Australas Psychiatry. 2017 Jan 1:1039856216684714. doi: 10.1177/1039856216684714.
Research is limited on psychiatrists’ opinions on the concepts of Internet Gaming Disorder (IGD) and Problematic Internet Use (PIU). We aimed to assess health literacy among psychiatrists on IGD/PIU.
A self-report survey was administered online to members of the Royal Australia and New Zealand College of Psychiatrists (RANZCP) ( n=289).
The majority (93.7%) were familiar with the concepts of IGD/PIU. The majority (78.86%) thought it is possible to be ‘addicted’ to non-gaming internet content, and 76.12% thought non-gaming addictions could possibly be included in classificatory systems. Forty-eight (35.6%) felt that IGD maybe common in their practice. Only 22 (16.3%) felt they were confident in managing IGD. Child psychiatrists were more likely to screen routinely for IGD (11/45 vs. 7/95; Fishers Exact test χ2=7.95, df=1, p<0.01) and were more likely to elicit specific symptoms of addiction (16/45 vs. 9/95; Fishers Exact test χ2=14.16, df=1, p<0.001).
We recommend adoption of terms alternate to PIU/IGD which are more in line with the content of material irrespective of medium of access. Screening instruments/ protocols are needed to assist in early diagnosis and service planning. Barriers to screening would need to be addressed both in research and service settings.
Young1 used ‘Internet Addiction Disorder’ first to describe patients having problems regarding computer use and internet access. Other terms include Problematic Internet Use (PIU)2 and Internet Gaming Disorder (IGD).3 PIU refers to internet-related problems within a broad addiction framework irrespective of the content.2 IGD has been included in the DSM 53 as a condition for further study. The prevalence of PIU/ IGD has varied widely but seems to be a significant problem in the community.4
‘Excessive Screen Time’ is an alternative conceptualisation which has been reported to contribute to significant physical and mental problems.5 Surveys of psychiatrists on internet-related problems are limited. Thorens et al.6 surveyed 94 out of 98 psychiatrists attending a symposium. They reported three groups: disbelievers, nosology believers and nosology/ treatment believers. While nosology/ treatment believers asserted the availability of effective treatment (mainly psychological), nosology believers were less affirmative regarding treatment. They concluded that the concept of internet addiction is largely acknowledged as a clinical reality by Swiss psychiatrists but routine screening and treatment remain uncommon. An earlier study7 surveyed 35 mental health practitioners. They noted content-based sub-types of internet addiction such as Cybersexual Addiction, Cyber-relationship Addiction (akin to modern-day social media), other cyber addictions, for example online gambling, information overload and ‘Computer Addiction’, for example gaming. The majority of respondents (90%) thought that addictive use of the internet may become a significant future problem.
No Australian study has assessed the health literacy of psychiatrists on the concepts of PIU or IGD. In this context health literacy is the knowledge, attitudes and beliefs regarding a health problem that assist recognition and management.8 The aim of the present study was to elicit the views and experiences of Australian and New Zealand psychiatrists.
The online survey was generated using Survey Monkey. All psychiatrists listed with the RANZCP (n=5400) were eligible.
A total of 289 responses were received (5.3% of those eligible). Demographic data are presented in Table 1.
Table 1. Demographic and other features of the study sample
The survey comprised 42 questions with an exit option after 20 questions on the basis of skip logic. The initial part of the survey was about opinions about the concept of IGD/ PIU, which was relevant to the sample as a whole. The second part explored clinical experience of psychiatrists. The questions were generated based on clinical experience, literature search and two previous surveys.6,7
Data were inspected for normal distribution. Descriptive data were calculated. Chi-square tests were used for between-group differences of categorical variables using SPSS v20.
The survey was approved by the Southwest Sydney Local Health District Human Research and Ethics Committee and the RANZCP Committee for Research. Written informed consent was obtained from all participants. Data regarding this paper will be stored under a password-protected document on the first author’s computer and can be accessed on request.
The vast majority of psychiatrists (93.70%) had heard of IGD/ PIU. Table 2 details psychiatrists’ opinions on IGD and PIU.
Table 2. Attitudes and beliefs of psychiatrists regarding Internet Gaming Disorder (IGD) and Problematic Internet Use (PIU)
After the exit option, 142 psychiatrists (58.2%) continued the survey. Child and adolescent psychiatrists (9/142) were less likely to exit the survey than others (133/142; Fishers Exact test χ2=31.4, df=1, p<0.001). Eighty-four (66.7%) considered IGD to be more common in males. The majority (n=74, 61.2%) thought patients with IGD would be more likely to have problems with gaming, followed by social networking (n=40, 33.1%). Barriers to screening for IGD in routine practice included lack of belief in the concept (n=96, 71.6%), lack of time (n=76, 55.6%), or lack of confidence in assessment (n=71; 52.6%). Table 3 details practices/experiences with IGD.
