ORIGINAL RESEARCH

published: 05 January 2022

doi: 10.3389/fpsyt.2021.777397

Diagnostic Contribution of the DSM-5

Criteria for Internet Gaming Disorder
Tao Luo 1,2 , Dan Wei 3 , Jiangfan Guo 4 , Maorong Hu 2 , Xuelin Chao 2 , Yan Sun 5 , Qian Sun 2 ,
Shuiyuan Xiao 1* and Yanhui Liao 6*
1
Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University,
Changsha, China, 2 Department of Psychology, The First Affiliated Hospital of Nanchang University, Nanchang, China,
3
Department of Psychiatry, Jiangxi Mental Hospital, Nanchang, China, 4 Publicity Division of Jiangxi Mental Hospital,
Nanchang, China, 5 National Institute on Drug Dependence, Peking University, Peking, China, 6 Department of Psychiatry, Sir
Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China

Background: Internet gaming disorder (IGD) can have long-term severe consequences
in affected individuals, especially adolescents and young people. Empirical studies of IGD
using the DSM-5 criteria are still lacking. This study aimed to evaluate the contribution
of specific criteria to the diagnosis of IGD based on the DSM-5 in the context of
Chinese culture.
Methods: The Chinese version of the Internet Gaming Disorder Scale–Short Form
Edited by: (IGDS9-SF) was applied to investigate the prevalence of IGD in a general sample of
Barna Konkoly-Thege, 28,689 middle school students aged 12–19 years from two cities in China.
Waypoint Centre for Mental Health
Care, Canada Results: The prevalence of IGD was 4.6% among this adolescent sample. The group
Reviewed by: of IGD students reported longer weekly gaming times and worse academic performance
Hyoun S. Kim,
than the group of non-IGD students. Although “preoccupation” and “playing to escape”
University of Calgary, Canada
Gallus Bischof, were the most frequently reported criteria, the conditional inference trees showed that
University of Lübeck, Germany “give up other activities,” ‘negative consequences,” and “continue despite problems”
*Correspondence: contributed most to the diagnosis of IGD based on the DSM-5.
Shuiyuan Xiao
xiaosy@csu.edu.cn Conclusions: The prevalence of IGD among Chinese adolescents (ages 12–19) was
Yanhui Liao 4.6%. This study provides evidence for retaining or deleting specific diagnostic criteria
liaoyanhui@zju.edu.cn
by the DSM framework in the future.
Specialty section: Keywords: internet gaming disorder, IGD, DSM-5, criteria, diagnostic, prevalence
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
INTRODUCTION
Received: 15 September 2021 Internet gaming disorder (IGD), an increasingly serious public health concern, can have long-term
Accepted: 30 November 2021 severe consequences (such as self-esteem problems, emotional distress, impaired executive control
Published: 05 January 2022
and cognitive function, and disrupted regional structural connectivity) in affected individuals,
Citation: especially adolescents and young people (1–3). Therefore, the American Psychiatric Association
Luo T, Wei D, Guo J, Hu M, Chao X,
(APA) included IGD in the appendix of the DSM-5 as a potential diagnosis. Referring to the
Sun Y, Sun Q, Xiao S and Liao Y
(2022) Diagnostic Contribution of the
diagnostic criteria for substance use disorders, the DSM-5 drafted diagnostic criteria for IGD and
DSM-5 Criteria for Internet Gaming indicated that further research is warranted.
Disorder. According to DSM-5, the clinical diagnosis of IGD as indicated by endorsing five (or more)
Front. Psychiatry 12:777397. of the following nine criteria: “(1) preoccupation with online/offline gaming (i.e., preoccupation);
doi: 10.3389/fpsyt.2021.777397 (2) experience of unpleasant symptoms when gaming is taken away (i.e., withdrawal);

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Luo et al. Validiting DSM-5 Criteria for IGD

