Background
Psychotic disorders (PD), are major mental disorders that affect 3% of
the population [1]. They occur during a critical period of life,
specifically in late adolescence and early adulthood [2]. Their
consequences include an increased rate of suicide and acts of
violence[3-5], low employment rates [6], reduced life expectancy
by 15 years [7, 8], as well as homelessness and experiences of
stigmatization [9, 10]. In Canada, the economic burden of these
conditions was estimated to be $7 billion in 2004 while the global
estimates indicate a range between 0.02% and 1.65% of the gross
domestic product in 2016 [11, 12]. While antipsychotic medications
are effective in alleviating certain symptoms, such as delusions and
hallucinations, they are not sufficient for achieving full recovery
[13]. In fact, PD are frequently associated with psychiatric
comorbidities, including substance use disorders, personality disorders,
and attention-deficit/hyperactivity disorder (ADHD), which can further
exacerbate the consequences associated with PD [14]. Therefore,
treating comorbidities is crucial for achieving recovery, particularly
in patients with first episode psychosis (FEP), where early intervention
has demonstrated the greatest impact on patients’ long-term outcomes
[15]. Amongst other comorbidities, excessive video gaming has become
a cause for concerns for clinicians due to its impact on patients’
lives, in particular among young adults, but a literature review
conducted by our team [16] has highlighted a significant paucity of
data on video gaming comorbid with FEP, despite recent interest and
developments on this topic.
In recent decades, there has been a growing interest about the
consequences of excessive video gaming on mental health. This attention
has been prompted by the inclusion of Internet Gaming Disorder (IGD) as
a “Condition for Further Study” in the Diagnostic and Statistical
Manual of Mental Disorders, fifth edition (DMS-5), in 2013 [17]. The
recognition of this disorder as an official diagnosis in the 11th
edition of the International Classification of Diseases (ICD-11) under
the term Gaming Disorder (GD) has reinforced the importance and urgency
to better understand the clinical impacts of this condition [18]. GD
is defined as a persistent and recurrent pattern of gaming behavior,
involving digital or video gaming, characterized by an impaired control
over gaming as well as an increased priority placed on gaming over other
activities to the extent that it takes precedence over other interests
and daily activities. Individuals with GD continue or escalate their
gaming behavior despite experiencing negative consequences such as
reduced occupational or academic functioning [18].
The reported prevalence of GD in the general population varies from
0.2% to 20% across studies [18]. This variability can be explained
by several factors, including the age of the participants studied, the
country where the study was conducted, or the definition of GD used in
the study. There are three main categories of risk factors associated
with GD: 1) those related to gaming and its practice (e.g. duration and
frequency of gaming, online and multiplayer games), 2) individual
factors (e.g. isolation, low self-esteem, impulsivity, difficulties in
emotion regulation, feelings of stigmatization, sex, gender, young age,
low education level), and 3) environmental factors (e.g. family
dysfunction, harassment and childhood neglect) [19, 20]. GD has also
been associated with other symptoms, mental disorders, and impairments
in functioning, such as depression, social anxiety, ADHD, impaired
academic performance, and deterioration in interpersonal relationships,
but a causal relationship has not been clearly established [21-30].
In terms of treatment, promising results have been achieved with various
approaches, including cognitive-behavioral therapy. However, there is
currently insufficient data to draw solid conclusions regarding the
effectiveness of existing approaches [31].
Regarding the comorbidity between GD and PD, the available literature is
limited to a few case reports describing the occurrence of brief
psychotic episodes following excessive video game use or abrupt
cessation [16]. Research on this comorbidity is therefore scarce and
lacks prospective data, which hinders the improvement of prevention,
detection, and treatment strategies. However, individuals with PD
present several common risk factors with GD: the male gender, social
isolation, low self-esteem, difficulties in emotion regulation,
impulsivity or behavioral inhibition, and onset of disorders during
adolescence or early adulthood [19, 20, 32-34]. Additionally, little
is known about the patterns of video game use among individuals with PD
(e.g. gaming time, game content, interface [console, mobile, computer,
online or offline]). For the affected youth, the consequences of GD
added to those of PD may further hinder recovery. Studying GD among
young adults with PD is then particularly relevant, as the risk factors
common to GD and PD are even more prevalent in this population compared
to the overall population with PD alone (e.g., substance use disorders,
male predominance, younger age) [35, 36]. Furthermore, it is well
established that clinical interventions in FEP significantly influence
clinical outcomes of affected individuals [15].
In line with prevalent societal beliefs, video games have often been
associated with a negative perception that links them to aggressive and
criminal behavior [37]. However, an increasing body of evidence
suggests that video games can have beneficial effects and even serve as
a therapeutic tool. The term ’serious games’ refers to software that
incorporates playful elements for educational, training, and therapeutic
purposes. Such games have been employed in the treatment of individuals
with PD, demonstrating a significant reduction in psychotic symptoms
[38, 39]. Additionally, they have shown improvements in cognitive
functions, social cognitions, and occupational status [40-43].
Although the understanding of the impact of commercial video games on PD
is limited, a recent literature review highlights several advantages of
these types of games, with seven studies reporting positive outcomes
[44]. Among them, four studies revealed enhanced processing speed,
memory, and executive functions through the use of commercial video
games, while three studies demonstrated improvements in aerobic fitness
and walking speed in patients who engaged in active video games
utilizing the Kinect for Xbox game system [45-48]. These potential
benefits in individuals with PD underscore the unique nature of gaming
addiction, where the objective is to promote healthy gaming habits
rather than complete avoidance, as seen in other forms of addiction. In
order to help patients to reach these healthy habits, it is imperative
to enhance our comprehension of the influence of gaming on the clinical
trajectory of individuals diagnosed with PD.
Using an innovative screening and assessment procedure for GD tailored
to young adults with FEP, the aim of this study is to better understand
the impact of gaming in people with FEP by: 1) determining the
prevalence of GD among FEP patients; 2) determining the consequences of
GD on the clinical trajectory of FEP patients; and 3) assessing
individual factors that differentiate patients who developed GD among
the overall study population