1
Internet Gaming Disorder: 3 Case Analyses
Pratham Dhoka
Department of Psychology,
Dr. Ram Manohar Lohiya National Law University, Lucknow
Psychology- II
Ms. Isha Yadav
31st March 2022
2
Declaration
I hereby declare that the project work entitled “Internet Gaming Disorder: 3 Case Analyses”
submitted to the Dr. Ram Manohar Lohiya National Law University, Lucknow is a record of
an original work done by me under the guidance of Ms. Isha Yadav, Assistant Professor,
Faculty of Psychology, Dr. Ram Manohar Lohiya National Law University, and this project
work is submitted in the partial fulfillment of the requirements for the award of the degree of
B.A. LLB. (Hons). The results embodied in this thesis have not been submitted to any other
University or Institute to award any degree or diploma.
Acknowledgment
I express my gratitude and deep regards to my teacher for the subject Ms. Isha Yadav for
giving me a chance to choose my topic and for her exemplary guidance, monitoring, and
constant encouragement throughout this project. I thank almighty, my family and friends for
their constant encouragement without which this assignment would not have been possible.
I know that despite my best efforts some discrepancies might have crept in which I believe
my humble Professor would forgive. Thanking You All.
-Pratham Dhoka
3
Contents
Internet Gaming Disorder: 3 Case Analyses .................................................................................... 1
Declaration ....................................................................................................................................... 2
Acknowledgment ............................................................................................................................. 2
Contents............................................................................................................................................ 3
Abstract ............................................................................................................................................ 4
Introduction ...................................................................................................................................... 4
Internet Gaming Disorder ................................................................................................................ 5
International View ........................................................................................................................ 5
Research ....................................................................................................................................... 5
Views............................................................................................................................................ 6
Symptomatology .......................................................................................................................... 6
Etiology ........................................................................................................................................ 7
Standard Treatment ...................................................................................................................... 7
Case Studies ..................................................................................................................................... 8
1. Dan, 19-year-old, Swiss male ............................................................................................... 8
Symptomatology ...................................................................................................................... 8
Etiology .................................................................................................................................... 8
Treatment ................................................................................................................................. 9
2. A 20-year-old male, University student ............................................................................. 10
Symptomatology .................................................................................................................... 10
Etiology .................................................................................................................................. 11
Treatment ............................................................................................................................... 11
3. 22-year-old South Korean male .......................................................................................... 12
Symptomatology .................................................................................................................... 12
Etiology .................................................................................................................................. 12
Treatment ............................................................................................................................... 13
Conclusion...................................................................................................................................... 13
References ...................................................................................................................................... 15
4
Abstract
In this paper, we will take a good look at Internet Gaming Disorder (IGD) and its
symptomatology, etiology, and standard treatment. In the 5th edition of the Diagnostic and
Statistic Manual of Mental Disorders (DSM V), IGD is not recognized exclusively as a
disorder in DSM V but has been identified as a condition requiring more research and clinical
experiences before being considered a formal disorder. So here we will discuss some basic
facets of the above disorder and analyze three different case studies through that standard
lens. We will touch upon symptomatology, etiology, and standard treatment in the context of
the 3 aforesaid studies. This disease is more prominent in males and so our 3 cases are men
aged 19, 20, and 22 who are addicted to gaming so as to counter social realities and can’t
even sleep due to it. The problem is very real and increasing each passing day, especially at a
time when people have been forced to stay inside their homes. In this age of higher
technology, IGD poses an even greater threat as the gaming experience is being made more
and more immersive and addictive, almost like an escape from the harsh realities of the world
and its social life. We will try to assess the problem, its signs, and its solutions.
Introduction
In our daily lives, we are in constant search of modes of entertainment. Playing video games
on the internet is one of the most popular activities to engage in. A large number of teenagers
(even adults) indulge themselves in these. Internet gaming has taken the world by a storm and
has become part of pop culture. Gamers are revered like celebrities and earn lavish lifestyles.
