints of talking to himself, repeated episodes of self-harm, and decreased sleep for the past 2 months. History revealed that the patient used to play an Internet game for the past year. His parents stopped him from playing the game because of his academic decline. Following this, family members noticed that the patient would mutter to himself while sitting alone, which was not comprehensible to others. There were also repeated episodes of self-harm. Because of this, he could not be left alone. When family members persuaded him to tell the reason for the same, the patient said that he could hear the voices of his fellow players asking him to kill himself as he had committed a mistake by stopping playing the game. On MSE, he was well-built and kept. Eye-to-eye contact was evasive, and responses were guarded. The affect was anxiety. Auditory hallucinations were present. Attention and concentration were impaired. He lacked insight, and there was no real contact. Routine investigations or urine screens for drugs were normal. No abnormalities were found on the NCCT brain. His score on the IAT was 70. The probable diagnosis was IGD with psychosis. He was treated with risperidone 3 mg, which was gradually increased to 6 mg, trihexyphenidyl 2 mg, and lorazepam 2 mg. During follow-up, there was significant improvement within 3 weeks.

Case 5: An 18-year-old unmarried woman from a lower socioeconomic status was brought to the Department of Psychiatry with complaints of fearfulness and decreased sleep for the past 2 months. History revealed that the patient used to play an Internet shooting game. Worried about her future, her parents took away her phone. Following this, the patient started remaining fearful and started saying that she can hear the voices of the players saying that they will suck blood from her and her family as she had shed the blood of so many players during the game. On MSE, she was thin-built and kept. The affect was anxiety. Thought content showed delusion of persecution, and auditory hallucinations were present. Attention and concentration were impaired. Insight was absent. Routine investigations or urine screens for drugs were normal. No abnormalities were found on the NCCT brain. Her score on the IAT was 65. The probable diagnosis was IGD with psychosis. He was treated with olanzapine 5 mg, which was gradually increased to 10 mg and clonazepam 0.5 mg. During follow-up, there was significant improvement within 1 month.

DISCUSSION

The patients developed florid psychotic symptoms due to Internet gaming. The content of hallucinations and delusion also reflected the theme of the video games. There was the loss of ego boundaries between the self and the world. The video games presumably send chaotic information causing “paralysis of analysis” of the brain. To handle this crisis, the brain focuses on single information of the virtual world by activating the thinking fast (instinctual) pathway rather than the thinking slow pathway of the real world. It makes the virtual world a reality and the real world a virtual world. The possible explanation could be sleep deprivation disrupting biorhythm, leading to increased formation of free radicals causing neurotoxicity and thus having detrimental psychological effects. Sleep deprivation is known to induce psychosis or precipitate mania in bipolar disorder.[5]

The neurobiological basis of IGD is still under investigation. Voxel-based morphometric studies demonstrated decreased gray matter in persons with IGD relative to controls in the inferior frontal lobe, insula, cingulate, dorsolateral prefrontal cortex (DLPFC), precuneus, and amygdala. These brain areas are involved in cognitive control, error processing, decision-making, impulse control, and reward.[6] The frontal neocortex is associated with the processing of sensory information from the limbic and rostral systems. This lack of sleep disrupts the frontal cortex-induced control of sensory inputs, resulting in hallucinations and delusions.[7] Internet gaming has now become an industry driven by profit. It uses technology that manipulates human psychology, encourages spending, and takes away free will from humans. In a way, digital technology has silently invaded non-negotiable essentials of human lives.

CONCLUSION

It is, therefore, recommended that future versions of DSM-5 diagnostic criteria should be modified for IGD by incorporating a specifier of psychosis when either the hallucination or the delusion occurs with the gaming-related theme.

Declaration of patient consent

The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.