In this exploratory study, we focused on online game habits and problematic overuse in adult MMORPG gamers, comparing three different instruments that could help to screen subjects with MMORPG problematic overuse. Concerning IA scales, we observed that the positivity rate observed with GIAD was higher than that observed with ISS and this confirmed that these 2 scales screened different dimensions (GIAD estimated dependence and addiction whereas ISS estimated addiction only). The superior rates obtained with GIAD mean that in substance use disorders, dependence is more frequent than addiction [37
]. Moreover, for the 3 instruments used, the trend was the same but no complete concordance was observed. Also, these 3 tools did not estimate the same entities, suggesting a difference between IA and online gaming addiction. This strengthens our working hypothesis of the need for specific tools for the Internet and other specific tools for MMORPG. We showed that the adapted substance DSM-IV-TR scale (named DAS) could be a good first-line instrument to evaluate MMORPG overuse.
While the literature has documented an increasing interest in MMORPG, no consensus currently exists concerning a validated scale for determining MMORPG addiction specifically. Most previous studies look at a particular adolescent population in relation to the Internet generally, and rarely focus on video games [38
]. The psychometric properties of IA scales are promising [15
], whereas others have based their research on gamer interviews [14
]. In addition, previous studies do not differentiate between the Internet and online video games, nor between different types of online video games [41
]. MMORPGs were more likely to be associated with problematic use [33
] than non-MMORPG games because MMORPG gamers tend to spend much more time playing [13
Our study has a number of limitations. Firstly, the representativeness of the sample analyzed here could be problematic. Participants were not randomly chosen, and participation was voluntary (subjects accepted to take part in the assessment on reaching the webpage for the online questionnaire). Probably not all types of MMORPG gamers were included in this study, especially hardcore (because the responses would cause them to waste time that could be spent playing) or casual gamers (because they may feel unconcerned by the study). On the other hand, online gamers are by definition difficult to reach in any other way apart from the internet. Secondly, we focused on a specific sample (French adult MMORPG gamers only). Our results are nevertheless comparable to American and Asian studies in terms of age, gender, and family and marital status [14
]. Additionally, the average time spent gaming observed here was similar to other studies [33
]. Thirdly, the assessments were only based on self-reports. Responders may have been defensive in their answers, i.e
. attempting to appear socially normal, which is an inevitable risk with any research based on self-reporting. Nevertheless, the guarantee of data anonymity may have encouraged gamers to provide honest answers. Fourthly, it was unlikely that the same gamer would respond to the questionnaire more than once because of its length (45 min). Moreover, as explained in the Results section, quality control of data eliminated inconsistent questionnaires. Fifthly, the concordance of the self-reported gradation of gaming engagement (Casual, Hardcore gamer and No life) and DAS positivity, and the different adverse effects reported suggested honest responses from a community which was cautious about providing information which may harm the public image of online games.
In terms of baseline characteristics, our study showed that French adult MMORPG gamers are often young, employed, adult University graduates, and tend to live alone in urban areas. Interpersonal interactions (77.5%) were the main attraction of this MMORPG according to their self-assessment, and not the role-play per se (30.9%). A young age of online gaming onset was a stronger variable associated with DAS positivity compared to the number of years of play. We observed the same number of years playing online video games for both groups [8.54 years (Standard Deviation (SD): 6.66; 95%CI: 7.81-9.26 for the DAS- group versus 8.41 years (SD: 5.93; 95%CI: 7.35-9.46) for the DAS+] (data not shown).
We chose to adapt the DSM-IV-TR substance dependence scale for online video games because excessive involvement in online games can be described as a form of behavioral addiction in which behavior is defined by gaming activity. This position was reinforced by the A.P.A.'s recent discussion and stance on the issue [7
], which took place as we were preparing this manuscript. In addition, the criteria for problematic video game playing including tolerance, derived from the diagnostic criteria of substance dependence [25
]. Furthermore, the adapted DSM-IV pathological gambling scale raised validity issues due to various distinct qualitative differences between gambling and gaming [23
]. Here, we observed that for the 3 scales, the addiction rate was higher compared to other studies [14
]. Addiction screening tools used in our study showed high and significant (p < 10-3
) concordance when screening positive or negative: DAS and ISS showed 77.5% of concordant pairs, and DAS and GIAD showed 72.5% of concordant pairs. The higher rates for IA in our study (32.5% of ISS+
and 44.3% of GIAD+
) compared to the literature could be explained by the sample characteristics: online gamers are more likely to overuse Internet vector for gaming as well as for other Internet activities. Moreover, these two tools did not measure the same dimensions. ISS focused on addiction with loss of control and the persistence of the behavior despite adverse consequences in important areas; whereas GIAD evaluated tolerance and withdrawal symptoms in relation to dependence.