(3) the need to spend increasing amounts of time engaged METHODS

in games (i.e., tolerance); (4) unsuccessful attempts to control
participation in games (i.e., loss of control); (5) loss of interest Study Population and Procedure
in previous hobbies and entertainment as a result of, and Between November 2019 and January 2020, a cross-sectional
with the exception of games (i.e., give up other activities); study was conducted among middle schools in Weifang city of
(6) continued excessive use of games despite knowledge of Shandong Province and Yingtan city of Jiangxin Province in
psychosocial problems (i.e., continuation); (7) deceiving family China. We first randomly selected 17 high schools from these
members, therapists, or others regarding the amount of gaming two cities and randomly selected 500 classes comprising 30,560
(i.e., deception); (8) use of games to escape or relieve negative students from these high schools. Among all students selected,
moods (i.e., escape); and (9) jeopardising or losing a significant 306 were not in school at the time of the survey, so they were
relationship, job, or education or career opportunity because of invited to complete the questionnaire at home. Finally, excluding
participation in games (i.e., negative consequences) (4).” 1,588 students who refused to participate in the research, a total
Many studies have also examined the validity of particular of 28,972 students participated in the research, and the overall
criteria in different cultural contexts. Rehbein et al. presented response rate was 94.80%.
an early population-based evaluation study of the DSM-5 The questionnaire mainly covered issues related to
criteria. They found that the criteria “playing to escape” and Internet use, including IGD, psychopathological status, family
“preoccupation” were less likely to predict IGD, whereas “give environment and school atmosphere. All students and their
up other activities,” “tolerance,” and “withdrawal” were the most parents were informed that the purpose of the study was to
important predictor variables for IGD in Germany (5). Similarly, understand adolescents’ life situation, mental health status, and
Király et al. conducted an online survey of Hungarian individuals Internet use. The students and their parents were also told that if
and demonstrated that “preoccupation” and “playing to escape” they were unwilling to participate in the survey, they could not
provided limited information for the estimation of IGD severity participate; or if they were willing to discontinue participation
(6). Both Besser et al. in Germany and Lemmens et al. in the in research, they could stop filling in the questionnaire at any
Netherlands found that “playing to escape” has limited diagnostic time, which would not have any impact on their study and
power (7, 8). Ko et al. clinically assessed the presence of the nine life. Then, informed consent was sent to each student’s parents.
criteria in China. They found that all DSM-5 criteria of IGD After obtaining informed consent from parents, an electronic
had good diagnostic performance except for “deception” and informed consent form was then obtained from each student.
“escape”; the criteria “continuation” and “negative consequences” The survey was carried out in accordance with the Declaration
showed the best diagnostic accuracy (9). of Helsinki. Ethical approval was obtained from the ethics
More recently, the 11th version of the International committee of Jiangxi Mental Hospital of Nanchang University
Classification of Diseases (ICD-11) officially included gaming (No. 20190113).
disorder as a mental disorder (10). Different from the DSM-
5 framework, the ICD-11 framework eschewed the criteria of
Measures
Socio-demographics such as sex and age were collected. Weekly
“tolerance” and “withdrawal” and applied a monothetic approach
game play was calculated as follows: (daily game play time on a
in which all criteria must be endorsed. The ICD-11 criteria
week day × 5) + (daily game play time on a weekend day × 2).
involve (1) impaired control over gaming; (2) increasing priority
given to gaming over other activities; (3) continuation of Internet Gaming Disorder
gaming despite the occurrence of negative consequences; and The Chinese version of the Internet Gaming Disorder
(4) resulting clinically significant distress or impairments in Scale–Short Form (IGDS9-SF) was administered to assess
important areas of functioning (10). the DSM-5 criteria for IGD (17, 18). This instrument is a 9-item
The prevalence rates of IGD among adolescents range from scale with each item representing a DSM-5 criterion. Each item
1.2 to 10% in Western countries and from 7.5 to 15% in was rated on a five-point Likert scale ranging from “1 = never”
Asian countries (8, 11, 12). China has the most gamers in to “5 = very often.” A criterion was considered endorsed if the
the world, with nearly 1 billion gamers reported in 2021 corresponding item was answered with “often” or “very often”
(13), resulting in a high prevalence of IGD ranging from (17). The suggested cut-off score for IGDS-9SF is 32 (19). In this
2.1 to 17% (14–16). The estimated prevalence of IGD among study, the Cronbach’s α was 0.92.
Chinese adolescents diverges considerably across studies, which
is partly due to differences in the assessment instruments used. Academic Record
Although overlap exists between the dimensions assessed with Academic records were assessed by asking participants the
these instruments and the DSM-5 criteria for IGD, few studies question “Based on the total scores of all subjects in your
have evaluated all nine DSM-5 criteria in the Chinese general most recent final exam, how about your academic performance?
population and estimated the IGD prevalence in a general 1 = very bad, 2 = bad, 3 = medium, 4 = good, or 5 = very good.”
adolescent sample.
The present study aimed to assess the discriminative validity Statistical Methods
of specific criteria based on the DSM-5 criteria of IGD Missing Data
and to determine the 12-month prevalence of IGD among Among the participants, 28,689 (99.02%) students responded
Chinese adolescents. to all items of the questionnaire. The data of 283 other