People have become passionate about it and invest a good amount of time in front of their
screens. Some people are able to keep their life separate from their gaming aspirations while
others are not. The latter face several issues with regard to their mental health. Obsessiveness
kicks in, they start to disregard their relationships, family, own self. They feel nothing is
more important than their game and spend hours away from the real world, resulting in or
because of social anxiety, depression, insomnia, and other disorders. Here, we will see three
such case problems, where the subjects of the study are young men who are lost in this unreal
world and potentially harmed themselves. We will also try to see how their issues can be
solved. The first is a case of a 19-year-old adolescent man who exhibited IGD and showed
social problems associated with his addiction. The second is a case of a 20-year-old student
who used to be addicted to Internet video gaming to counteract his stress and social problem.
And the last one showcases a 22-year-old South Korean man who exhibits severe
5
implications of IGD. Before delving into their cases let’s first have a look at the main
attraction, the Internet Gaming Disorder itself.
Internet Gaming Disorder
Addiction to gaming is described in the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), which is used by mental health
professionals to diagnose mental disorders. There was not sufficient evidence to determine
whether the condition is a unique mental disorder or the best criteria to classify it at the time
the DSM-5 was published in 2013. However, it recognized internet gaming disorder in the
section recommending conditions for further research, along with caffeine use disorder and
other conditions.
The DSM-5 includes substance-related addictive disorders, such as alcohol, tobacco,
stimulants, marijuana, and opioids. Gambling disorder is the only behavioral addiction (as
opposed to substance use) identified in DSM-5. (American Psychiatric Association, 2018)
International View
In late 2017, the World Health Organization (WHO) announced that in the upcoming edition
(11th Revision) of the International Classification of Diseases* (ICD), gaming disorder will be
identified as a new disorder. In some countries, including South Korea and China, video
gaming has been recognized as a disorder and treatment programs have been established.
(American Psychiatric Association, 2018)
Research
A study published in American Journal of Psychiatry in March 2017 sought to examine the
validity and reliability of the criteria for internet gaming disorder, compare it to research on
gambling addiction and problem gaming, and estimate its impact on physical, social and
mental health. The study found that among those who played games, most did not report any
symptoms of internet gaming disorder and the percentage of people that might qualify for
internet gaming disorder is extremely small.
The research involved several studies of adults in the U.S., United Kingdom, Canada and
Germany. They found more than 86 percent of young adults ages 18 to 24 and more than 65
percent of all adults had recently played online games. The percentages of men and women
6
who recently played was roughly equal. However, the research is mixed on whether those
who met the criteria for internet gaming disorder had poorer emotional, physical and mental
health than those who did not meet the criteria. (American Psychiatric Association, 2018)
Views
Writing in a commentary about the study in the American Journal of Psychiatry, Patrick M.
Markey, Ph.D., and Christopher J. Ferguson, Ph.D., concluded that the study suggests "video
game addiction might be a real thing, but it is not the epidemic that some have made it out to
be."
The research and the debate are ongoing. Some argue, for example, that gaming could be a
symptom of an underlying problem, such as depression or anxiety, and not a disorder or
addiction itself.
Even while professionals debate, individual stories in the media point to struggles and
devastation from the phenomenon.
The Proceedings of the National Academy of Sciences summarizes the current debate:
"Adding video gaming to the list of recognized behavioral addictions could help millions in
need. It could also pathologize a normal behavior and create a new stigma." (American
Psychiatric Association, 2018)
Symptomatology
The DSM-5 notes that gaming must cause "significant impairment or distress" in several
aspects of a person's life. This proposed condition is limited to gaming and does not include
problems with general use of the internet, online gambling, or use of social media or
smartphones. The proposed symptoms of internet gaming disorder include:
o Preoccupation with gaming
o Withdrawal symptoms when gaming is taken away or not possible (sadness, anxiety,
irritability)
o Tolerance, the need to spend more time gaming to satisfy the urge
o Inability to reduce playing, unsuccessful attempts to quit gaming
7
o Giving up other activities, loss of interest in previously enjoyed activities due to
gaming
o Continuing to game despite problems
o Deceiving family members or others about the amount of time spent on gaming
o The use of gaming to relieve negative moods, such as guilt or hopelessness
o Risk, having jeopardized or lost a job or relationship due to gaming