The difference in the positivity level observed for the 3 instruments underlined a real difference between gaming and generalized PIU, and requires specific tools for each field of IA. We showed that, of these three different instruments, the DAS seemed to be a valuable screening instrument for MMORPG addiction. The DAS appeared to be the one most associated with the other entities studied. This was explained firstly by the fact that ISS and GIAD scales were dedicated to the Internet, so they included other elements beside gaming, whereas DAS was specific to online video games. Secondly, we observed several analogies between DAS positivity and other addictions for which the usual scales were validated, such as alcohol addiction. For example, the odds ratio associated with a positive response to the question "Increasing time spent on the Internet to obtain satisfaction" was high (OR: 2.99); this effect could be defined as a tolerance phenomenon, which is classically found in substance addiction [28
]. It is likewise well established that addiction to substances such as alcohol is associated with health and social difficulties such as family and work problems [43
]. Examining behavior related to MMORPG addiction allowed us to define a "gaming adult population at risk of addiction" with numerous implications for health and personal behavior, as observed during the preparation of this manuscript by Billieux et coll
]. Indeed, gamers from all positive groups were younger than those in negative groups and were less likely to be University graduates (48.2% had at least a High School Diploma) compared to the general population of our study, which is consistent with the fact that younger gamers considered themselves more addicted [14
]. Because of similarities with previous studies [14
], a multivariate logistic regression analysis was carried out with adjustments for age, sex and educational level. All variables studied here (25/25) remained significant in the final model after adjustment. In terms of gamer characteristics, positive group gamers spent more time on the Internet per week than negative group ones and more time gaming than the population as a whole. Additionally, there was a strong relationship between the definition given by participants (Casual, Hardcore gamer or No life) and addiction level: the higher up the scale definition is, the more dependent the gamer is compared to the overall population. Gamers who felt greater personal satisfaction, sense of power or of belonging to a group and did not sleep restfully were more often in the DAS+
group gamers also slept fewer hours per night than DAS-
ones and suffered sleep deprivation or diurnal sleepiness. As in Hussain's study [46
], gamers claiming to feel more irritable and more anxious were more addicted than those who said they felt happier. Seeking and obtaining pleasure from games could be a protective factor from excessive gaming. Unsurprisingly, gamers claiming to be sadder were also 12 times more likely to be associated with the DAS+
group than those who said they were happier. This could be due to a mood improvement sought in the game, or a consequence of adverse effects related to excessive gaming. In terms of health, players with self-reported physical or psychological effects linked to gaming were also more often in the DAS+
group, and this association was 14 times more likely to be found when gamers reported both kind of adverse effects. We observed the same relationship between DAS positivity and confusing real life with fiction. In the same way, gamers who felt that guilds required time and exerted pressure were more often in the DAS+
group. These feelings could be explained by the need to belong to a guild to progress in the game, to reach high levels. Guilds often organize raids and other events requiring planning, which could create a sense of obligation for members [47
]. Some guilds select members who are most available and have been gaming the longest, with the aim of competing with other guilds. Moreover, we observed that guilds protected gamers, as the risk of DAS positivity increased in gamers who felt that guilds made demands on their time compared to gamers who did not feel this. Finally, as far as social impairments are concerned, DAS+
group gamers appeared to go out less, see fewer friends, have marital, family, work and financial difficulties and deprive themselves of necessary purchases to play, as observed in other addictions.
In view of these results, this study underlines the fact that DAS seemed a good first-line instrument for screening gamers who could be at risk of online excessive gaming. Gamers with some of the characteristics mentioned above were not necessarily addicts but appeared to be at a substantial risk of addiction. From a public health point of view, it was therefore important to identify this population in order to describe the phenomenon in sufficient detail.