Psychiatry and Clinical Neurosciences 2017; 71: 479–491
12457
Review Article
Typology of Internet gaming disorder and its clinical
implications
Seung-Yup Lee, MD,1 Hae Kook Lee, MD, PhD1* and Hyekyung Choo, PhD2
1
Department of Psychiatry, College of Medicine, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Uijeongbu,
Republic of Korea and 2Faculty of Arts and Social Sciences, Department of Social Work, National University of Singapore,
Singapore
Various perspectives exist regarding Internet gaming
disorder. While the concept of behavioral addiction
is gaining recognition, some view the phenomenon
as merely excessive indulgence in online pastimes.
Still, in recent years, complaints from patients or
their family members about problems related to
Internet use, particularly Internet gaming, have
become more common. However, the clinical pic-
ture of Internet gaming disorder could be obscured
by its heterogeneous manifestations with other
intertwined factors, such as psychiatric comorbid-
ities, neurodevelopmental factors, sociocultural fac-
tors, and game-related factors, which may influence
the pathogenesis as well as the clinical course. To
mitigate such problems, clinicians should be able to
consider diverse aspects related to Internet gaming
T HE DSM-5, PUBLISHED by the American Psy-
chiatric Association, includes Internet gaming
disorder (IGD) as a condition that warrants further
investigation. One of the most noticeable changes
regarding addiction diagnoses in the DSM-5 is the
introduction of non-substance addiction as a formal
psychiatric diagnosis. Pathological gambling in the
DSM-IV was moved from the impulse-control disor-
der section to the addiction section and renamed as
gambling disorder (GD). The medical system has
recognized and accepted ‘behavior addiction’ as an
addictive disorder. This conceptual change also
increases the likelihood of IGD eventually becoming
*Correspondence: Hae Kook Lee, MD, PhD, Department of Psychiatry,
Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic
University of Korea, 271, Cheonbo-Ro, Uijeongbu-si, Gyeonggi-do
11765, Republic of Korea. Email: nplhk@catholic.ac.kr
Received 5 April 2016; revised 12 August 2016;
accepted 14 September 2016.
© 2016 The Authors
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
doi:10.1111/pcn.
disorder. Classifying such a heterogeneous problem
into subtypes that share a similar etiology or phe-
nomenology may provide additional clues in the
diagnostic process and allow us to designate availa-
ble clinical resources for particularly vulnerable fac-
tors. In this review paper, we suggest a typology of
‘impulsive/aggressive,’ ‘emotionally vulnerable,’
‘socially conditioned,’ and ‘not otherwise specified’
as subtypes of the heterogeneous phenomena of
pathological Internet gaming. The implications of
these subtypes for assessment and treatment pla-
nning will also be highlighted.
Key words: behavior addiction, classification, Inter-
net gaming disorder, pathways model, typology.
a formal diagnosis in future DSM updates, as IGD,
GD, and substance use disorder share diagnostic cri-
teria1 (Table 1).
Like other addictive disorders, IGD may negatively
affect multiple domains, such as interpersonal,
social, academic, and occupational functioning, and
is associated with many psychiatric problems.2,3
With the continuous growth of information technol-
ogy and its increasing acceptance by the general pop-
ulation, problems related to IGD are also anticipated
to rise. In the Republic of Korea, the nation with the
highest fixed-broadband subscription rate,4 the prev-
alence of high-risk Internet addiction was reported to
be 12.5% for adolescents and 5.8% in the adult pop-
ulation.5 Furthermore, the socioeconomic losses
experienced in Korea in 2009 due to Internet addic-
tion were estimated to be in the range of 1.5–-
4.5 billion US dollars.6 For mental health, IGD was
reported to be associated with a variety of mental
479
480 S-Y. Lee et al. Psychiatry and Clinical Neurosciences 2017; 71: 479–491

Table 1. Comparison of DSM-5 diagnostic criteria between Internet gaming disorder and gambling disorder

Internet gaming disorder† Gambling disorder

Analogous criteria
Preoccupation Preoccupation with Internet games Is often preoccupied with gambling

Withdrawal Withdrawal symptoms when Internet Is restless or irritable when

gaming is taken away
Tolerance Needs to spend increasing amount of
time on Internet games
Loss of control Unsuccessful attempts to control the
participation of Internet games
Lie Has deceived family members,
therapists, or others regarding the
amount of Internet gaming
Escape/self-remedy Use of Internet games to escape or
relieve a negative mood
Significant impairment in role Has jeopardized or lost a significant
function relationship, job, or educational or
career opportunity because of
participation in Internet games
Unique criteria
5 (or more) in a 12-month period
Continued excessive use of Internet
games despite knowledge of
psychosocial problems
Loss of interest in previous hobbies
and entertainment as a result of,
and with the exception of, Internet
games
†
As in research criteria.
attempting to cut down or stop
gambling
Needs to gamble with increasing
amounts of money in order to
achieve the desired excitement
Has made repeated unsuccessful
efforts to control, cut back, or stop
gambling
Lies to conceal the extent of
involvement with gambling
Often gambles when feeling
distressed
Has jeopardized or lost a significant
relationship, job, or educational or
career opportunity because of
gambling
4 (or more) in a 12-month period
Relies on others to provide money
to relieve desperate financial
situations caused by gambling
After losing money gambling, often
returns another day to get even

disorders, such as depression, anxiety, and other • Depression

• Anxiety • Violence/crime
health issues, including sleep problems (Fig. 1).2,3 • ADHD • Accident/injury
As concerns related to IGD continue to rise, clini- • Addiction • Online risky behavior
cians should acquaint themselves well with this par- Mental health Behavioral problem
ticular issue. Many factors may influence the
presentation and clinical course of IGD. Various
Excessive
environmental factors (e.g., cultural, socioeconomic, Internet gaming
parental, and external stressors7–11), individual fac-
tors (e.g., comorbid psychiatric disorders including
depression, social phobia and attention-deficit Physical health Functional problem
hyperactivity disorder [ADHD]3,7,9,12–17, personality • Vision • Cognitive function
traits and developmental aspects) and game-related • Musculoskeletal problem • Familial/social problem
• Sleep problem • Academic problem
factors18–22 can all affect IGD. These complex associ- • Sudden death • Occupational problem
ated factors contribute to the pleomorphic clinical
manifestations of IGD. The heterogeneous nature of Figure 1. Potential harms due to excessive Internet gaming.
IGD may obscure the clinical picture and also ADHD, attention-deficit hyperactivity disorder.