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Luo et al. Validiting DSM-5 Criteria for IGD

TABLE 1 | Sample characteristics and game-play-related behaviours (n = 28,689).

Total sample Male students Female students Male students vs. female students

(N = 28,689) (n = 12,674) (n = 16,015) t/Z/χ2 P Effect size

M (SD) M (SD) M (SD)

Age 15.61 (1.90) 15.55 (1.82) 15.65 (1.97) t = −4.37 <0.001 Cohen’s d = 0.05
Weekly gaming (hours) 6.31 (8.04) 8.27 (9.55) 4.70 (6.25) Z = −48.10 <0.001 r = 0.28
IGDS9-SF score 15.74 (7.39) 18.54 (7.99) 13.53 (6.02) Z = −60.74 <0.001 r = 0.36
Academic Record 3.05 (1.05) 3.14 (1.17) 2.98 (0.95) Z = −14.05 <0.001 r = 0.08
N (%) N (%) N (%)
Middle school stage
Junior middle school 13,474 (46.97) 5,671 (44.75) 7,803 (48.72) χ 2 = 44.95 <0.001 φ = 0.04
Senior middle school 15,215 (53.03) 7,003 (55.25) 8,212 (51.28)
Internet gaming disorder 1,327 (4.63) 995 (7.85) 332 (2.07) χ 2 = 535.36 <0.001 φ = 0.36

IGDS9-SF, The nine-item Internet Gaming Disorder Scale–Short-Form.

(0.98%) students were excluded from the analysis because of

TABLE 2 | Validation of IGD classification (n = 28,689).
missing important information (without information for IGDS9-
SF values). IGD-students Non-IGD students Z P r

Statistical Procedures Weekly game time 29.47 (10.40) 5.14 (5.98) −60.03 <0.001 0.35
We calculated Cohen’s kappa coefficients to assess the IGDS9-SF score 35.69 (3.44) 14.77 (6.04) −62.06 <0.001 0.37
endorsement of specific criteria corresponding to IGD. Then, we Academic Record 2.97 (1.33) 3.05 (1.04) −2.42 <0.01 0.01
used non-parametric conditional inference trees (C-Trees) to IGDS9-SF, The nine-item Internet Gaming Disorder Scale–Short-Form; IGD, Internet
explore the contributions of specific criteria to the diagnosis of Gaming Disorder.
IGD. The predictive variables were age, gender, weekly gaming
time, and nine IGD criteria, while the response variable was
IGD diagnosis. TABLE 3 | Endorsement of DSM-5 IGD criteria (n = 28,689).

