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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 89-92

Psychosis unmasked by gaming: A case series

Department of Psychiatry, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission10-Aug-2020
Date of Acceptance26-Sep-2020
Date of Web Publication18-Jun-2021

Correspondence Address:
Dr. Amey Yeshwant Angane
Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_84_20

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With easy accessibility and advancements in technology, there has been an upsurge in gaming. Players may neglect their real life, even using gaming as a medium to build self esteem. This has led to increased prevalence of gaming disorder. There is a dearth of literature regarding the interplay between gaming disorder and psychosis. Here, we present three cases where a prodromal history of progressively increasing time spent gaming was found to be followed by the emergence of florid psychotic symptoms. Gaming might act as a risk factor for precipitating psychosis. Individuals experiencing PLEs (Psychotic Like Experiences) have been shown to use the Internet for reality substitution. Mental Health Professionals should be aware of the threat that Internet Gaming Disorder provides to mental health. Irrespective of whether it is an etiology or consequence of the psychosis, it warrants treatment.

Keywords: Internet gaming disorder, online gaming, psychosis

How to cite this article:
Angane AY, Keshari PK, Mane AS, Nayak AS. Psychosis unmasked by gaming: A case series. Ann Indian Psychiatry 2021;5:89-92

How to cite this URL:
Angane AY, Keshari PK, Mane AS, Nayak AS. Psychosis unmasked by gaming: A case series. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Aug 5];5:89-92. Available from: https://www.anip.co.in/text.asp?2021/5/1/96/318685

  Introduction Top

The rapid evolution of technology has led to easy access to the Internet. The Internet has opened a vault of knowledge and experiences bringing the world at our doorstep. Our lives have changed like never before. However, every coin has two sides. There has been a tremendous upsurge in the domain of gaming. The advent of role-playing games (RPGs) and massive multiplayer online RPGs (MMORPGs), where several hundred computers connect and communicate simultaneously has revolutionized the gaming world. The real-time experience of existing as a character like a vigilante or fighting along with the virtual allies toward the common goal, making alliances, and strategizing against the one common enemy has captured the imagination of the youth. The gaming environment exists before the player logs on and continues to exist even after the player logs off. Events and interactions occur in the gaming world (driven by other users) even when the user is not logged on which makes players feel highly obligated to stay online. The vivid experiences of speeding a car, experiencing a snowfall, hopping bridges, or clearing forests have been nothing less than close to real. These blissful experiences have led to spending hours and at times, days at a computer screen or gaming console. A lot many times, a person who has felt neglected in “real-life,” finds gaming a medium for building self-esteem. The unprecedented number of hours being spent gaming without tending to basic bodily needs such as eating and bathing leads to unfulfilled social, academic, financial, and occupational responsibilities.

A massive surge in mental health issues associated with gaming has been witnessed. Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and International Classification of Diseases 11 draft have each included gaming as internet gaming disorder (IGD) and gaming disorder (GD) in its diagnostic criteria.[1],[2] The prevalence of IGD/GD is estimated between 1.2% and 5.5% in teenagers, and a problematic gaming use would concern about one out of ten adolescents playing internet games.[3] IGD has been associated with anxiety disorders, depression, suicidal ideation, behavioral disorders, social phobia, autism spectrum disorder, attention-deficit hyperactivity disorder, obsessive–compulsive disorder, and personality disorders.[4],[5],[6] However, there is a dearth of literature investigating the complex interplay of gaming and psychosis. Here is a series of three cases, exploring the intertwined relationship between gaming and psychosis.

  Case Reports Top

Case 1

Mr. A was a 20-year-old student, pursuing bachelor's degree in commerce, was referred to the psychiatry outpatient department for suspiciousness toward neighbors and aggressive and abusive behavior lasting for 2 weeks, for which he was expelled from college. He had a rough childhood, where he was exposed to constant fights between his parents. For the past 5 years, he had resorted to online gaming to avoid this hostile environment at his home. He would mostly indulge in playing RPGs and first-person shooter games with violent scenarios. Daily sessions usually lasted for 6–8 h at a stretch. However, for the past 3 months, gaming sessions had increased gradually, with the current playing time of approximately 16 h a day with minimal breaks. He would play compulsively to the exclusion of other activities including going to college. Two weeks back, he developed suspiciousness over neighbors that they were against him and are trying to poison him. He would often hear noises of explosions and would believe neighbors are deliberately setting up firecrackers to disturb him. He would convey to his parents about hearing voices of his neighbors talking constantly ill about him coming from across the house wall. His sleep decreased to only 4 h a day, along with decreased appetite and self-care. On mental status examination, there was delusion of persecution and delusion of reference with second person auditory hallucinations. The patient was admitted to the hospital as he was unmanageable at home. He was treated with oral atypical antipsychotics (tablet risperidone up to 6 mg) and a course of six electroconvulsive therapy sessions. The patient stabilized after 3 weeks and was discharged. The patient is currently undergoing follow-up in the outpatient department for 6 months and is well maintained and socioacademically functioning.