© 2016 The Authors

Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
hinder its effective management. Therefore, ade-
quate subtyping of IGD through the proper identifi-
cation of attributing vulnerabilities and motives for
excessive gaming may facilitate a more accurate
diagnosis of IGD and enable us to provide more tar-
geted and personalized treatment for patients with
each subtype of IGD.
TYPOLOGY OF IGD: THE ADAPTION
OF AN INTEGRATED PATHWAY
MODEL
Typologies are relatively well established in sub-
stance use disorders and GD. Gamblers have been
classified as having an early versus a late onset.
Early-onset pathological gamblers are more likely to
be male and never married with a lower income and
a cluster B personality disorder. In contrast, later-
onset pathological gamblers are more likely to suffer
from a mood disorder. However, no differences
existed between the two groups in regards to
treatment-seeking or preferred types of gambling.23
An empirical study classified problematic gamblers
into three different latent classes. While withdrawal
and loss of control differentiated individuals with a
mild severity from those with moderate severity, the
presence of severe functional impairment set GD
patients with a moderate severity apart from those
with a high severity.24 The moderate and severe
groups also significantly differed in psychiatric
comorbidities, with the severe group displaying
more nicotine dependence, conduct disorder, and
antisocial personality disorder. In another latent
class-analysis study, gamblers were also classified
into three groups: non-problematic gamblers
(88.9%), preoccupied chasers (9.7%), or antisocial-
impulsive gamblers (1.4%).25 The preoccupied
chaser group and the antisocial impulsive gambler
group differed in their clinical profiles, which is in
line with prior research that revealed qualitative dif-
ferences by gambling severity; gamblers with the
highest severity were often involved in illegal acts to
support their gambling.26
In contrast, a theory-derived typology of GD has
provided useful insight and aided in the conceptual-
ization of gambling problems.27 Using an integrated
pathway model, Blaszczynski and Nower have sug-
gested three subtypes of gamblers: behaviorally con-
ditioned, antisocial impulsive, and emotionally
vulnerable gamblers. In this model, the behaviorally
conditioned subtype has no underlying psychiatric
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Typology of IGD 481
problems or severe control problems and shows the
most favorable prognosis. In contrast, the worst
prognosis was found in the antisocial impulsive sub-
type. Despite their severe problems, the antisocial
impulsive gamblers displayed a low motivation for
treatment. They began gambling early, were impul-
sive and inattentive, were often substance abusers,
and frequently were associated with suicidal or crim-
inal behaviors. An emotionally vulnerable subtype
is associated with a high premorbid level of depres-
sion/anxiety and adverse early-life experiences. These
patients often begin gambling in their later years,
lack problem-solving skills, and use gambling as a
means to escape negative emotions. Antisocial
impulsive and emotionally vulnerable gamblers
both demonstrated a higher gambling severity than
behaviorally conditioned gamblers. Differences in
preferences for gambling types have also been
reported. The behaviorally conditioned gamblers
preferred to play strategic games like roulette.28
While impulsive gamblers preferred gambling on
sports, emotionally vulnerable gamblers often
selected games of chance, like slot machines or lot-
tery scratch cards.27,29
Recently, a typology for problematic mobile
phone use has been suggested as a type of addic-
tion30; however, apart from classification in terms of
severity31,32 or motivation,33 the literature on IGD
typology is limited.34 Thus, we propose a theoretical
framework for classifying IGD that was adapted
from the integrated pathway model specifically
developed for GD. The proposed typology of IGD
consists of three subtypes: (i) the impulsive/aggres-
sive type; (ii) the emotionally vulnerable type; and
(iii) the socially conditioned type. The suggested
subtypes are also in line with the bio-psycho-social
model; each subtype corresponds to the salience of
bio-, psycho-, and social vulnerability, respectively.
In the following sections, the proposed subtypes will
be discussed in relation to their differences in pre-
disposing vulnerable conditions, motives for gam-
ing, and preferences for game genres. The implica-
tions of these subtypes for assessment and treatment
planning will also be highlighted.
Impulsive/aggressive type
Similarly to the antisocial, impulsive subtype in GD,
it is hypothesized that there are impulsive/aggressive
gamers who play Internet games as a means to
release their aggressive impulses and seek sensation
© 2016 The Authors
482 S-Y. Lee et al.
to alleviate boredom.15 Empirical studies have con-
sistently found significantly higher impulsiv-
ity13,22,35 and aggression among youth with
IGD15,16,36,37 compared to those without IGD.
Given that impulsivity is a core clinical feature of
ADHD and antisocial behavior38,39 and is also a key
risk factor for addiction,40–42 previous studies that
have suggested significant associations between
externalizing problems like ADHD and IGD have
also offered further supporting evidence for the criti-
cal role of impulsivity in IGD.15,16,36,37 The impul-
sive/aggressive subtype may differ from other IGD
subtypes in that the impulse to release anger is the
main motivation for gaming. Specifically, impulsiv-
ity is often observed as a preference for particular
game genres, such as multiplayer online battle arena
and first-person shooter games, which may contain
more violent content than other types of massively
multiplayer online role-playing games
(MMORPG).22 Furthermore, these game genres have
been found to significantly increase the risk for IGD
compared with other game genres.18,19
The empirical evidence thus far indicates that
impulsivity, a major contributing factor for externa-
lizing problems like ADHD, may also act as a risk
factor for IGD. Impulsivity could be mediated by
externalizing problems as predisposing conditions
that motivate gamers to impulsively release their
aggression through excessive gaming. Externalizing
psychiatric disorders have been associated with IGD
symptoms of ‘jeopardizing relationship/career’ and
‘loss of control.’ This finding may indicate the pre-
disposing role of low executive control over IGD in
the impulsive/aggressive subtype.43 In addition,
excessive gaming can also increase impulsiveness
and reduce executive control,44,45 creating a vicious
cycle where impulsivity is responsible for excessive
gaming, which in turn exacerbates the impulse con-
trol problem further, resulting in IGD. As such,
understanding what contributes to higher impulsiv-
ity before IGD even develops is crucial in assessing
excessive gaming behaviors.
In general, impulsivity is affected by genetic, neu-
rotransmitter, or neurodevelopmental perspectives.
In twin studies, 45% of the individual difference in
impulsivity can be explained by genetic factors.46
Serotonergic and dopaminergic polymorphisms
have also been reported to exert effects on impulsiv-
ity.47 Low serotonergic tone has been implicated in
impulsivity,48 and dopamine was suggested to mod-
ulate cognitive control based upon rewards.49
© 2016 The Authors
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
During adolescence, the immature brain has a rela-
tive lack of inhibition capacity.50,51 Prefrontal top-
down control develops comparatively slower than
the functions in the subcortical regions that are
involved in desire in neurodevelopment. This mis-
matched neurodevelopment may increase adoles-
cents’ impulsivity and reward-seeking behavior, as
they are not fully controlled by ‘the slower develop-
ing inhibitive frontal cortex.’51 This is one explana-
tion for the higher prevalence of IGD among
adolescents and young adults than in their older
counterparts. Therefore, clinicians must consider
neurodevelopmental aspects in the assessment and
treatment-planning stages for youth with IGD.5
With regard to the treatment of impulsivity and
IGD, evidence suggests that altered prefrontal func-
tion improved following 6 weeks of bupropion
treatment.45 This outcome indicates that it may be
possible to improve prefrontal function that has
been deteriorated by IGD, even if the underlying
genetic or neurodevelopmental factors cannot be
modified.
Emotionally vulnerable type
Individuals with excessive Internet gaming for
escapism or mood-modification purposes can be
characterized as the emotionally vulnerable type of
IGD. To these players, Internet gaming may act as
a positive reward and also functions as a self-
remedy for their emotional suffering or self-
dissatisfaction.52–54 Escapism or mood modifica-
tion describes a situation where one plays Internet
games to get away from a stressful reality or unsat-
isfactory moods. Nearly one-third of online gamers
used gaming as a means to escape negative feelings
and everyday problems.54 Furthermore, lower self-
esteem and decreased satisfaction with daily life
were found to be associated with a higher severity
of IGD among male students.11 Increased levels of
depression and anxiety have also been reported
among IGD patients in a prior study.3 Internalizing
psychiatric disorders has shown associations with
IGD symptoms of ‘preoccupation,’ ‘withdrawal,’
and ‘decrease in activities other than gaming.’43
These findings indicate that any emotional distress
that develops prior to excessive gaming behavior
may trigger emotionally vulnerable people to
develop IGD. Incorporating this notion, the DSM-5
research criteria for IGD included the ‘use of
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