Under the proposed criteria, a diagnosis of internet gaming disorder would require experiencing
five or more of these symptoms within a year. The condition can include gaming on the internet,
or on any electronic device, although most people who develop clinically significant gaming
problems play primarily on the internet. (American Psychiatric Association, 2018)
Etiology
The etiology and course of development of IGD are not well understood. One study measured
IGD-like symptoms over a 2-year period among more than 3000 children in Singaporean
elementary and secondary schools. Of the roughly 9% of children who were classified as
suffering from IGD at the beginning of the study, IGD persisted 2 years later for 84%. There
were not many clear indicators in this sample of who was most at risk for developing more
symptoms (impulsivity, lower social competence, higher amounts of gameplay), but those
who had increased gaming symptoms evidenced greater levels of depression, academic
declines, and worsened relationships with parents over time, along with increased aggressive
tendencies. In contrast, the authors of another study found that only 26% of problematic
gamers maintained a high level of symptoms over a 2-year period, whereas the authors of a
third study reported an ∼50% resolution rate over a 1-year period. (Douglas A. Gentile, et al.,
2017)
Standard Treatment
Reviews of the literature indicate that there are no randomized, well-controlled studies for the
treatment of IGD. Although various iterations of cognitive-behavioral therapy are most
widely represented in published literature and practice, other approaches, including family
therapy and motivational interviewing, have also been used alone or in conjunction with
cognitive-behavioral therapy. Definitive conclusions about the efficacy of any one approach
8
or set of combined approaches or their comparative effectiveness cannot yet be made because
of the lack of randomized, controlled research. (Douglas A. Gentile, et al., 2017)
Case Studies
1. Dan, 19-year-old, Swiss male
The following case describes a 19-year-old Swiss male who acquired no psychiatric
comorbidities before. Following, we use “Dan” as a pseudonym. Dan grew up in a typical
Swiss family in a rural city in the Canton of Baselland (Switzerland). He had a three-
yearolder sister, but unfortunately, she died seven years before when Dan was twelve years
old. Dan began playing video games starting at the age of five. His parents had two well-paid
jobs and were living in a huge house. At the age of eight, he was officially allowed to play
video games for one hour per day. However, he admits later that he often played for a longer
time. In fact, he played much more because his parents were not home often. At the age of
five, he started by learning games (sort numbers). At the age of eight, he quickly moved to
social games, and by the age of eleven, he turned to first-person shooter games. The whole
family gave him all the games and consoles he wanted; they did not realize that his gaming
behavior could be an expression of an addiction. (Niedermoser, D.W.; Hadjar, A.; Ankli, V.;
Schweinfurth, N.; Zueger, C.; Poespodihardjo, R.; Petitjean, S.; Wiesbeck, G.; Walter, M,
2021)
Symptomatology
Dan met all the above listed nine criteria. He played daily for about twelve hours a
day. In addition, as is typical of many other addictions, his addictive gaming started with a
little dose of “only a few minutes”. That intense gaming time in combination with almost no
sleep resulted in poor performance. This is in line with the findings of Mössle et al. (2010)
that extensive media use and gaming negatively affect learning, as it may draw some
attention away from learning and divert cognitive abilities away from school-related
activities. Moreover, the patient tried to conceal his gaming use at first, but then he
continued, although his parents were confronting him about his possible gaming addiction.
(D. W. Niedermoser et al., 2021)
Etiology
9
From a retrospective perspective, it is hard to tell if Dan’s social anxiety was the result of
social isolation and setting the priorities to video gaming, or if he initially began to play
video games as an avoidance strategy in response to his isolated social situation. Our working
hypothesis was a mixture of both, but the avoidance strategy could be used in combination
with his negative experience with his PE teacher. After having successfully coped with an
addiction, several shifts in addiction were often reported (e.g., pornography). This was
discussed regularly. In this case no shifts were reported. The absence of such shifts makes
our case a distinct and unique case. (D. W. Niedermoser et al., 2021)
Treatment
The sessions were mainly held once a week. At first, we had to establish some basic rules
(being on time, keeping appointments, and so on) for the patient but also had to inform his
parents and the new company about Dan’s progress. Dan’s parents and boss were informed to
assure a transparent and constant flow of information for all involved people. Baseline
assessment was measured using the Hamilton-21 (Hamilton), the Insomnia Severity Index
(ISI), and average game time per day (AGT) (see Table 1). The Hamilton questionnaire is an
experts’ rating scale for depression. The Insomnia Severity questionnaire measures a patient’s
current perception in terms of severity, stress, and impairment during the last two weeks.