Case 2

Mr. B was an 18-year-old student of a high school presented to the psychiatry emergency services with severe agitation and irrelevant talks. He was the only son in the household and was hence pampered during his upbringing. His social interactions with peers were limited, and time spent outside the home was strongly discouraged as the parents were overprotective toward him. He would spend most of his time indoors and would increasingly resort to internet gaming. For the past 2 years, his internet gaming time had increased to 6–8 h a day. This had led to a decline in scholastic performance. When he made a transition to playing MMORPG games, his gaming time increased to 14 h a day. For 1 month, parents noticed a change in behavior in the form of increased irritability on trivial issues and irrelevant talks. He started voicing out that people were against him, would follow him on the road, and would laugh at him. He believed that a hidden camera has been fitted in his house to keep a watch over him. He would also say that a group of people could read his thoughts. On Mental Status Examination, there was delusion of persecution, delusion of reference, and thought broadcasting. Owing to the severity of his symptoms, the patient was admitted and treated with oral antipsychotics (tablet olanzapine up to 20 mg). The patient responded well and was discharged on stabilization after 2 weeks. The patient is currently undergoing follow-up in the outpatient department for 3 months and is well maintained and has resumed his high school.

Case 3

Mr. C, a 19-year-old high school student, was brought to the psychiatry emergency services with aggressive, abusive, assaultive behavior and irrelevant talks. He was always considered by his parents and peers as a shy, introvert, and an anxious boy. He began playing video games on the mobile 3 years ago. Initially, he would play for 1–2 h a day. Gradually, the time spent gaming increased to 6–8 h a day extending up to 12 h on weekends. Gradually, there was an increased irritability when he was devoid of a mobile phone by his parents. Simultaneously, his academic performance also started declining. Since last week, he started voicing out regarding some antireligious groups, who are following him everywhere and are planning to kill him. He would convey hearing their footsteps throughout the day which would make him fearful and aggressive. He would also convey to everyone of being able to hear gunshots and explosions. The patient would be extremely fearful and refuse to eat food due to suspicion. On Mental Status Examination, there was delusion of persecution, delusion of reference, and unstructured auditory hallucinations. The patient was admitted to the hospital as he was unmanageable at home. He was treated with oral atypical antipsychotics (tablet olanzapine up to 30 mg) and was discharged on stabilization after 3 weeks. The patient is currently undergoing follow-up in the outpatient department for 3 months and is well maintained and passed his higher secondary schooling exams.


The IGD Scale-Short-Form (IGDS9-SF) was used to assess the gaming behavior, while the positive and negative syndrome scale was used to assess the psychosis [Table 1].
Table 1: Scale scores

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The IGDS9-SF is a brief psychometric scale comprising nine items, based on the 9 core IGD criteria described in the DSM-5. The nine items of the IGDS9-SF load on to a single factor. It assesses the degree of severity of IGD and its detrimental effects by assessing both online and offline gaming activities over the past 12-month period. The responses to the nine items were self-rated by the participants on a 5-point Likert scale as follows: 1 = “Never,” 2 = “Rarely,” 3 = “Sometimes,” 4 = “Often,” and 5 = “Very Often.” The total score was calculated by adding the scores obtained on all the nine items. It ranged from 9 to 45, with higher scores suggestive of greater severity of IGD. Further, for research purposes, it may be used to classify disordered gamers and nondisordered gamers by considering IGD in all those participants who have endorsed at least five or more items on the scale structure. Several studies demonstrate adequate reliability and validity for measuring IGD.[7]

  Discussion Top

In all the above three cases, a history of prodromal progressively increasing time spent gaming was found followed by the emergence of florid psychotic symptoms. In each of the above cases, several factors such as age, gender, personality, and poor social support have evidently added to the vulnerability of the individual for psychosis. We have attempted to explore the dynamics between prodromal gaming addiction and the evolution of psychosis. There are two aspects that we would like to discuss regarding the same.