Internet games to escape/relieve a negative mood’
as one of its diagnostic criteria.
However, this criterion could be empirically criti-
cized because gaming as a means for mood modifi-
cation can also be properly utilized as a coping
strategy by relatively healthy people.36,55,56 Escap-
ism was the most frequently endorsed criterion in
German (5.3%) and Singaporean (30%) stud-
ies.35,56 However, escapism was not found to be
associated with an IGD diagnosis56 and showed the
lowest diagnostic accuracy (74%) and specificity
(73%).36 In fact, escapism was also associated with
lower IGD severity.55 These findings suggest that tak-
ing part in gaming to modify negative feelings or
release stress could also be a type of normative cop-
ing behavior. Therefore, an affirmative response to
this criterion must not be construed as a pathologi-
cal symptom of IGD without further probing.
Information on the specific context of gaming to
escape is required for the accurate assessment and
interpretation of the endorsed escapism. For exam-
ple, if the patient uses gaming to alleviate stress
from daily hassles, which, in turn, improves the
patient’s daily functioning, the endorsement of
escapism may not necessarily need to be interpreted
as pathological. Such a gaming motivation could be
better understood as an adaptive coping strategy.
However, if the adverse mood is not a reaction to a
stressor, but rather originates from internalizing
other problems, such as depression or anxiety disor-
ders, escapism needs to be considered more seri-
ously. Positive correlations between depression/
anxiety and IGD have been consistently found in
the scientific literature.3,12,15,57,58 Moreover, pre-
existing depressive symptoms can worsen over time
as a consequence of untreated IGD.59 Another con-
sideration in the assessment of escapism is whether
gaming is the exclusive strategy used by the patient
to cope with negative feelings. We argue that if the
patient is unable to adopt other healthy ways of
mood modification and becomes over-reliant on
gaming for such purposes, escapism can be assessed
as maladaptive and is more likely to indicate IGD.
Socially conditioned type
Instead of the behaviorally conditioned pathway in
GD, we propose the socializing pathway. Although
gambling addicts may not enter casinos for socializ-
ing purposes, serious online gamers often build a
guild of their own and socialize when carrying out
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Typology of IGD 483
game missions that require teamwork. Social self-
efficacy, loneliness, and reduced family relationship
quality have been reported to be associated with
IGD.7,9 We therefore propose the ‘socially condi-
tioned’ subtype based on our clinical experience and
empirical findings that highlight the importance of
social motives in IGD, as reported by a recent study
showing that social motives were the main reason
for accessing the Internet among adolescents, fol-
lowed by skills enhancement and coping motives
among problematic Internet users.60 We hypothesize
that for gamers with this subtype of IGD, their
online social engagement may not be behaviorally
conditioned by gaming, but instead is pre-
conditioned by unmet social needs in the real
world.
Despite the common motive to socialize, we also
argue that two categories exist under the socially
conditioned subtype of IGD: covert and overt. The
covert type displays high levels of harm avoidance
and social withdrawal and resembles avoidant per-
sonality/social phobia. In contrast, those of the overt
type share narcissistic personality traits, which have
demonstrated a positive correlation with IGD.16
Gamers with covert, socially conditioned IGD have
a strong tendency to avoid risks/harm, and they fear
social rejection in real life. The presence of this type
of gamer is evidenced by prior research findings.
Investigations have identified low social
competence,59 high interpersonal sensitivity,37 and
social withdrawal7 as risk factors for IGD. Offline
social competence was significantly negatively corre-
lated with IGD, while online social competence has
been significantly positively correlated with IGD.9
Such findings suggest the possibility that these indi-
viduals may long for social acceptance but are una-
ble to form close relationships in real life due to
their low self-esteem, fear of rejection, or prior
experiences of being bullied. They instead seek
online social relationships; Internet gaming may
provide a safer alternative source for social rewards.
In some extreme cases, real-life interpersonal rela-
tionships have even been replaced by online rela-
tionships. One study reported that over one-fifth of
online gamers preferred socialization online to off-
line and some even considered the online world as
a place of equality.61 To such gamers, playing freely
with others anonymously, making new online
relationships, being recognized as competent
players, and feeling a sense of belonging seemed
to fulfill social needs that were unmet in real life.
© 2016 The Authors
484 S-Y. Lee et al.
However, research evidence suggests that the more
people engage in online social relationships, the
less real-life socialization they seek out and take
part in.62
In contrast to the covert type, overt-type gamers
display self-aggrandizement and seek attention and
admiration from others. As previously reported,
extroversion is a key personality characteristic
among online gamers with this type of IGD.63
Extroversion also corresponds to the ‘extroversion
pathway,’ one of three subtypes that have been
suggested for problematic mobile phone users.30
In this model, the ‘extroversion pathway’ explains
the behavior of those with ‘a constant need for
stimulation and a high sensitivity to rewards.’
Overt type gamers may have motives to show off
their skills or high-ranking status through gaming.
For Internet addiction, the addicted group (74.9%)
was more likely to respond that they gain more
social recognition in the online compared to the
offline world than the general population
(13.7%).5 Satisfying their demand for social recog-
nition while remaining unharmed from social criti-
cisms or aversive reactions in the real world may
cause the overt types to indulge in more Internet
gaming.
Among various game genres, two particular types
prompt patients with IGD to spend more time
playing than normal players: shooting games and
role-playing games (RPG).18 However, this phe-
nomenon was only displayed for online shooting
or RPG. The same off-line game genres failed to
produce a significant difference in playtime
between IGD and non-IGD groups.18 Similarly,
shooting games and RPG had previously been
reported to be the two most preferred game genres
to play with others compared with playing alone.19
Thus, certain game genres or games with strong
social components may have an additional role in
the pathogenesis of the socially conditioned sub-
type of IGD. Although this hypothesis is theoreti-
cally appealing, more empirical studies are
required to clarify this specific IGD subtype and its
associated characteristics. Moreover, not every game
has major social components; other motivations
may also play a role in the development of IGD.
Therefore, a pathway not otherwise specified was
also added to Figure 2. Future well-designed stud-
ies should be conducted to investigate the precise
role of socializing needs on the development of
IGD among other motivations.
© 2016 The Authors
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
IMPLICATIONS OF SUBTYPES FOR
ASSESSMENT, TREATMENT, AND
FUTURE RESEARCH
Psychiatric comorbidities
The conceptual framework underlying the proposed
typology of IGD delineates a pathway that links pre-
disposing vulnerabilities, motives, and gaming fac-
tors to IGD (Fig. 2). We highlight psychiatric
comorbidities as a key consideration in the typology
of IGD. As individuals with IGD manifest a wide
range of psychiatric disorders, such as ADHD and
depression and anxiety disorders (including social
phobia),3,64 the proposed subtypes suggest that the
psychiatric comorbidity of the IGD patient also be
examined. This investigation may aid in systemati-
cally understanding the patient’s specific motives for
gaming, his or her corresponding preference for
game genres and gaming behaviors, and whether
and how all of these contribute to the development
of IGD. However, it should also be noted that psy-
chiatric comorbidities are not the only predisposing
vulnerabilities to be considered when classifying
subtypes and that not all IGD patients present with
a psychiatric comorbidity despite the high preva-
lence of such conditions among the IGD population
in general.3,64 When IGD patients are not diagnosed
with a psychiatric disorder, their personality traits
should also be considered. These traits may be par-
ticularly relevant when assessing patients with the
overt, socially conditioned subtype of IGD. While
ADHD (for the impulsive/aggressive subtype),
depression (for the emotionally vulnerable subtype),
and social phobia (for the covert, socially condi-
tioned subtype) may be easily observed, few psychi-
atric disorders may be detected in those with the
overt, socially conditioned subtype. In this subgroup
of IGD patients, extroversion and narcissistic person-
ality traits rather than a specific mental disorder may
more effectively illuminate the underlying motives,
gaming behaviors, and manifestations of IGD
symptoms.
Also, we argue that regardless of any associated
comorbid psychiatric conditions, these psychiatric
comorbidities and IGD may mutually reinforce each
other. For example, while ADHD may contribute to
excessive gaming as a predisposing risk factor,14
excessive gaming may also increase impulsivity, one
core ADHD feature, as demonstrated by decreased
orbitofrontal function in the sufferers.65 Hence, the
Psychiatry and Clinical Neurosciences 2017; 71: 479–491 Typology of IGD 485