AGT focuses on self-reported game time per day.
Applying cognitive behavioral therapy (CBT) for eight months (psychoeducation, goal-
attainment scale) was quite successful. The patient accepted his gaming addiction and
gaming time was reduced to 90 minutes. Various CBT methods were applied;
psychoeducation (e.g., sleep and functioning, addiction, control, and desire); cognitive
restructuring (e.g., evaluation of break in play, the relevance, and importance of offline vs
online relationships, individual handling of craving, development of alternative actions); and
mindfulness (e.g., what is good for me?). He was tasked with researching his own addiction
on the internet. In the therapy sessions, discussions took place. What he learned and from
10
where he learned became important. They also segregated what applied to him and what did
not. In the process, he saw success and got a major reduction in his gaming time. Further, his
sleep quality improved, and his social life became important. The therapeutic process
witnessed a self-acceleration thereon. He became involved in the local church and also
performed well in the final stages of his apprenticeship and had successful summer
graduation. (D. W. Niedermoser et al., 2021)
2. A 20-year-old male, University student
A 20-year-old University student was referred to a psychiatric clinic by the family doctor, He
has no past or history of psychological illness. We get information during psychiatric
evaluation that he started to spend hours on his computer and began playing video games at
the age of 7 years. Initially, he used to play an hour every day then slowly increased 3–4
hours a day and 5–6 hours or more a day at weekends. During college holidays it increases
even more because he was alone at home whilst his parents are at work. He claims that the
Internet is the most important thing in his life. He said that the Internet can change his mood
and he gets pleasure whenever he used to sit on a computer, he also feels a compulsion to
play video games to get rid of stress from academic study. Whenever he will not get a chance
to sit on the computer, he gets very irritable and starts to shake. However, he does not view
himself as an “addict,” he also said that he can’t work or live without it and my social,
intellectual life is linked directly to it. He has no friends outside, but he made many Internet
friends through online chat. He also feels that Internet has improved his level of knowledge.
As a result of these situations, he started suffering a lack of confidence and inferiority
complex when dealing with peers and school teachers, and his social interaction with family
members was limited therefore, he gets very sad. This condition worsened day by day and his
academic performance declined. (J. A. Siddiqui, S. F. Qureshi, A. K. Alghamdi, 2017)
Symptomatology
His mother and himself are upset over his behavior like: decreasing in academic performance,
decreasing the time which is given him for studying and doing homework, spending more
time playing video games, decreasing in work performance, inability to quit playing, staying
up too late at night in order to play, neglecting the important responsibilities while playing,
aggression toward a family member who tries to limit or prevent access to the video games,
and other problems like difficulties and changes in sleeping patterns, decrease in personal
11
hygiene, irregular or poor eating habits, headaches, red or dryness in eyes, and weight gain.
Lying to others and blaming them if they disturb the game. (J. A. Siddiqui et al., 2017)
Etiology
Our patient started spending more time playing video games to get rid of the pressure and
stress of academic study, as his family member had high expectations from him regarding his
bright academic performance. He appears to use the machine as an “electronic friend,” a
behavior that has been reported with other technological products such as video games.
His preoccupation with video games resulted in his poor academic performance and his
attempt to conceal his gaming use and its consequences ultimately resulted in the loss of
family ties, but he continued gaming. (J. A. Siddiqui et al., 2017)
Treatment
After taking the complete history, we diagnosed him with IGD and we referred him to our
clinical psychologist for his behavioral therapy such as cognitive behavior therapy (CBT),
habit reversal therapy (HRT), and reality therapy (RT). During his sessions, he refused to
attempt abrupt and complete cessation of video game use; instead, he opted to gradually
discontinue his involvement with video games by stepping down the number of hours of
daily play. Motivational interviewing (MI) can be used as a part of therapeutic intervention.
MI borrows strategies from cognitive therapy, client-centered counseling, and the social
psychology of persuasion and contains elements of both directive and non-directive
therapeutic approaches. With applied CBT and psychotherapy sessions for one and a half
years, he identified his video game addiction, stop gaming, and manage his depression
without medication. Slowly, he established his routine work and his sleep and diet improved.
