Introduction
Gaming disorder (GD) was recognized by the World Health Organization in the ICD-11 as a behavioral addiction, characterized by impaired control over gaming, prioritization of gaming over other activities, and continued gaming despite negative consequences (WHO, 2019). A meta-analysis estimates its prevalence at 3.3% in the general population (Kim et al. Reference Kim, Son, Roh, Ahn, Kim, Shin, Chey and Choi2022). While gaming can enhance cognitive functions and foster social connections (Granic et al. Reference Granic, Lobel and Engels2014, Quiles & Verdoux, Reference Quiles and Verdoux2023), GD is associated with anxiety, depression, functional impairments, interpersonal conflict, social withdrawal, and academic or occupational difficulties (Ji et al. Reference Ji, Yin, Zhang and Wong2022, Richard et al. Reference Richard, Temcheff and Derevensky2020).
GD frequently co-occurs with psychiatric conditions, including attention-deficit/hyperactivity disorder, mood disorders, and anxiety disorders, though causal relationships remain unclear (Ahmed et al. Reference Ahmed, Abdalla, Mohamed, Mohamed and Shamaa2022, VAN et al. Reference van Rooij, Kuss, Griffiths, Shorter, Schoenmakers and van de Mheen2014, Hygen et al. Reference Hygen, Skalicka, Stenseng, Belsky, Steinsbekk and Wichstrom2020, Lee et al. Reference Lee, Bae, Kim and Han2021, Gonzalez-Bueso et al. Reference González-Bueso, Santamaría, Fernández, Merino, Montero and Ribas2018, Huot-Lavoie et al. Reference Huot-Lavoie, Gabriel-Courval, Béchard, Corbeil, Brodeur and Massé2023) However, its prevalence, clinical impact, and mechanisms of co-occurrence with more severe psychiatric conditions, particularly psychotic disorders, remain poorly understood (Huot-Lavoie et al. 2022, González-Bueso et al. Reference González-Bueso, Santamaría, Fernández, Merino, Montero and Ribas2018).
Psychotic disorders and the importance of early intervention
Psychotic disorders encompass multiple symptom domains, including positive symptoms (delusions, hallucinations), cognitive and disorganized symptoms, mood-related symptoms (anxiety, depression), agitation and hostility, negative symptoms (diminished affect and reduced motivation), and manic symptoms, which are more common in bipolar spectrum or schizoaffective disorders (Lehoux et al. Reference Lehoux, Lefebvre, Maziade, Roy and Gobeil2009, American Psychiatric Association, 2013).
Reducing the duration of untreated psychosis is critical for improving long-term clinical outcomes (Marshall et al. Reference Marshall, Lewis, Lockwood, Drake, Jones and Croudace2005, Perkins et al. Reference Perkins, Gu, Boteva and Lieberman2005, Correll et al. Reference Correll, Galling, Pawar, Krivko, Bonetto, Ruggeri, Craig, Nordentoft, Srihari, Guloksuz, Hui, Chen, Valencia, Juarez, Robinson, Schooler, Brunette, Mueser, Rosenheck, Marcy, Addington, Estroff, Robinson, Penn, Severe and Kane2018). Early intensive, age-appropriate intervention programs have demonstrated superior outcomes compared to standard treatment, particularly for first-episode psychosis (FEP) (Correll et al. Reference Correll, Galling, Pawar, Krivko, Bonetto, Ruggeri, Craig, Nordentoft, Srihari, Guloksuz, Hui, Chen, Valencia, Juarez, Robinson, Schooler, Brunette, Mueser, Rosenheck, Marcy, Addington, Estroff, Robinson, Penn, Severe and Kane2018).
The need for a comprehensive approach to recovery
Pharmacological treatments play a critical role in FEP management, achieving remission of positive symptoms in approximately 80% of patients within the first year (Robinson et al. Reference Robinson, Woerner, McMeniman, Mendelowitz and Bilder2004, Malhi et al. Reference Malhi, Adams, Moss and Walter2010). However, symptom remission does not equate to full recovery, as many individuals experience persistent functional impairments, social withdrawal, and difficulties in personal and occupational domains. When broader recovery measures – such as social reintegration, autonomy, and life satisfaction – are considered, only 21% with FEP achieve full recovery (Hansen et al. Reference Hansen, Speyer, Starzer, Albert, Hjorthøj, Eplov and Nordentoft2023). This underscore the need for holistic approaches that extend beyond symptom management to encompass functional, social, psychological, and personal health dimension (Roy MA et al. Reference Roy, Cellard, Côté, Demers, Lehoux, Menear, Morin, Péloquin and Vigneault2024).