Types & vulnerable factors Motives Game preferences

Emotional vulnerability
- Escapism
- Entertainment
- Depression for self-remedy
- Anxiety

Covert:
Socializing need SNS games
- Safe social
engagement
Covert : Harm avoidant - Belongingness MMORPG
Social phobic
Overt: MOBA
Overt : Narcissism - Social recognition
- Power/admiration
Action

Figure 2. A pathway model to Inter- Impulsivity/aggression

FPS
net gaming disorder. ADHD, - Lack of executive control - Competition/
release of anger
attention-deficit hyperactivity disorder; - Exciting pleasure
: Neurodevelopmental mismatch
FPS, first-person shooter games; ADHD/conduct/antisocial
MMORPG, massively multiplayer
online role-playing games; MOBA,
multiplayer online battle arena games; Not otherwise specified
SNS, social network service.

deteriorated ADHD condition may further escalate
excessive gaming behavior into a more severe state
of IGD. According to research findings, the same
pattern could also be applicable to depression and
IGD.3,59 In other words, while psychiatric problems
may create a vulnerability for the development of
IGD, the adverse psychosocial effects of IGD can
also contribute to psychiatric comorbidity. Further-
more, considering the high comorbidity of IGD with
depression and anxiety disorders, determining
whether the internalizing problem originated from
an underlying psychiatric comorbidity or the IGD
itself could prove challenging. Nevertheless, some
may argue that it is still crucial to determine the
order of manifestation between psychiatric problems
and IGD when developing a therapeutic approach.
In our pathway model for IGD, we conceptualize
psychiatric comorbidity as a predisposing vulnerabil-
ity similar to aggression, anhedonia, and emotional
problems, which has predicted Internet addiction in
longitudinal studies.66–68 This association may indi-
cate that mitigating such predisposing risk factors
can also facilitate recovery from IGD.45,68 However,
given that IGD has its own independent and detri-
mental effects on other mental disorders,59 direct
intervention for IGD is also critical to preventing the
deterioration of psychiatric comorbidities. Hence,
we conclude that concurrent treatment of the psychi-
atric disorder and IGD would be most beneficial.
Social risk factors
Another consideration for assessment and therapeu-
tic planning when using the proposed subtypes is
how social risk factors influence certain subtypes of
IGD. Specifically, as implied in the previous
section on subtypes, while the impulsive/aggressive
type of IGD can primarily be explained by biological
variables, such as a neurodevelopmental mismatch,
the clinical manifestations of the predisposing vul-
nerabilities and motives of socially conditioned IGD
patients can be further explicated by understanding
their social surroundings. This determination is par-
ticularly relevant when identifying the motives for
gaming among those of the covert, socially condi-
tioned subtype: to obtain safe social engagement,
connectedness, and a sense of belonging. As sug-
gested in the covert, socially conditioned subtype,
people with IGD are more likely to live in socially
isolated environments compared to those without
IGD.31 For example, children living with only one
parent69,70 or living under little parental
supervision,71 or adults who reside alone70 are more
likely to report problems with Internet gaming. In
addition, available research evidence indicates that