He returned to the university, where his social life and academic performances satisfied him
and his parents. Using techniques such as open-ended questions, reflective listening,
affirmation, and summarization, helps the individuals give up addictive behaviors and learn
new behavioral skills to help individuals express their concerns about change. Family therapy
may be necessary among addicts whose family relationships have been disrupted and
negatively influenced by IA. (J. A. Siddiqui et al., 2017)
12
3. 22-year-old South Korean male
A 22-year-old first-generation South Korean male with a psychiatric history of major
depression with anxious features presented to the mental health clinic at reSTART because
his compulsive video game use had progressively interfered with his interpersonal
relationships and motivation to work. He began playing video games at age 6 in the context
of physically and verbally abusive parenting. Initially, he played for an hour on weekdays
and up to 5 hours on the weekends, with strict time limitations set by his parents. He was the
only son in the household, and he was expected to earn placement at a prestigious university
by achieving high academic marks throughout grade school. As a result of these
circumstances, his social interactions with peers were exceptionally limited, and time spent
outside of the home was strongly discouraged. Other than dating one female in secret for a
brief period and running on the cross-country team, he spent most of his time indoors and
increasingly resorted to video games, pornography, and anime for entertainment and sexual
release. (A. Voss, H. Cash, S. Hurdiss, F. Bishop, W. P. Klam, A. P. Doan, 2015)
Symptomatology
The patient described in this case study met all the criteria for diagnosis under the proposed
definition of IGD. His use of video games began as an escape from the pressure of family
expectations and increased over time (from 1 to 2 hours of daily play before college and
increasing to 16 to 17 hours of daily play before seeking treatment). His preoccupation with
video games resulted in poor academic performance and financial distress. Furthermore, his
attempt to conceal his gaming use and its consequences ultimately resulted in the loss of
family ties, but he continued to use. He gave up school so he could continue gaming, and
when he finally sought help because he could not reduce gaming use on his own, he struggled
with anxiety and irritability consistent with withdrawal systems. However, it is important to
note that the patient has a previous history of anxiety, which makes it difficult to determine
the degree of anxiety associated with IGD. In the present case, there was no known familial
history of addiction, though this should be reviewed given the genetic variables that
contribute to addictive behavior. In addition, it is important to note that the patient’s social
anxiety and dysfunction may have contributed to the patient’s excessive use of video gaming
and the development of IGD. (Ashley Voss et al., 2015)
Etiology
13
This case exemplifies the complexity of psychosocial factors that perpetuate pathologic
gaming behavior. The patient in this case report began playing video games at a young age,
which is a vulnerable time for both social development and addiction. Furthermore, given the
immersive nature of modern gaming, the patient was likely reinforced by the escape video
games provided from his rigid parenting structure, in addition to the satisfaction players feel
when they advance levels or complete tasks. Pleasure and excitement associated with video
games involve physiological arousal and stimulation of the HPA axis, resulting in increased
heart rate, blood pressure, and sympathetic tone. Our patient demonstrated attraction toward
the Internet gaming culture and playing with others, and perhaps the arousal associated with
playing with other people contributed to his addiction to Internet video gaming. While IGD
appears to affect large numbers of males, this may be due to the type and nature of the games
available. (Ashley Voss et al., 2015)
Treatment
During his sessions, he refused to attempt abrupt and complete cessation of video game use,
and the concept of doing so evoked immense anxiety and irritability. Instead, he opted to
gradually discontinue his involvement with video games by stepping down the number of
hours of daily play. His treatment goal was to reduce video game use to obtain a job, but due
to years of social isolation while gaming, his social anxiety was worse than before gaming.
