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Metrics details. With the growing number of gamers worldwide, adverse effects isolation, hospitalizations, excessive use, etc. In this exploratory study, we focused on characteristics, online habits and problematic overuse in adult MMORPG gamers. For all scales, a score above a specific threshold defined positivity.
The participating adult gamers were mainly young adult university graduates living alone in urban areas. Participants showed high rates of both Internet addiction This study found high MMORPG addiction rates, and self-reported adverse symptoms in important aspects of life, including mood and sleep. This confirms the need to set up relevant prevention programs against online game overuse. Dependence involves a complex system of bio psychosocial factors affecting individuals, their actions and their culture, and has also been referred to as a syndrome with multiple expressions [ 1 ].
The term dependence can be used generally with reference to the whole range of psychoactive drugs drug, chemical or substance use dependence or with specific reference to a particular drug or class of drugs alcohol or opioid dependence and refers to both physical and psychological elements [ 2 ].
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision DSM-IV-TR , substance dependence may involve several symptoms tolerance, withdrawal, adverse repercussions on social and professional areas, loss of control of the consumption, and persistence despite the adverse effects engendered.
The concept has since undergone major revision with the appearance of new types of entities, entitled non-chemical i. Clinicians tend to distinguish between abuse, dependence and addiction, referring to either substance or behavior. This distinction is sustained by recent neurobiological findings on the different neuronal processes involved in dependence or addiction [ 4 ].
Dependence could be defined as an adaptive neural response to the pharmacological effect of substance abuse, and is associated with withdrawal when the substance is not accessible. This definition corresponds to what was previously called "physical dependence", that is inadequate to explain substance and non-substance addiction. Several types of behavior, besides psychoactive substance use, produce a short-term reward that may engender persistent behavior, despite knowledge of adverse consequences.
These disorders have been conceptualized as lying along an impulsive-compulsive spectrum or an addiction spectrum such as "behavioral" addictions. In support of the second hypothesis, growing evidence suggests that behavioral addictions resemble substance addictions in many domains, including natural history, phenomenology, tolerance, and comorbidity, overlapping genetic contribution, neurobiological mechanism, and response to treatment [ 6 ].
The American Psychiatric Association A. A press release quoted O'Brien, chair of the Substance-Related Disorders Work Group, as saying: "substance research supported that pathological gambling and substance use disorders were very similar because both were related to poor impulse control and brain's system of reward and aggression" [ 7 ].
Since then, this "new disorder" has been the subject of scientific interest until the recent call for it to join the ranks of DSM V classification. Davis's theoretical model on Problematic Internet Use PIU distinguishes two different entities: i Specific PIU, related to a particular content and which could exist independently from the Internet vector, such as gambling and videogames and ii Generalized PIU which is related to specific Internet content such as chats, e-mails and social networks [ 9 ].
These games are the latest Internet-only gaming experience, and are typically represented by large, sophisticated and evolving virtual worlds set in different environments [ 12 ].
MMORPGs are played for much longer periods of time than other games [ 13 ], which could also indicate a potential for greater negative effects on players [ 14 ]. Up to now, little research has been carried out on online video games, particularly on the different aspects of online gaming, the characteristics of adult gamers and their addiction level.
Kim evaluated online game addiction using a modified version of Young's Internet Addiction Scale and observed a positive correlation between online game addiction and aggression and narcissistic personality traits, and a negative correlation between online game addiction and self-control [ 15 ].
In an exploratory study, Hussain examined the gender swapping phenomenon [ 16 ] and in a qualitative analysis using 71 online interviews, showed how gamers used MMORPG to alleviate negative feelings, providing detailed descriptions of personal problems that arise due to playing MMORPG in a third of subjects [ 17 ].
In another exploratory study, Longman separated international participants into 2 groups according to time spent playing MMORPG per week, and observed that the high use group presented low levels of offline social support and high levels of negative psychological symptoms [ 18 ]. Another approach focused on the relationship between addiction and avatar, the game character [ 14 ]. In this international study, Video games are a highly attractive leisure activity, and can even be used in medical applications pain, muscular rehabilitation, cognitive stimulation, etc.
To address this growing phenomenon, the government of South Korea, a pioneering country for MMORPG development, has just decided to introduce a midnight ban for young gamers with a lockout of 6 hours. MMORPG addiction is an emerging phenomenon which has been acknowledged for a decade in a context of controversy surrounding theories on behavioral addictions and "conceptual chaos" in the field of addictions [ 22 ]. Currently, no scientifically established and unanimously recognized classification for diagnosing online video game addiction exists [ 23 ].
Emerging data point to clinical and neurobiological similarities between substance use disorders and behavioral addictions [ 26 , 27 ]. To address IA, 2 different scales were used: the qualitative Goldberg Internet Addiction Disorder GIAD [ 8 ] including tolerance and withdrawal dependence criteria and the quantitative Orman Internet Stress Scale ISS [ 30 ] excluding tolerance and withdrawal dependence criteria and focusing on addiction characteristics such as loss of control and adverse consequences of excessive Internet use.
The target population of our study consisted of French MMORPG gamers aged over 18 and recruited online in discussion forum guilds often visited by the gamers. The self-administered nature of the questionnaire is, however, less robust than directed interviewing.