© 2016 The Authors

Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
486 S-Y. Lee et al.
youth with IGD are more likely to be deprived of
the social resources necessary for their healthy devel-
opment compared with those without IGD. Chil-
dren of parents with low socioeconomic status have
also been reported to experience more problems
with online gaming addiction than those of parents
with high socioeconomic status.72 In addition, social
activities with parents have been reported to provide
protection against gaming addiction.9 The fact that
gaming problems were more prevalent among stu-
dents living in rural areas than in urban areas also
indicates that excessive gaming problems could be
promoted by the availability of fewer after-school
activities.72 A cohort study reported that any base-
line conflict between a child and a parent signifi-
cantly increased the risk of developing Internet
addiction after 1 year.69 Therefore, social environ-
mental factors, including socioeconomic status,
parent–child relationship quality, parental guidance,
and the availability of interesting activities other
than gaming, should be considered in the evalua-
tion and treatment of IGD.
Consideration of these social conditions of IGD
also indicates that some of the DSM-5 criteria for
IGD, such as lying (‘has deceived a family member
regarding the amount of Internet gaming’), poor
social role functioning (‘has jeopardized or lost a
significant relationship because of Internet gaming’),
and loss of interest in activities other than gaming
(‘loss of interest in previous hobbies and entertain-
ment as a result of and with the exception of Inter-
net gaming’), may not merely be symptoms of IGD.
Instead, these may be social interaction patterns
shaped by pre-existing and unhealthy social rela-
tionships and environments prior to their engage-
ment in excessive gaming. As such, when examining
the social aspects of IGD patients, especially those
of the socially conditioned subtype, the DSM-5 cri-
teria on these three symptoms – lying, poor social
role functioning, and loss of interest – should be
used with some caution; patients’ responses to these
criteria must be further explored both before and
after their excessive gaming behavior to determine
their social relationships and environments. Such
information would, in turn, lead to psychosocial
interventions in improving the patient’s parent–
child, family, and peer relationships as well as his or
her living environment, which will ultimately
improve the treatment outcomes of IGD. Last but
not least, one other issue that commonly arises from
assessing the social aspects of IGD in relation to the
© 2016 The Authors
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
proposed subtype warrants further investigation.
Thus far, it remains unexplored whether poor social
resources and social relationships are significantly
more salient for the covert, socially conditioned sub-
type than they are for the other subtypes. Although
robust evidence indicates that the aforementioned
unfavorable social conditions are associated with
IGD in general, it is unclear whether these factors
pose more of a risk for the socially conditioned sub-
type than the others; not all Internet games have
highly social components. Future research is needed
to provide empirical evidence about the relative con-
tribution of social risk factors by different IGD
subtypes.
Gaming factors
Our classification of subtypes presumes that online
gamers select game content and genres that reflect
their own needs. The game content may provide
meaningful clues to the vulnerabilities of the
affected individuals. In addition, game genres may
substantially influence the gaming pattern as well as
the clinical course. Although few studies have been
conducted on the effects of different game genres on
IGD, prior research findings have demonstrated that
real-time strategy games and RPG were associated
with IGD more frequently than other game genres.20
MMORPG are also heavily played by and are thus
more addictive to gamers with low self-esteem
and/or unmet social needs (i.e., the covert, socially
conditioned subtype).21 In addition, as already
highlighted, those of the impulsive/aggressive sub-
type may prefer game genres with highly violent
content. Understanding IGD patients’ preferences
for game genres as an indication of their underlying
psychosocial needs based on subtype may help us
tailor a personalized therapeutic plan and also
enhance patient treatment response. However, dif-
ferent preferences for game genres and content by
subtype that were identified from available research
findings remain unclear, especially for the emotion-
ally vulnerable subtypes who complain of negative
moods and may play Internet games for escapism
and as a self-remedy. As such, further research is nec-
essary to identify the game preferences of the emo-
tionally vulnerable group of IGD patients. In
addition, the strong correlations between certain
game genres or contents and IGD in general as well
as between game genres/content and specific sub-
types suggest that clinicians must be equipped with
Psychiatry and Clinical Neurosciences 2017; 71: 479–491 Typology of IGD 487

basic knowledge regarding Internet game genres and CONCLUSION

contents. Without such knowledge, it will be chal-
Problematic Internet gaming may damage various
lenging for clinicians to understand the nature of
life domains, such as interpersonal, social, academic,
their IGD patients and to build a therapeutic alli-
and occupational functioning, and is known to be
ance during assessment and treatment.
associated with many psychiatric pro-
blems.2,3,13,14,58 Some may argue that Internet gam-
ing may not be as addictive as alcohol, cigarettes, or
Future research regarding the proposed illicit drugs. Nonetheless, stricter regulations are
typology of IGD applied to these substances, while opportunities for
gaming are ubiquitous, especially with the introduc-
In this paper, we have proposed a typology for IGD
tion and availability of smartphones. The detrimen-
to help clinicians and researchers explain the com-
tal consequences of IGD do not remain at the
plexity of the clinical manifestations of IGD. While
individual level, but may also extend to the level of
the typology is based on a theory-derived pathway
society.6 With the increasing number of households
in which predisposing vulnerabilities, motives, and
that have high-speed Internet access around the
gaming patterns are interlinked to IGD, the distinc-
globe, Internet-related problems are anticipated to
tive main features of each subtype were explained
grow continuously; gaming is a major component
with relevant empirical research findings. However,
that induces Internet addiction.73 IGD is particularly
our proposed typology is still subject to further vali-
alarming as young populations are more predis-
dation through future research. Specifically, there
posed to IGD.5 Due to neurodevelopmental mis-
are two main issues to be resolved. First, it is
match, adolescents’ top-down control is relatively
unclear whether the three types are clinically dis-
deficient,51,74 which may render the young more
crete groups or if they overlap. In clinical practice,
prone to this type of addiction.
emotionally vulnerable IGD patients and covert,
Herein, a typology of three distinct IGD groups
socially conditioned patients may not be distin-
has been proposed: ‘impulsive/aggressive,’ ‘emotion-
guishable, given that loneliness, a psychological
ally vulnerable,’ and ‘socially conditioned’ gamers.
trait of the covert, socially conditioned type, and
To enable the application of typology in real-life
depressive mood, a psychological trait of the emo-
practice, we argue that maintaining simplicity while
tionally vulnerable type, are usually highly corre-
also not compromising the legitimacy of classifica-
lated. Likewise, impulsive/aggressive IGD patients
tion is essential. The first two groups correspond to
and overt, socially conditioned patients who are
the ‘antisocial, impulsive’ and the ‘emotionally vul-
overachievers and seek admiration from others may
nerable’ problem gamblers in the pathway model in
appear similarly and share certain personality traits.
GD.27 The ‘impulsive/aggressive’ group may lack
Hence, validation of this typology requires further
frontal executive control or have high inner-tension
clinical observation of the proposed subtypes that
to release their aggression. They may prefer games
will be subject to scientific investigation. The sec-
with more aggressive or violent features, such as
ond issue concerns potential differences in the
first-person shooter games. Their decreased executive
severity of IGD by subtype. In our current classifica-
control may stem from mismatched neurodevelop-
tion system, we do not suggest that any subtype
ment or psychiatric comorbidities, such as ADHD or
manifests or would possibly manifest a higher or
conduct disorder. In the latter cases, treating the pri-
lower severity of IGD than the others. However, it
mary psychiatric disorders may also enhance the
would be useful for clinicians to determine whether
treatment response for gaming problems. The ‘emo-
the severity of IGD differs according to subtype, as
tionally vulnerable’ group may utilize Internet gam-
this distinction would have implications for the
ing mainly for mood-modification purposes. For
mode, intensity, and setting of effective treatments.
these types, an intervention that addresses the
Research that examines the relative effects of differ-
underlying depression or external stressors may
ent psychiatric comorbidities or personality traits
improve the treatment response. The ‘socially condi-
on the severity levels of IGD may provide insight
tioned’ group, both of the covert subtype (high
into which subtype is more likely to manifest a
harm avoidance and social anxiety) and the overt
higher severity of IGD, thus requiring more inten-
subtype (narcissistic), may prefer games with
sive clinical intervention.