Table 3. Psychiatrists’ practice and experience with Internet Gaming Disorder (IGD)
There was a statistical trend for child and adolescent psychiatrists to be more likely to agree IGD is a problem across all ages (20/51 vs. 47/188 (χ2=5.6, df=2, p=0.06)). Child psychiatrists were more likely to support routine screening for IGD (29/50 vs. 68/186) (χ2=8.6, df=2, p<0.02), and all media issues during clinical assessment (45/50 vs. 110/186) (χ2=16.7, df=2, p<0.001). However, child psychiatrists were not more likely to agree IGD is a mental health problem (χ2=4.2, df=2, p=0.12), a significant problem across all ages in the future (χ2=.16, df=2, p=0.92) and is more common in children and adolescents (χ2=.74, df=2, p=0.69). In their practice, child and adolescent psychiatrists were more likely to screen routinely for IGD (11/45 vs. 7/95; Fishers Exact test χ2=7.95, df=1, p<0.01) and were more likely to inquire regarding specific symptoms of addiction (16/45 vs. 9/95; Fishers Exact test χ2=14.16, df=1, p<0.001). However, child psychiatrists and others did not differ in their degree of confidence of managing PIU/IGD (33/42 vs. 77/88 felt they were not confident in managing IGD; Fishers Exact test χ2=1.741, df=1, p=0.15)
Most psychiatrists (82.64%) agreed that electronic games are useful for children’s education/ development. Most could name two games which they considered useful, while 40.98% indicated that they at least sometimes encourage children to play certain games on the internet.
The majority of the 289 respondents were aware of the concept and magnitude of IGD/PIU. About one-fifth of psychiatrists in this survey opined that problems with gaming do not reflect a disorder at all. It is common for children to have conflict with their parents around gaming, as a parenting issue. These would correspond with the nosological disbelievers in Thorens et al.’s study.6
Both PIU and IGD suffer from significant limitations in their definition and concept. PIU describes the problems experienced with internet use irrespective of content. This goes against the DSM’s current conceptualisation of IGD, where the disorder seems to take into account both content (gaming) and signs of problematic use. The term IGD includes content (gaming) but not other content which could be problematic, for example excessive social networking. Further, it is confusing in that it could include non-internet electronic gaming. Perhaps this explains why more psychiatrists in this study agreed that PIU is a better diagnostic category than IGD.
More than half of the psychiatrists agree with the statement that ‘conceptually, a substance abuse/pathological gambling model is best suited to understand IGD’. However, problems with the addiction model include applicability of addiction criteria to IGD,9 IGD as a coping mechanism,10 the relevance of the concepts of flow, satisfaction and frustration as contributing to overuse of gaming10 and wider exploration of the meaning of social networking.11 While duration of online activity certainly has implications for physical health,4 its applicability as a criterion for IGD has been criticised.9 Gaming has been used in the treatment of mental health issues and in development of positive resilience.12 Perhaps this explains why a fifth of respondents in this survey did not agree with the idea of a substance addiction model.
Like others,6,7,9 the majority of psychiatrists in this survey noted that it is possible to be addicted to non-gaming content. This supports arguments that ‘internet addiction’ should be replaced by terms that refer to the specific behaviours regardless of whether these are performed online or offline. Neither PIU nor IGD capture non-internet-based electronic gaming. The common point is the presence of a screen. Therefore, we propose that a broad category named ‘Screen Use Disorder’ be created in future systems of classification. This term would be seen as akin to ‘Substance Use Disorder’ as an overarching term that refers to the specific behaviours regardless of whether these are performed online or offline. We propose that further classification should be behaviour specific, for example Screen Use Disorder: Gaming, or Screen Use Disorder: Social networking, etc. This is in line with other recommendations.7,9 We note that this would not address some of the deficiencies of the concept of the addiction model as above.
The majority of psychiatrists inquire about duration of screen time and presence of a screen in the bedroom; however, fewer psychiatrists screen for IGD. This potentially suggests a gap in practice, where psychiatrists are probably more aware of EST as opposed to IGD. As with previous surveys,6 psychiatrists in this survey are aware of the concept, they do not necessarily screen for the disorder and they have limited confidence in managing it. In this survey PIU was perceived as a greater problem in males. A recent survey13 shows that while gaming rates are higher in males, problem internet behaviours were more common in females. This adds credence to the idea that girls are not necessarily gaming on screen but are equally affected by the associated problems. Perhaps girls are more likely to spend time social networking or on other screen-based activities. This population is unlikely to be captured by the concept of IGD.
To our knowledge this is the first report of psychiatrists’ attitudes and beliefs on the clinical utility of the concepts of IGD/PIU. The overall response was 5.3% of those eligible. The main limitation of the survey is that it cannot be interpreted as representative of Australasian psychiatrists broadly. However, the higher response from child and adolescent faculty (29.4%) indicates it may be more representative of these psychiatrists.
This survey has implications for the concept of IGD/ PIU and the practice of psychiatrists dealing with these issues. While PIU/ IGD seem to be significant problems in the community, their place in classificatory systems is as yet unclear. We recommend adoption of alternate terms which are more in line with the content of material irrespective of medium of access. Psychiatrists seem more aware of amount of screen time spent both regarding gaming specifically and any content generally. Confidence among psychiatrists in managing IGD was low. This is a matter of concern. Considering the scale of the problem, this has significant implications for service delivery. We recommend that screening instruments/ protocols be developed to assist in early diagnosis and plan services. Countries such as Singapore and South Korea have extensive services organised specifically for patients with IGD. These would need to be replicated in Australia. Barriers to screening for IGD would need to be addressed both in research and service settings.
Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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