Self-administered online questionnaires have been used in other studies in these fields and have been described as a satisfactory method [ 31 ]. To ensure anonymity, we sent an invitation summarizing our study, with a link to the personalized study website, to guilds of WoW games between May and March Once gamers connected to the website, they had access to information on the researchers, aims of the study and clear instructions on the questionnaire, confidentiality and their right to withdraw at any time from the study.
Questionnaires were strictly anonymous and confidential, and no data that could identify gamers was collected [ e. Internet Protocol IP address which is a numerical label assigned to each computer participating in a computer network] according to French ethical standards.
All subjects were volunteers and declared that they were aged 18 years or older. All responders consented to online study participation and authorized the researchers to use their incomplete data when necessary. The online questionnaire took 45 minutes to complete. The first part of the questionnaire, consisted of a item self-administered list of questions assessing social and demographical data, the relationship between gaming and health, gaming and socio-professional consequences, and clinical criteria screening for IA and online game addiction.
The questionnaire had a consistent pattern and participants had to answer each question to gain access to the following one. Participants answered yes or no to all questions except for the following: i for the question "What are your qualifications?
The first part of the online questionnaire comprised 63 items including three Internet and online gaming screening instruments. Each scale has its own independent items. It has 7 items as for the original scale associated with online game use. The withdrawal symptoms for this tool were "agitation", "continuous thoughts of the Internet" and "involuntary hand movements". A score between 0 and 3 relates to a low tendency to addiction while a score between 4 and 9 corresponds to an addiction risk.
The benefit of this tool was its IA severity screening, the absence of "tolerance" or "withdrawal" symptoms, the focus on the adverse consequences of Internet abuse, the self-reported unsatisfying Internet abuse and loss of control. For all items of the 3 scales, participants answered yes or no. For each scale, the subjects whose score reached the cut-off point were considered to be positive.
A univariate analysis was performed using the two-sample t-test continuous variables and Pearson's chi-square test unmatched categorical variables. To assess independent factors associated with the DAS score recoded as positive or negative , a multivariate analysis was conducted using a logistic regression model.
The Benjamini and Hochberg procedure was used to control the effect of multiple comparisons [ 35 , 36 ]. The correction was applied to groups of simultaneous tests of null hypotheses. Analyses were considered as simultaneous when the independent variables described a characteristic from the same family addiction scales, baseline demographics, social impairment, etc.
Corrected p-values and corrected Confidence Intervals were calculated in order to control the False Discovery Rate. The significance threshold was set to 0.
Of the visitors to the online website dedicated to this project, completed the online questionnaire Sixty three records were excluded: 56 subjects had indicated that they did not agree to the data being used if their data were incomplete.
Four hundred and forty eight responders were therefore included in this data analysis According to the DAS Scale, With adjustment for age, sex and educational level [ 14 , 15 , 17 , 33 , 34 ], the DAS score was significantly associated with a large number of variables in the following dimensions: social life, Internet and online gaming, emotional changes and health impairment.
In the same way, they increased the amount of time spent on the Internet to obtain satisfaction for at least 12 months OR: 2. We also assessed factors associated with gaming Table 7. Sleep deprivation due to play OR: 2. For the question "how do you feel since you started playing? We also studied the effects of gaming on health Table 7.
Concerning the role of guilds, gamers who felt their guild imposed demands on their time reported higher rates of DAS positivity 3. Also, these 3 tools did not estimate the same entities, suggesting a difference between IA and online gaming addiction.
The psychometric properties of IA scales are promising [ 15 , 39 , 40 ], whereas others have based their research on gamer interviews [ 14 , 17 , 38 ]. In addition, previous studies do not differentiate between the Internet and online video games, nor between different types of online video games [ 41 ]. Our study has a number of limitations. Firstly, the representativeness of the sample analyzed here could be problematic. Participants were not randomly chosen, and participation was voluntary subjects accepted to take part in the assessment on reaching the webpage for the online questionnaire.
Probably not all types of MMORPG gamers were included in this study, especially hardcore because the responses would cause them to waste time that could be spent playing or casual gamers because they may feel unconcerned by the study.
On the other hand, online gamers are by definition difficult to reach in any other way apart from the internet. Additionally, the average time spent gaming observed here was similar to other studies [ 33 ]. Thirdly, the assessments were only based on self-reports. Responders may have been defensive in their answers, i.
Nevertheless, the guarantee of data anonymity may have encouraged gamers to provide honest answers. Fifthly, the concordance of the self-reported gradation of gaming engagement Casual, Hardcore gamer and No life and DAS positivity, and the different adverse effects reported suggested honest responses from a community which was cautious about providing information which may harm the public image of online games. In terms of baseline characteristics, our study showed that French adult MMORPG gamers are often young, employed, adult University graduates, and tend to live alone in urban areas.
Interpersonal interactions A young age of online gaming onset was a stronger variable associated with DAS positivity compared to the number of years of play. We observed the same number of years playing online video games for both groups [8. We chose to adapt the DSM-IV-TR substance dependence scale for online video games because excessive involvement in online games can be described as a form of behavioral addiction in which behavior is defined by gaming activity.
This position was reinforced by the A. In addition, the criteria for problematic video game playing including tolerance, derived from the diagnostic criteria of substance dependence [ 25 ].
Here, we observed that for the 3 scales, the addiction rate was higher compared to other studies [ 14 , 17 ]. The higher rates for IA in our study ISS focused on addiction with loss of control and the persistence of the behavior despite adverse consequences in important areas; whereas GIAD evaluated tolerance and withdrawal symptoms in relation to dependence.