© 2016 The Authors

Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
488 S-Y. Lee et al.
socializing features, such as teamwork or an avenue
to gain fame and social recognition. Social isolation
has been identified as an important risk factor for
IGD; therefore, we viewed that being connected to
others, one of the main features of Internet gaming,
is a major motive for gaming that contributes to the
development of IGD. We speculate that gamers may
have already been ‘socially conditioned’ due to past
adverse social experiences that took place before the
emergence of the gaming problems.
Identification and appropriate treatment of IGD are
difficult tasks due to the pleomorphic clinical presen-
tations of IGD. More factors are involved than just
game-related factors, such as the genres, designs, and
contents of the games that are played. With regard to
individual factors, genetic, neurodevelopmental, cog-
nitive, and personality factors can all play a role in the
pathogenesis of IGD and its subtypes. Moreover, the
development of IGD could also be affected by various
socio-environmental factors, including parent–child
relationships, adequate monitoring/guidance related
to gaming, societal attitudes towards gaming, peer
pressure, and accessibility to the Internet.
Although empirical studies are required to vali-
date our theoretical typology of IGD, we believe
such classifications could be useful in diagnosis of
this condition and therapeutic approach to it. The
authors also anticipate that the suggested typology
may facilitate further active research on IGD. Clus-
tered phenomena may indicate shared underlying
mechanisms and also increase the possibility of dis-
playing a similar clinical course. An adequate typol-
ogy may assist in the early identification of target
symptoms among heterogeneous clinical features.
Appropriate symptom targeting may also ultimately
improve treatment outcomes by enabling persona-
lized treatment in the early stages of IGD. Such early
therapeutic intervention will hopefully minimize the
adverse consequences of IGD.
ACKNOWLEDGMENT
This study was supported by a grant from the
Korean Mental Health Technology R&D Project,
Ministry of Health and Welfare, Republic of Korea
(HM15C1124).
DISCLOSURE STATEMENT
All authors have completed and submitted the Inter-
national Committee of Medical Journal Editors
© 2016 The Authors
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
Form and declare no potential conflicts of interest.
Although Dr Lee’s research has been supported by a
grant from the Ministry of Health and Welfare,
Republic of Korea (HM15C1124), the funder had
no role in the design or conduct of this research.
AUTHOR CONTRIBUTIONS
S.Y.L. drafted the manuscript and figures. H.K.L.
conceptualized and supervised the writing of the
manuscript. H.C. further developed the concept and
took part in writing the manuscript.
REFERENCES
1. Petry NM, Rehbein F, Gentile DA et al. An international
consensus for assessing internet gaming disorder using
the new DSM-5 approach. Addiction (Abingdon, England)
2014; 109: 1399–1406.
2. Lam LT. Internet gaming addiction, problematic use of
the internet, and sleep problems: A systematic review.
Curr. Psychiatry Rep. 2014; 16: 444.
3. Wei HT, Chen MH, Huang PC, Bai YM. The association
between online gaming, social phobia, and depression:
An internet survey. BMC Psychiatry 2012; 12: 92.
4. International Telecommunication Union. ICT Facts and
Figures 2015. International Telecommunication Union,
Geneva, 2015.
5. Ministry of Science, ICT and Future Planning & National
Information Society Agency. A Survey on Internet Addiction.
Ministry of Science, ICT and Future Planning & National
Information Society Agency, Seoul, 2014.
6. Lee HK, Kim HS, Lee TJ. Cost-Effect Analysis on the Introduc-
tion of Online Game Shut Down Regulation. Ministry of
Gender Equality & Family, Seoul, 2011.
7. Schmit S, Chauchard E, Chabrol H, Sejourne N. Evalua-
tion of the characteristics of addiction to online video
games among adolescents and young adults. L’Encephale
2011; 37: 217–223.
8. Brindova D, Pavelka J, Sevcikova A et al. How parents can
affect excessive spending of time on screen-based activ-
ities. BMC Public Health 2014; 14: 1261.
9. Jeong EJ, Kim DH. Social activities, self-efficacy, game
attitudes, and game addiction. Cyberpsychol. Behav. Soc.
Netw. 2011; 14: 213–221.
10. Park HS, Kwon YH, Park KM. Factors on internet game
addiction among adolescents. Taehan Kanho Hakhoe Chi
2007; 37: 754–761.
11. Ko CH, Yen JY, Chen CC, Chen SH, Yen CF. Gender dif-
ferences and related factors affecting online gaming
addiction among Taiwanese adolescents. J. Nerv. Ment.
Dis. 2005; 193: 273–277.
12. Yen JY, Ko CH, Yen CF, Wu HY, Yang MJ. The comorbid
psychiatric symptoms of Internet addiction: Attention
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
deficit and hyperactivity disorder (ADHD), depression,
social phobia, and hostility. J. Adolesc. Health 2007;
41: 93–98.
13. Walther B, Morgenstern M, Hanewinkel R. Co-occurrence
of addictive behaviours: Personality factors related to sub-
stance use, gambling and computer gaming. Eur. Addict.
Res. 2012; 18: 167–174.
14. Weinstein A, Weizman A. Emerging association between
addictive gaming and attention-deficit/hyperactivity dis-
order. Curr. Psychiatry Rep. 2012; 14: 590–597.
15. Mehroof M, Griffiths MD. Online gaming addiction: The
role of sensation seeking, self-control, neuroticism,
aggression, state anxiety, and trait anxiety. Cyberpsychol.
Behav. Soc. Netw. 2010; 13: 313–316.
16. Kim EJ, Namkoong K, Ku T, Kim SJ. The relationship
