Internet gaming disorder (IGD) is the persistent and repetitive use of the Internet to engage in video games through a single or multiplayer interface, which can cause significant impairment or distress. With technological advancements through portable handheld devices over the past decade, along with their global presence, video games have found a new medium that can provide instant access for both casual and avid users. Unfortunately, this increases the likelihood of addiction exponentially. IGD shares a similar pathophysiological etiology to drug or gambling addictions. However, IGD can be difficult to manage due to the ease of access to video gaming and the limited understanding of the newly recognized disorder.
This study aims to fill the knowledge gap regarding the limited research on Internet gaming addiction, its effects on human cognitive-behavioral function, and pharmacotherapy management, as observed in our patient who developed IGD, which started as a casual recreational hobby among peers. . This incident also highlights the lack of social awareness and seriousness attributed to this disorder. It focuses on the use of N-acetylcysteine as well as other psychological and psychotropic drugs in management.
In today’s world, video games have become a regular part of daily activities as a form of recreation and entertainment. In recent years, many technological innovations have been made in the field of Internet and computer games. These changes change the concept of the game, making it highly addictive for some. As a result, internet gaming disorder (IGD) was recently included as a potential diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (APA). . In addition, the World Health Organization (WHO) has recognized the impact of gaming on public health. Therefore, in the 11th revision of the International Classification of Diseases (ICD-11), the diagnosis “gaming disorder” is mentioned. .
The APA defines IGD as persistent and repeated internet use to engage in gaming that causes significant impairment. WHO defines this disorder as a loss of control over play, increasing the priority given to play, and continuing to play despite negative consequences. A pattern of gaming behavior results in marked difficulty or significant impairment in multiple domains of functioning, including, but not limited to, personal, family, social, educational, and occupational domains. This disorder includes online and offline gaming, digital or video. Online games such as massively multiplayer online role-playing games (MMORPGs) in which Internet users interact with each other are highly addictive. .
Neurobiological findings suggest that pathological gambling and drug addiction share a common pathophysiology. In gambling, there has been a shift from traditional casinos to online gambling. Online gambling is promoted and advertised through social media and email marketing. In addition, the frequent use of online devices for gambling on the stock market and bitcoin trading has been noted. . Online games like MMORPGs are the most addictive. IGD may also be associated with such addictive findings. The prevalence of IGD is estimated between 1.2% and 5.5%.
Additionally, one in ten teens who play video games may have problematic game use . Thus, more treatments are needed to prevent or treat such addiction-related pathologies. N-acetylcysteine (NAC) is a glutaminergic drug that has been studied as a treatment option to reduce clinical symptoms among individuals with addiction or dependence. . If the pathophysiology of gaming addiction is potentially similar, similar therapy and intervention may also be beneficial.
We present the case of a college student who presented with symptoms of IGD and associated addictive behavior. In our case, we consider the use of the NAC protocol as an intervention for the treatment of IGD, as glutaminergic drugs have shown potential in the treatment of substance use disorder and pathological gambling.
A 19-year-old college student was brought to the emergency department by his parents for spending too much time playing video games. According to his parents, he spent 12 to 14 hours a day gaming during the 2019 coronavirus pandemic for the past three months, isolated in his bedroom. He reported having disrupted sleep cycles, irregular mealtimes, neglecting self-care and personal hygiene. He was irritable and verbally aggressive when confronted with his gambling obsession. He has lost interest in his daily extracurricular and sports activities and recently received repeated complaints from his professors about his poor academic performance.
He was introduced to the online video game by his peers two years ago. At first, he started playing for one to two hours on weekdays and five to six hours on weekends. As his passion for gaming began to increase with great success in games (i.e. awards, achievements, winning streaks, etc.), his gaming time increased to six to eight hours each day. There was no family or personal history of psychiatric illness or any symptoms of depression, anxiety, or psychosis associated with any substance use disorder.