The first aspect being how gaming per se might be a risk for precipitating psychosis. Gaming leads to being cut off from the world. Players can lock themselves up within in bedrooms for days, months, or even years. This decrease in communication with family, peers, and venturing out only for bodily needs creates social withdrawal. When events are absent or minimal, a state of sensory deprivation may ensue.[8] It has been known that sensory deprivation leads to a tendency to erroneously allocate an external source to internally generated stimulus ultimately leading to hallucination proneness, psychotic-like experiences (PLEs), and ultimately psychosis.[9] While there is a dearth of literature studying gaming addiction and psychosis, much of our understanding comes from studying PLEs.

PLEs manifest as bizarreness of thought characterized by nonconventional logic, paranoid ideas, perceptual disturbances, or magical thinking. A recent report of 170 university students who experienced PLEs found an associated problematic Internet use in the past 2 months.[10] PLEs are an established risk factor for formal psychosis. Cessation in problematic internet gaming has seen an accompanying improvement in PLEs which provides indirect evidence for gaming addiction as a factor for precipitating psychosis.[11]

The other facet in studying dynamics between gaming addiction and psychosis is pathology as an etiology. Patients may find psychotic symptoms extremely distressing. PLEs, hallucinations, and delusions may be frightening. Individuals may then turn up to gaming as their “haven.” Individuals experiencing PLEs have been shown to use the Internet in ways that encourage them to live in the virtual world. They begin to use the Internet for reality substitution. This might then come up as increased time spent gaming to the point of addiction in the prodromal phase of psychosis.[10]

Whether the IGD during “prodrome” is an etiology or a consequence of the psychopathology or an entity with combined ingredients complementing each other cannot be elucidated. There is a lack of systemic studies analyzing the temporal linearity of these events. Further studies are needed into whether a specific psychiatric problem leads to the development of the IGD or a person with a diagnosis of IGD – due to negative consequences stemming from it – later develops a comorbid psychiatric disorder. Another hypothesis is that psychosis and IGD share underlying biological, sociodemographic, or psychological mechanisms that make an individual vulnerable to both the pathologies (which manifest at the same time).

Mental Health Professionals should be aware of the threat; the IGD provides to mental health, and whether it is an etiology or consequence of the psychosis, either ways it warrants treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Washington, DC 20024: American Psychiatric Pub; 2013.  Back to cited text no. 1
Luciano M. The ICD-11 beta draft is available online. World Psychiatry 2015;14:375-6.  Back to cited text no. 2
Gentile DA, Bailey K, Bavelier D, Brockmyer JF, Cash H, Coyne SM, et al. Internet gaming disorder in children and adolescents. Pediatrics 2017;140:S81-5.  Back to cited text no. 3
Brunborg GS, Mentzoni RA, Frøyland LR. Is video gaming, or video game addiction, associated with depression, academic achievement, heavy episodic drinking, or conduct problems? J Behav Addict 2014;3:27-32.  Back to cited text no. 4
Hellström C, Nilsson KW, Leppert J, Åslund C. Effects of adolescent online gaming time and motives on depressive, musculoskeletal, and psychosomatic symptoms. Ups J Med Sci 2015;120:263-75.  Back to cited text no. 5
Schou Andreassen C, Billieux J, Griffiths MD, Kuss DJ, Demetrovics Z, Mazzoni E, et al. The relationship between addictive use of social media and video games and symptoms of psychiatric disorders: A large-scale cross-sectional study. Psychol Addict Behav 2016;30:252-62.  Back to cited text no. 6
Lemmens JS, Valkenburg PM, Gentile DA. The internet gaming disorder scale. Psychol Assess 2015;27:567-82.  Back to cited text no. 7
Stip E, Thibault A, Beauchamp-Chatel A, Kisely S. Internet addiction, hikikomori syndrome, and the prodromal phase of psychosis. Front Psychiatry 2016;7:6.  Back to cited text no. 8
Mason OJ, Brady F. The psychotomimetic effects of short-term sensory deprivation. J Nerv Ment Dis 2009;197:783-5.  Back to cited text no. 9
Mittal VA, Dean DJ, Pelletier A. Internet addiction, reality substitution and longitudinal changes in psychotic-like experiences in young adults. Early interv Psychiatry 2013;7:261-9.  Back to cited text no. 10
Kelleher I, Cannon M. Psychotic-like experiences in the general population: Characterizing a high-risk group for psychosis. Psychol Med 2011;41:1-6.  Back to cited text no. 11


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