Sociodemographic details

A 16-year-old boy with easy premorbid temperament, studying in senior secondary, belonging to a joint family of upper socioeconomic strata and living in an urban area, presented with excessive use of online gaming accompanied by aggressive behaviour towards family members for the last 1 year. History revealed that the patient had experienced cyberbullying from his schoolmates 2 years ago. His peers circulated his photoshopped pictures with obscene content as a joke on him. He felt humiliated and was hesitant to share it with his parents due to the content. After 1 year of continuous bullying, he finally confided in his parents, who in turn informed the school authorities. The bullying stopped when school authorities intervened and informed the parents of the perpetrators. Although he was satisfied with the outcome, he had difficulty in resolving feelings of shame associated with the bullying. From the time of the incident, his academic performance deteriorated and he became withdrawn from his peers, which continued even after the bullying has stopped. However, his mood was not persistently low and his biological functions (sleep, appetite) were not impaired. He managed to pass his examinations and graduated to class 11, where he was introduced to online gaming by one of his friends.

Clinical symptomatology: online gaming addiction

The patient found online gaming to be a pleasurable pastime and started spending 3–4 hours per day playing online games. He would play the games on his personal computer. He played Fortnite: Save the World, a cooperative shooter-survival game of up to four players to fight off zombie-like creatures and defend objects with fortifications they can build, Fortnite Battle Royale and Fortnite Creative, where players are given complete freedom to create worlds and battle arenas. His usage increased gradually over the next 6 months and he would spend less time with his family and remain restricted to his room. Eventually, he would become verbally aggressive if his gaming devices were taken away. He would stay up whole night to play games and miss his classes the next morning, leading to further deterioration in academics.

While he used to play games with virtual companions, at other times he was completely absorbed in a state of daydreaming, often fantasising about the game in the absence of playing. Intermittently he got flashbacks related to the bullying incident and would resort to listening to music to ‘self soothe’ and distract himself from those thoughts.

Clinical symptomatology: MD

In the last 6 months, while listening to music he started to fantasise about the games that he used to play and stay in what he called a ‘dream like state’. During this period, he would imagine elaborate scenes inspired by the themes of the online games. The themes of his daydreams were mostly related to him, assuming the identity of the gaming character and an idealised version of himself (owning the characteristics he yearned for), having a lot of friends, having conversations with friends, being powerful and dominant, and taking revenge for the bullying. He would imagine these scenarios in elaborate detail. During ‘daydreaming’ he would remain completely immersed in the ‘fantasy world’ and it helped him to calm down and relax. The process of daydreaming was often initiated when the patient listens to music in his leisure time. On other occasions, he would also start daydreaming whenever he had feelings of distress or boredom. He would initially spend 1–2 hours daydreaming, and gradually the duration would increase to 4–6 hours, where he would feel an urge to return to daydreaming as soon as possible when interrupted. The patient would also start daydreaming while in class. During this period, he was also spending 5–6 hours playing internet games. This interfered with his ability to get his basic chores done and he had difficulties in paying attention or sustaining attention in a task without daydreaming. He would often appear inattentive to others while being spoken to, leading to social dysfunction and complaints from his teachers. The vivid fantasies with detailed storylines he imagined while daydreaming served as a distraction from the painful memories related to being bullied. Although the patient was gradually able to perceive that his urge to daydream was interfering with his daily activities, he was unable to control this urge. When daydreaming he perceived a sensation of calmness and comfort, but he would later be distressed thinking about the time wasted over it. Due to the steady academic deterioration and family disturbances, he was brought to the outpatient clinic for management.

Clinical evaluation

On mental status examination, the patient was well-kempt, conscious, oriented and cooperative for interview. Eye-to-eye contact was made and sustained, and rapport could be established. His affect was euthymic. His attention was aroused but ill-sustained. He did not report any perceptual abnormalities and his higher mental functions were intact. The patient reported about his preoccupation with the bullying incident and feelings of subjective distress related to it. The patient also reported about his daydreaming which he had not previously told his parents. There was no past or family history of psychiatric illness. There was no history suggestive of attention deficit hyperactivity disorder (ADHD) traits in childhood. The patient did not report use of any psychotropic substance. Following detailed assessment an objective evaluation was made using the Maladaptive Daydreaming Scale-16 (MDS-16).7 His score on MDS-16 was 65, which was above the cut-off of 50. For gaming use the Internet Gaming Test (IGT-20)8 was used, where he scored 86 (cut-off 71).

Diagnostic consideration

The patient was clinically evaluated for syndromal mood (depression), anxiety (obsessive compulsive disorder (OCD), dissociative disorders), and trauma and stressor-related disorders (adjustment disorder, post-traumatic stress disorder (PTSD)). However, at the time of evaluation, the patient did not suffer from persistent low mood, recurrent intrusive irrational thoughts or impulses, preoccupation with the stressful event of bullying, flashbacks, nightmares, autonomic arousal and so on. He did not fulfil the criteria for a syndromal mood or anxiety (OCD, PTSD) disorder. The patient demonstrated impaired control over gaming and ‘daydreaming’, preference for both activities over other life interests and daily activities, and continuation of both activities irrespective of significant impairment in socio-occupational functioning. These symptoms have been present over the last 1 year. Because currently only the International Classification of Diseases (ICD-11) accommodates internet gaming disorder as well as other forms of behavioural addiction, the patient was given a comorbid diagnosis of gaming disorder, specifically online (6C51.0), and other specified disorders due to addictive behaviour (6C5Y), as per ICD-11.

Intervention

Intervention was planned from a psychological viewpoint in three phases: behavioural modification, cognitive restructuring and relapse prevention. The antecedent-behaviour-consequences model was used to identify triggers and associated negative outcomes. The client was taught distraction techniques and ‘urge surfing’ to replace the maladaptive behaviour with more adaptive coping techniques. Self-soothing strategies such as grounding, mindfulness and deep belly breathing were practised to regulate emotions when experiencing withdrawal in relation to playing games or daydreaming behaviour. Cognitive restructuring was done to address negative self-thoughts associated with the experience of cyberbullying, such as ‘I am not worthy’, ‘I am ashamed’ and ‘I am unliked’. Good therapeutic alliance enabled positive self-image and increased self-efficacy. Relapse prevention included strategies to cope with urges, identification of triggers (internal–external), seeking company in real life than online, and time used on social media and gaming usage. At the individual level, keeping a diary of occurrence of MD helped to identify activities or stimuli that triggered the onset. Once the underlying causes of escape, avoidance and self-soothing by MD were identified, behavioural interventions for skill-building, such as distraction and relaxation techniques, would help to replace the maladaptive behaviour with adaptive coping responses. The core beliefs of shame and unworthiness established after the bullying incident were dealt with using cognitive–behavioural therapy. There was marked improvement after 12 weeks of therapy (once a week). Post-therapy score on MDS-16 was 46 and on IGT-20 was 62.