Criterion Mean SD Criterion (%) Cohen’s kappa

RESULTS
Preoccupation 2.28 1.27 15.63 0.39
Sample Characteristics and Withdrawal 1.60 0.93 4.87 0.41
Game-Play-Related Behaviours Tolerance 1.76 1.04 7.55 0.42
The demographic characteristics are shown in Table 1. The Loss control 1.70 0.98 5.48 0.45
students ranged from 12 to 19 years old (15.61 ± 1.90), and 44.2% Give up 1.61 0.98 5.41 0.51
were male. Male students showed more gaming time per week Continuation 1.61 0.94 4.32 0.45
than female students (8.27 ± 9.53 h vs. 4.70 ± 6.25 h) and higher Deception 1.52 1.00 6.63 0.37
IGDS9-SF scores (18.54 ± 7.99 vs. 13.54 ± 6.02). Escape 2.06 1.23 14.10 0.36
Negative consequences 1.62 0.96 5.49 0.47
Prevalence of Internet Gaming Disorder IGD, Internet Gaming Disorder.
The estimated 12-month prevalence of IGD was 4.63%. The
prevalence of IGD was 7.85% among male students, which was
higher than that among female students (2.07%) (Table 1). As The criterion “give up other activities” corresponded best to
shown in Table 2, the IGD students reported more weekly game the DSM-5 IGD diagnosis (Cohen’s κ = 0.51), and other criteria
time and lower academic records than the non-IGD students. including “loss of control,” “continue despite problems,” and
“negative consequences” corresponded well to the IGD diagnosis
Endorsement and Predictive Power of the (Cohen’s κ > 0.45).
DSM-5 Criteria As illustrated in Figure 1, “give up other activities” was
As shown in Table 3, “preoccupation” was the most endorsed the single input variable with the highest predictive value for
criterion (15.63%), followed by “escape” (14.1%). The proportion the DSM-5 IGD diagnosis, with a percentage of 49.36% (95%
of participants endorsing “tolerance,” “loss of control,” “give CL: 46.87, 51.85). For those adolescents who had endorsed
up other activities,” “deception,” and “negative consequences” “give up other activities,” if they also endorsed “continuation”
ranged between 5 and 8%. The most rarely endorsed criteria were and “negative consequences,” the percentage of adolescents
“continuation” (4.32%) and “withdrawal” (4.87%). (Subgroup 6) meeting the IGD diagnosis increased to 93.00%

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Luo et al. Validiting DSM-5 Criteria for IGD

FIGURE 1 | Conditional inference tree plot predicting DSM-5 IGD by diagnostic criteria, age, gender and gaming time (n = 28,689).

(95% CL: 90.76, 95.24); if they endorsed “negative consequences” (2.96%) adolescents who did not meet the criteria for IGD
but denied “continuation,” the IGD diagnostic rate was 51.59% but endorsed negative consequences. Given that functional
(95% CL: 45.37, 57.80) (Subgroup 5); If they denied “negative impairment is necessary for a diagnosis of GD in the
consequences,” the IGD diagnostic rate was 21.38% (95% CL: ICD-11 framework, we compared socio-demographics and
18.53, 24.22) (Subgroup 4). game-play-related behaviours of adolescents with IGD endorse
As shown in the left part of Figure 1, a small percentage negative consequences, adolescents with IGD but did not
(2.07%, 95% CL: 1.90, 2.24) of adolescents meeting the endorse negative consequences, adolescents without IGD but
IGD diagnostic standard did not endorse “give up other endorse negative consequences, and adlescents without IGD did
activities.” For those adolescents who had denied “give up other not endorse negative consequences.
activities,” if they also denied “continuation,” the IGD diagnostic As shown in Table 4, there were no significant differences in
rate was 1.68% (95% CL: 1.52, 1.83) (Subgroup 1); if they terms of gender and age among the group of IGD adolescents
endorsed “continuation” but denied “negative consequences,” endorsed with negative consequences, IGD adolescents denied
the IGD diagnostic rate was 11.04% (95% CL: 8.14, 13.93) negative consequences, and non-IGD adolescents endorsed
(Subgroup 2); and if they endorsed “continuation” and “negative negative consequences; however, compared to the group
consequences,” the IGD diagnostic rate was 46.15% (95% CL: of adolescents without IGD denied negative consequences,
37.88%, 54.42%) (Subgroup 3). these three groups of adolescents tended to be male
and older.
Comparison Variables of Impairment for In terms of game-play-related behaviours, adolescents
IGD with IGD endorsed negative consequences reported the
There were 600 (2.10%) adolescents who met the criteria for most amount of weekly game time, and the highest score
IGD but did not endorse negative consequences, while 849 of IGDS9-SF, followed by adolescents with IGD but did not

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Luo et al. Validiting DSM-5 Criteria for IGD

TABLE 4 | Comparison variables of impairment for IGD (n = 28,689).