between online game addiction and aggression, self-
control and narcissistic personality traits. Eur. Psychiatry
2008; 23: 212–218.
17. Wang CW, Ho RT, Chan CL, Tse S. Exploring personality
characteristics of Chinese adolescents with internet-
related addictive behaviors: Trait differences for gaming
addiction and social networking addiction. Addict. Behav.
2015; 42: 32–35.
18. Lemmens JS, Hendriks SJ. Addictive online games: Exam-
ining the relationship between game genres and Internet
gaming disorder. Cyberpsychol. Behav. Soc. Netw. 2016; 19:
270–276.
19. Lee MS, Ko YH, Song HS et al. Characteristics of Internet
use in relation to game genre in Korean adolescents.
Cyberpsychol. Behav. 2007; 10: 278–285.
20. Eichenbaum A, Kattner F, Bradford D, Gentile DA,
Green CS. Role-playing and real-time strategy games
associated with greater probability of Internet gaming
disorder. Cyberpsychol. Behav. Soc. Netw. 2015; 18:
480–485.
21. Kim JW, Han DH, Park DB et al. The relationships
between online game player biogenetic traits, playing
time, and the genre of the game being played. Psychiatry
Investig. 2010; 7: 17–23.
22. Nuyens F, Deleuze J, Maurage P, Griffiths MD, Kuss DJ,
Billieux J. Impulsivity in multiplayer online battle arena
gamers: Preliminary results on experimental and self-
report measures. J. Behav. Addict. 2016; 5: 351–356.
23. Verdura Vizcaino EJ, Fernandez-Navarro P, Petry N,
Rubio G, Blanco C. Differences between early-onset path-
ological gambling and later-onset pathological gambling:
Data from the National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC). Addiction (Abingdon,
England) 2014; 109: 807–813.
24. Xian H, Shah KR, Potenza MN et al. A latent class analysis
of DSM-III-R pathological gambling criteria in middle-
aged men: Association with psychiatric disorders.
J. Addict. Med. 2008; 2: 85–95.
25. McBride O, Adamson G, Shevlin M. A latent class analysis
of DSM-IV pathological gambling criteria in a nationally
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Typology of IGD 489
representative British sample. Psychiatry Res. 2010; 178:
401–407.
26. Toce-Gerstein M, Gerstein DR, Volberg RA. A hierarchy of
gambling disorders in the community. Addiction
(Abingdon, England) 2003; 98: 1661–1672.
27. Blaszczynski A, Nower L. A pathways model of problem
and pathological gambling. Addiction (Abingdon, England)
2002; 97: 487–499.
28. Bonnaire C, Bungener C, Varescon I. Subtypes of French
pathological gamblers: Comparison of sensation seeking,
alexithymia and depression scores. J. Gambl. Stud. 2009;
25: 455–471.
29. Valleur M, Codina I, Venisse JL et al. Towards a validation
of the three pathways model of pathological gambling.
J. Gambl. Stud. 2016; 32: 757–771.
30. Billieux J, Maurage P, Lopez-Fernandez O, Kuss DJ,
Griffiths MD. Can disordered mobile phone use be con-
sidered a behavioral addiction? An update on current evi-
dence and a comprehensive model for future research.
Curr. Addict. Rep. 2015; 2: 156–162.
31. Demetrovics Z, Urban R, Nagygyorgy K et al. The develop-
ment of the Problematic Online Gaming Questionnaire
(POGQ). PLoS One 2012; 7: e36417.
32. Pontes HM, Kiraly O, Demetrovics Z, Griffiths MD. The
conceptualisation and measurement of DSM-5 internet
gaming disorder: The development of the IGD-20 test.
PLoS One 2014; 9: e110137.
33. Zanetta Dauriat F, Zermatten A, Billieux J et al. Motiva-
tions to play specifically predict excessive involvement in
massively multiplayer online role-playing games: Evi-
dence from an online survey. Eur. Addict. Res. 2011; 17:
185–189.
34. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 5th edn. American Psychiatric
Publishing, Arlington, VA, 2013.
35. Choo H, Gentile DA, Sim T, Li D, Khoo A, Liau AK. Path-
ological video-gaming among Singaporean youth. Ann.
Acad. Med. Singapore 2010; 39: 822–829.
36. Lemmens JS, Valkenburg PM, Gentile DA. The Internet
Gaming Disorder Scale. Psychol. Assess. 2015; 27:
567–582.
37. Kim NR, Hwang SS, Choi JS et al. Characteristics and psy-
chiatric symptoms of internet gaming disorder among
adults using self-reported DSM-5 criteria. Psychiatry Inves-
tig. 2016; 13: 58–66.
38. Nandagopal JJ, Fleck DE, Adler CM, Mills NP,
Strakowski SM, DelBello MP. Impulsivity in adolescents
with bipolar disorder and/or attention-deficit/hyperactiv-
ity disorder and healthy controls as measured by the Bar-
ratt Impulsiveness Scale. J. Child Adolesc. Psychopharmacol.
2011; 21: 465–468.
39. Luengo MA, Carrillo-de-la-Pena MT, Otero JM,
Romero E. A short-term longitudinal study of impulsiv-
ity and antisocial behavior. J. Pers. Soc. Psychol. 1994;
66: 542–548.
© 2016 The Authors
490 S-Y. Lee et al.
40. Crews FT, Boettiger CA. Impulsivity, frontal lobes and risk
for addiction. Pharmacol. Biochem. Behav. 2009; 93:
237–247.
41. Kreek MJ, Nielsen DA, Butelman ER, LaForge KS. Genetic
influences on impulsivity, risk taking, stress responsivity
and vulnerability to drug abuse and addiction. Nat. Neu-
rosci. 2005; 8: 1450–1457.
42. Ersche KD, Turton AJ, Pradhan S, Bullmore ET,
Robbins TW. Drug addiction endophenotypes: Impulsive
versus sensation-seeking personality traits. Biol. Psychiatry
2010; 68: 770–773.
43. Lee SY, Lee HK, Jeong H et al. The hierarchical implica-
tions of internet gaming disorder criteria: Which indicate
more severe pathology? Psychiatry Investig. (forthcoming).
44. Ge L, Ge X, Xu Y, Zhang K, Zhao J, Kong X. P300 change
and cognitive behavioral therapy in subjects with Internet
addiction disorder: A 3-month follow-up study. Neural
Regen. Res. 2011; 6: 2037–2041.
45. Han DH, Hwang JW, Renshaw PF. Bupropion sustained