On Mental Status Examination (MSE), the patient appeared sad and withdrawn with minimal verbal interaction. There were no formal thought disorders, delusions, obsessions, or suicidal ideation. There were no perceptual abnormalities or cognitive impairment. However, his addiction to video games resulted in his impaired thinking and judgment. IGD was assessed with a nine-item IGD scale. He was subsequently diagnosed with IGD based on the MSE, DSM-5, and IGD scale.
A complete blood count, thyroid, kidney, and liver function tests, as well as a urine drug screen revealed no abnormalities.
The patient was transferred to a rehabilitation center for three months to provide a gadget-free environment and supportive psychotherapy. Pharmacological treatment consisted of NAC 600 mg twice daily to control game-seeking urges, olanzapine 5 mg once daily to control aggressive behavior (eventually tapered and discontinued over a month), and diazepam 5 mg at bedtime for insomnia.
During the first weeks of rehabilitation, the patient showed no significant improvement, with limited perception, reluctance to share thoughts, depression, and intermittent bouts of crying. Withdrawal symptoms such as strong cravings, restlessness, frequent headaches, and reoccurrence of game-play scenarios in his sleep were frequently reported. After a month, the patient began to understand his pathological behavior. Her mood and sleep improved and she reported less cravings. He began to actively participate in indoor/outdoor activities, became more sociable during therapy, and kept up with his academics.
At the one-month follow-up, the patient and parents denied witnessing any addictive behavior or undue indifference to play. He uses his mobile smartphone for daily internet and social media use under parental supervision. He continues his medication regularly.
When investigating video games for their highly addictive potential, it is important to understand how repetitive neural stimulation during gameplay can affect cortical activity and the cognitive system. Decreased gray matter volume in the anterior cingulate gyrus, dorsolateral prefrontal cortex, and motor cortex was noted in patients with IGD. .
Changes in the structure of the putamen have been reported in patients with IGD. Functional magnetic resonance imaging analysis also demonstrated increased activation in bilateral cingulate cortex, anterior insula, and striatum. . Impaired cognitive control in patients with IGD leading to compulsive gaming behavior may be associated with increased striatum volume. The amygdala is responsible for emotional control, and its dysfunction may be associated with heightened emphasis on emotions and immediate rewards, leading to excessive gaming.
The mesolimbic dopamine pathway is an intrinsic reward circuit pathway. It includes dopaminergic projections from the ventral tegmental area to the nucleus accumbens and olfactory tubercle. As with substance use disorders, decreased dopaminergic activity associated with a lack of general reward results in excessive Internet use and gaming. .
Glutamate is the main excitatory neurotransmitter of the nervous system. Addiction results from a reduced ability to inhibit drug-seeking in response to environmental constraints. The proposed mechanism is a change in glutamate homeostasis and activation of N-methyl-D-aspartate and dopamine glutamatergic receptors. Blocking glutamate release prevents drug-seeking behaviors in substance-using patients .
Glutamatergic drugs act simultaneously on the dopaminergic and glutamatergic systems and prevent relapse in substance abusers. NAC, a glutamatergic drug, is derived from the amino acid L-cysteine and can increase extracellular levels of glutamate in the nucleus accumbens. It is used effectively in the treatment of substance use disorder and trichotillomania, and may be useful in the treatment of obsessive-compulsive disorder and gambling disorder. Glutamate acts on metabotropic and ionotropic glutamate receptors. NAC can stimulate inhibitory metabotropic glutamate receptors, reduce synaptic release of glutamate, and help control drug and behavioral addiction. .
There are no long-term follow-up studies for the treatment of IGD. However, early diagnosis of IGD can prevent detrimental effects on functional and social domains of life. Management must be done with great care due to the potential consequences of withdrawal symptoms, anxiety, depression, and negative self-esteem, along with addictive behavior through other forms of “reward.”
This case report, while proposing the use of NAC as a new treatment approach for IGD, highlights the lack of social awareness, understanding, and consequent impact of IGD on an individual’s life. Although data on the use of NAC in the treatment of addictions, including gambling disorders, are limited, further research may shed light on its potentially widespread use while revealing the consequences of gaming addiction and its broader social and mental health implications.