IGD students IGD students denied Non-IGD students Non-IGD students t/χ2 P Effect size
endorsed negative negative endorsed negative denied negative
consequences consequences consequences consequences
N = 727 N = 600 N = 849 N = 26 513
N (%) N (%) N (%) N (%)

Gender (male) 549 (75.52)a 446 (74.33)a 610 (71.85)a 11 069 (41.75)b χ2 = 837.77* <0.001 φ = 0.17
M (SD) M (SD) M (SD) M (SD)
Age 15.98 (1.78)a 16.00 (1.61)a 16.05 (1.68)a 15.58 (1.92)b t = 35.42 <0.001 Cohen’s d = 0.03
Weekly game time 34.60 (7.17)a 23.25 (10.32)b 12.17 (10.32)c 4.92 (5.64)d χ2 = 4,387.69** <0.001 φ = 0.35
IGDS9-SF score 37.83 (3.23)a 33.11 (1.67)b 23.79 (4.91)c 14.49 (5.84)d χ2 = 5,140.35** <0.001 φ = 0.37
Academic Record 2.64 (1.30)a 3.36 (1.25)b 3.46 (1.15)c 3.04 (1.04)d χ2 = 275.56** <0.001 φ = 0.01

IGDS9-SF, The nine-item Internet Gaming Disorder Scale–Short-Form; IGD, Internet Gaming Disorder.
*χ2 value was obtained by χ2 test.
**χ2 values were obtained by Kruskal-Wallis H test. Different subscript letters (a, b, c) in the same row reflect significant (p < 0.05) difference between the rates or means while same
subscript letters in one row reflect non-significant difference between the rates or means according to χ2 test or Mann-Whitney U-test.

endorse negative consequences, adolescents without IGD additionally endorsed “continuation” to “give up other activities”
but endorse negative consequences, and adolescents without and ‘negative consequences,” the probability of being classified
IGD did not endorse negative consequences. Adolescents as having IGD was increased to 93%. “Loss of control” is also
without IGD who endorse negative consequences reported viewed as an essential feature of addictive behaviour, and it is
the highest academic record, while adolescents with IGD a necessary diagnostic criterion in the ICD-11 framework (10,
who endorsed negative consequences reported the lowest 21). Although this criterion did not provide more information
academic record. in the multivariate analysis, it had high predictive power for
IGD independently.
Our results support the views of most clinical experts and
DISCUSSION researchers in this field. Most recently, a Delphi study conducted
by Castro-Calvo et al. reported that the criteria of “give up
This study found that the 12-month prevalence of IGD was other activities,” “continuation,” “loss of control” and “negative
4.6% among Chinese adolescents, and the prevalence of IGD consequences” had the highest approval rate among international
among boys was significantly higher than that among girls. In experts for their high diagnostic validity, while other criteria had
addition, consistent with other studies, the students classified as the low approval rate (25). The present study provides evidence
having IGD by the DSM-5 criteria reported more gaming time for inclusion of these criteria by the DSM framework in the
and worse academic performance than those classified as not future and supports the definition of gaming disorder in the
having IGD (5). ICD-11 framework.
Agreement upon the criteria would allow the establishment of The criteria of “tolerance” and “withdrawal” were of key
correct diagnoses to identify game players who need professional importance for identifying IGD in the study of Rehbein et al. (5),
support and effective treatments (20). Our results demonstrated however, these two criteria did not provide more information
significant differences in the relationship between specific DSM- in the multivariate analysis in this study. This might be due
5 criteria and IGD diagnosis in the context of Chinese culture. to cultural differences. Although previous study has proven the
The criterion “give up other activities” was the most relevant adequate diagnostic accuracy of these two criteria (9), there are
to the diagnosis of IGD based on the DSM-5, which is in also doubts about whether these two criteria can distinguish
accordance with Rehbein et al. (5). This criterion reflects between unpathological high involvement, such as a “gaming
increased priority given to gaming over other activities, implying passion,” and problematic gaming (26).
behavioural salience, and is viewed as an essential feature of The criteria of “preoccupation” and “escape” have high
addictive behaviour (5, 21). In our study, if this criterion support rates, but the ability to predict IGD is weak, which
was endorsed, the probability of meeting the DSM-5 IGD is consistent with Rehbein’s study (5). We also found that
criteria increased from 2 to 50%. “Negative consequences,” criterion “deception” showed a weak ability to predict IGD,
which reflects serious impairment of social function, was the which matches findings from studies in different cultural
next most relevant criterion to the IGD diagnosis (22–24). contexts (9, 27, 28). Thus, these three criteria may have
Among the adolescents who endorsed both “give up other limited distinguishing ability between gaming disorders and non-
activities” and “negative consequences,” 80% were classified as pathological game participation cross-culturally. Preoccupation
having IGD. “Continuation” also reflected the perceived negative with gaming behaviour may relate to high engagement (29,
consequences of gaming behaviour and was the third most 30), escaping a negative mood by playing games may reflect
relevant criterion to the IGD diagnosis (21). For those who a coping style for emotions (29, 31), and deceiving others