release treatment decreases craving for video games and
cue-induced brain activity in patients with Internet video
game addiction. Exp. Clin. Psychopharmacol. 2010; 18:
297–304.
46. Congdon E, Canli T. A neurogenetic approach to impul-
sivity. J. Pers. 2008; 76: 1447–1484.
47. Varga G, Szekely A, Antal P et al. Additive effects of sero-
tonergic and dopaminergic polymorphisms on trait
impulsivity. Am. J. Med. Genet. B Neuropsychiatr. Genet.
2012; 159b: 281–288.
48. Coccaro EF, Fanning JR, Phan KL, Lee R. Serotonin and
impulsive aggression. CNS Spectr. 2015; 20: 295–302.
49. Goschke T, Bolte A. Emotional modulation of control
dilemmas: The role of positive affect, reward, and dopa-
mine in cognitive stability and flexibility. Neuropsychologia
2014; 62: 403–423.
50. Crone EA. Executive functions in adolescence: Inferences
from brain and behavior. Dev. Sci. 2009; 12: 825–830.
51. Smith DG, Xiao L, Bechara A. Decision making in chil-
dren and adolescents: Impaired Iowa Gambling Task per-
formance in early adolescence. Dev. Psychol. 2012; 48:
1180–1187.
52. Gaetan S, Bonnet A, Pedinielli JL. Self-perception and life
satisfaction in video game addiction in young adolescents
(11–14 years old). L’Encephale 2012; 38: 512–518.
53. Festl R, Scharkow M, Quandt T. Problematic computer
game use among adolescents, younger and older adults.
Addiction (Abingdon, England) 2013; 108: 592–599.
54. Hussain Z, Griffiths MD. The attitudes, feelings, and
experiences of online gamers: A qualitative analysis.
Cyberpsychol. Behav. 2009; 12: 747–753.
55. Kiraly O, Sleczka P, Pontes HM, Urban R, Griffiths MD,
Demetrovics Z. Validation of the Ten-Item Internet Gam-
ing Disorder Test (IGDT-10) and evaluation of the nine
DSM-5 Internet Gaming Disorder criteria. Addict. Behav.
2015. doi: 10.1016/j.addbeh.2015.11.005
© 2016 The Authors
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
56. Rehbein F, Kliem S, Baier D, Mossle T, Petry NM. Preva-
lence of internet gaming disorder in German adolescents:
Diagnostic contribution of the nine DSM-5 criteria in a
state-wide representative sample. Addiction (Abingdon,
England) 2015; 110: 842–851.
57. Achab S, Nicolier M, Mauny F et al. Massively multiplayer
online role-playing games: Comparing characteristics of
addict vs non-addict online recruited gamers in a French
adult population. BMC Psychiatry 2011; 11: 144.
58. Van Rooij AJ, Kuss DJ, Griffiths MD, Shorter GW,
Schoenmakers MT, Van de Mheen D. The (co-) occur-
rence of problematic video gaming, substance use, and
psychosocial problems in adolescents. J. Behav. Addict.
2014; 3: 157–165.
59. Gentile DA, Choo H, Liau A et al. Pathological video
game use among youths: A two-year longitudinal study.
Pediatrics 2011; 127: e319–e329.
60. Bischof-Kastner C, Kuntsche E, Wolstein J. Identifying
problematic Internet users: Development and validation
of the Internet Motive Questionnaire for Adolescents
(IMQ-A). J. Med. Internet Res. 2014; 16: e230.
61. Hussain Z, Griffiths MD. Gender swapping and socializ-
ing in cyberspace: An exploratory study. Cyberpsychol.
Behav. 2008; 11: 47–53.
62. Cole H, Griffiths MD. Social interactions in massively
multiplayer online role-playing gamers. Cyberpsychol.
Behav. 2007; 10: 575–583.
63. Peters CS, Malesky LA. Problematic usage among
highly-engaged players of massively multiplayer online
role playing games. Cyberpsychol. Behav. 2008; 11:
481–484.
64. Ha JH, Yoo HJ, Cho IH, Chin B, Shin D, Kim JH. Psychi-
atric comorbidity assessed in Korean children and adoles-
cents who screen positive for Internet addiction. J. Clin.
Psychiatry 2006; 67: 821–826.
65. Tian M, Chen Q, Zhang Y et al. PET imaging reveals brain
functional changes in internet gaming disorder. Eur.
J. Nucl. Med. Mol. Imaging 2014; 41: 1388–1397.
66. Strittmatter E, Parzer P, Brunner R et al. A 2-year longitu-
dinal study of prospective predictors of pathological
Internet use in adolescents. Eur. Child Adolesc. Psychiatry
2016; 25: 725–734.
67. Stavropoulos V, Kuss DJ, Griffiths MD, Wilson P, Motti-
Stefanidi F. MMORPG gaming and hostility predict Inter-
net Addiction symptoms in adolescents: An empirical
multilevel longitudinal study. Addict. Behav. 2015. doi:
10.1016/j.addbeh.2015.09.001
68. Guillot CR, Bello MS, Tsai JY, Huh J, Leventhal AM,
Sussman S. Longitudinal associations between anhedonia
and internet-related addictive behaviors in emerging
adults. Comput. Hum. Behav. 2016; 62: 475–479.
69. Ko CH, Yen JY, Chen CS, Yeh YC, Yen CF. Predictive
values of psychiatric symptoms for internet addiction in
adolescents: A 2-year prospective study. Arch. Pediatr. Ado-
lesc. Med. 2009; 163: 937–943.
Psychiatry and Clinical Neurosciences 2017; 71: 479–491
70. Griffiths M, Wardle H, Orford J, Sproston K, Erens B.
Sociodemographic correlates of internet gambling: Find-
ings from the 2007 British gambling prevalence survey.
Cyberpsychol. Behav. 2009; 12: 199–202.
71. Koo HJ, Kwon JH. Risk and protective factors of internet
addiction: A meta-analysis of empirical studies in Korea.
Yonsei Med. J. 2014; 55: 1691–1711.
72. Korea Creative Content Agency. A Survey on Problematic Inter-
net Gaming. Korea Creative Content Agency, Naju, 2015.
Psychiatry and Clinical Neurosciences © 2016 Japanese Society of Psychiatry and Neurology
Typology of IGD 491
73. Kuss DJ, Griffiths MD, Karila L, Billieux J. Internet addic-
tion: A systematic review of epidemiological research for
the last decade. Curr. Pharm. Des. 2014; 20: 4026–4052.
74. Galvan A, Hare T, Voss H, Glover G, Casey BJ. Risk-taking
and the adolescent brain: Who is at risk? Dev. Sci. 2007;
10: F8–F14.
© 2016 The Authors