Utilizing the criteria proposed by Gentile, he fit the criteria for IGD by answering yes to all
11 questions. With applied cognitive behavioral therapy (CBT) and psychotherapy for 2
years, he was eventually able to acknowledge his video game addiction, stop gaming, and
manage his depression without medication. He was able to establish a more regular diet and
sleep schedule. He returned to the university, where his social life and academic
performances satisfied him. After several experiences of playing video games and seeing
how they interfered with his ability to perform academically, he resisted his gaming urges by
keeping his computer at his parents’ home. (Ashley Voss et al., 2015)
Conclusion
After going through these cases and their trivialities, we have drawn lots of knowledge about
the internet gaming disorder. What are its affects? How does it affect? How to possibly treat
those affects? This form of obsession with gaming destroys one’s personal and professional
life as well. It has bad influence on one’s family and intimate ties. It also spoils one’s
14
academic and working aspirations. It is not a substance addiction but has similar
ramifications. Display of more than 5 of the listed symptoms may confirm the disorder;
symptoms may include preoccupation, withdrawal, longer durations, loss of self-control,
continuance despite awareness, lying or misleading others, use of games as escape corridor,
loss of interest in old hobbies, loss of job or relationship. It even poses extreme risk of
physiological damage in the form of eye ailments, back and spine problems etc. This disorder
can be result of mistakes in parenting, extra pampering to all demands of the patient, too
early introduction to video games, unaccounted for and reckless screen timings. Many
patients who suffer from social anxiety and depression look towards gaming as an outlet for
the negativity inside them and to gain satisfaction and happiness. A dominant majority of the
victims of this disorder are males due to the design of modern games, games which showcase
brutality, gore, profanity, alpha behavior, sexual objectification of females, and the
protagonist being a cis male; all these factors together along with assumed gender roles
appeal mostly to boys and men, the outcome being the fact that gaming is done mostly by
males and as a result, the disorder is quite gender specific and less occurring in females. The
treatment of IGD requires, firstly, that the patient should accept that they are suffering from a
disorder, and something is not right in their day-to-day affairs. If they do this much, their
further treatment becomes easier because then they have a very active involvement in the
procedural parts. Applying cognitive behavioral therapy (CBT) is one major line of treatment
seen across the three studies. Other than that, psychoeducation and teaching mindfulness also
help. In therapeutic interventions, Motivational interviewing (MI) may put counselling and
persuasion aids to good use and result in giving the patient a rope out of his struggle. Family
therapy is recommended for those having ups and downs in their household relations due to
their excessive gaming and not giving adequate time to the family, it may help in building
better understanding and communication between the patient and family members. Though
IGD is not included in the main list of disorders, it has a potential to feature there in the next
DSM because our technology is constantly evolving and games are getting better, more
people are getting hooked to their devices and suffering from the above-mentioned
symptoms. It requires more clinical research, study, and attention. More than hundreds of
thousands of people today don’t know they are suffering from a disorder, a formal
classification and more awareness about it will mean that many lives will get fixed and many
more people will be able to live to the fullest of their potential.
15
References
www.google.com
www.scholar.google.com
https://www.psychiatry.org/patients-families/internet-gaming
Gentile, Douglas & Bailey, Kira & Bavelier, Daphne & Brockmyer, Jeanne & Cash, Hilarie
& Coyne, Sarah & Doan, Andrew & Grant, Donald & Green, C. & Griffiths, Mark & Markle,
Tracy & Petry, Nancy & Prot, Sara & Rae, Cosette & Rehbein, Florian & Rich, Michael &
Sullivan, Dave & Woolley, Elizabeth & Young, Kimberly. (2017). Internet Gaming Disorder
in Children and Adolescents. Pediatrics. 140. S81-S85. 10.1542/peds.2016-1758H.
https://www.researchgate.net/publication/320773148_Internet_Gaming_Disorder_in_Childre
n_and_Adolescents
Niedermoser, D.W.; Hadjar, A.; Ankli, V.; Schweinfurth, N.; Zueger, C.; Poespodihardjo, R.;
Petitjean, S.; Wiesbeck, G.; Walter, M. A Typical Case Report: Internet Gaming Disorder
Psychotherapy Treatment in Private Practice. Int. J. Environ. Res. Public Health 2021, 18,
2083. https://doi.org/10.3390/ijerph18042083
Siddiqui, J. A., Qureshi, S. F., & Alghamdi, A. K. (2018). Internet gaming disorder: A case
report. J. Behav. Health, 7, 41-44. https://www.researchgate.net/profile/Javed-Siddiqui-
3/publication/321141990_Internet_Gaming_Disorder_A_Case_Report/links/5d8f3e39458515
202b6f483d/Internet-Gaming-Disorder-A-Case-Report.pdf
Voss, A., Cash, H., Hurdiss, S., Bishop, F., Klam, W. P., & Doan, A. P. (2015). Focus:
Addiction: Case Report: Internet Gaming Disorder Associated With Pornography Use. The
Yale journal of biology and medicine, 88(3), 319.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553653/pdf/yjbm_88_3_319.pdf