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Luo et al. Validiting DSM-5 Criteria for IGD

may be influenced by others’ attitudes towards the game, DATA AVAILABILITY STATEMENT
but this behaviour is not necessarily pathological (29). Future
research can explore the impact of the removal of “escape” The data that support the findings of this study are available
and “deception” on the validity of the DSM-5 framework. from the corresponding author upon reasonable request and with
Given that salience is one of the core features of addictive completion of data user agreement.
behaviours (32), “preoccupation” might be worth keeping,
but a more clearer definition might be needed to increase ETHICS STATEMENT
its validity.
Theoretically, all adolescents with IGD should report This study was carried out in accordance with the Declaration
impaired social function (10, 28). However, 2% of IGD of Helsinki. Ethical approval was obtained from the Ethics
adolescents in our study did not report that gaming activity Committee of Jiangxi Mental Hospital of Nanchang University
often leads to jeopardisation or loss of an important relationship, (No. 20190113). All students and their parents were fully
job or an educational or career opportunity. However, 3% of informed the purpose of the study. After obtaining informed
non-IGD adolescents reported that gaming activity often causes consent from parents, an electronic informed consent form was
negative consequences. This may be due to the possibility of then obtained from each student.
false positives or false negatives on the one hand; on the other
hand, it may be due to the different insight of adolescents on the AUTHOR CONTRIBUTIONS
consequences of their gaming activity. These results suggest that
the criteria for IGD should be defined by more specific intensity TL, YL, and SX: contributed in conceptualising and designing
and frequency thresholds in future clinical practise and research the study, analysis and interpretation of data, drafting and
work, such as for severe events, one event was sufficient; for revising the article, and final approval of the version to be
moderate events, events needed to be repeated 3 times a week or published. DW, JG, MH, and XC: contributed in collecting,
more (28, 30). analysis, interpretation of data, drafting the article, and final
There were some limitations of the present study. First, the approval of the version to be published. YS and QS: contributed
IGD was assessed using self-reports and not clinical interviews in revising the article. All authors contributed to the article and
by trained professionals. Second, the sample was restricted to 12- approved the submitted version.
and 19-year-old Chinese students, and other groups may have
different patterns of criteria endorsement. FUNDING
CONCLUSIONS This study was supported by the Hundred Talents Program
funding from Zhejiang University.
In conclusion, our study found that the estimated 12-month
prevalence of IGD was 4.6%. Furthermore, symptoms related to ACKNOWLEDGMENTS
“give up other activities,” “negative consequences,” and “continue
despite problems,” are the most relevant to an IGD diagnosis in The authors would like to thank all the participants and
this sample. their parents.

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Frontiers in Psychiatry | www.frontiersin.org 7 January 2022 | Volume 12 | Article 777397