In addition to many issues associated with psychotic disorders, comorbidities significantly influence recovery engagement and outcomes (Wade et al. Reference Wade, Harrigan, McGorry, Burgess and Whelan2007, Wisdom et al. Reference Wisdom, Manuel and Drake2011, Blanchard et al. Reference Blanchard, Brown, Horan and Sherwood2000, Volkow, Reference Volkow2009, Thoma & Daum, Reference Thoma and Daum2013). Substance use disorders (SUD), which are highly prevalent in psychotic disorders (Baker et al. Reference Baker, Hiles, Thornton, Hides and Lubman2012, Hunt et al. Reference Hunt, Siegfried, Morley, Brooke-Sumner and Cleary2019, Rygaard Hjorthoj et al. Reference Rygaard Hjorthoj, Baker, Fohlmann and Nordentoft2014, Sara et al. Sara et al. Reference Sara, Burgess, Malhi, Whiteford and Hall2014), are associated with earlier psychosis onset (Donoghue et al. Reference Donoghue, Doody, Murray, Jones, Morgan, Dazzan, Hart, Mazzoncini and MacCabe2014, Di Forti et al. Reference Di Forti, Sallis, Allegri, Trotta, Ferraro, Stilo, Marconi, La Cascia, Reis Marques, Pariante, Dazzan, Mondelli, Paparelli, Kolliakou, Prata, Gaughran, David, Morgan, Stahl, Khondoker, MacCabe and Murray2014, Addington & Addington, Reference Addington and Addington2007), greater symptoms severity (Wade et al. Reference Wade, Harrigan, Edwards, Burgess, Whelan and McGorry2006, Sorbara et al. Reference Sorbara, Liraud, Assens, Abalan and Verdoux2003, Abdel-Baki et al. Reference Abdel-Baki, Ouellet-Plamondon, Salvat, Grar and Potvin2017, Addington & Addington, Reference Addington and Addington2007, Harrison et al. Reference Harrison, Joyce, Mutsatsa, Hutton, Huddy, Kapasi and Barnes2008, Wade et al. Reference Wade, Harrigan, McGorry, Burgess and Whelan2007, Linszen & van Amelsvoort, Reference Linszen and van Amelsvoort2007), higher relapse rates (Malla et al. Reference Malla, Norman, Bechard-Evans, Schmitz, Manchanda and Cassidy2008, Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Priede, Hetrick, Bendall, Killackey, Parker, McGorry and Gleeson2012, Foti et al. Reference Foti, Kotov, Guey and Bromet2010, González-Pinto et al. Reference Gonzalez-Pinto, Alberich, Barbeito, Gutierrez, Vega, Ibanez, Haidar, Vieta and Arango2011, Lambert et al. Reference Lambert, Conus, Lubman, Wade, Yuen, Moritz, Naber, McGorry and Schimmelmann2005), poorer social and occupational functioning (Abdel-Baki et al. Reference Abdel-Baki, Ouellet-Plamondon, Salvat, Grar and Potvin2017, Hunt et al. Reference Hunt, Siegfried, Morley, Brooke-Sumner and Cleary2019, Barrowclough et al. Reference Barrowclough, Haddock, Beardmore, Conrod, Craig, Davies, Dunn, Lewis, Moring, Tarrier and Wykes2009, Wade et al. Reference Wade, Harrigan, McGorry, Burgess and Whelan2007), and an increased risk of treatment disengagement (Conus et al. Reference Conus, Lambert, Cotton, Bonsack, McGorry and Schimmelmann2010, Miller et al. Reference Miller, Ream, McCormack, Gunduz-Bruce, Sevy and Robinson2009, Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Priede, Hetrick, Bendall, Killackey, Parker, McGorry and Gleeson2012, Wade et al. Reference Wade, Harrigan, McGorry, Burgess and Whelan2007). Consequently, SUD is a critical focus of early psychosis intervention (Stavely, Reference Stavely2013, sociaux, 2017, Hughes et al. Reference Hughes, Crlenjak, Hetrick, Nicoll, Elkins, Cementon and Leceister2015).
Expanding the focus to gaming disorder and care model
Given the impact of SUD on FEP outcomes, attention is shifting toward other addictions that may similarly impede recovery. Emerging evidence suggests that individuals with psychotic disorders may be at increased risk for GD, as both conditions frequently emerge during adolescence or early adulthood, disproportionately affect males and are linked to social withdrawal and social anxiety disorders (Hartz et al. Reference Hartz, Pato, Medeiros, Cavazos-Rehg, Sobell, Knowles, Bierut and Pato2014, Roy et al. Reference Roy, Achim, Vallières, Labbé, Mérette, Maziade, Demers and Bouchard2015, Fusar-Poli et al. Reference Fusar-Poli, Tantardini, De Simone, Ramella-Cravaro, Oliver, Kingdon, Kotlicka-Antczak, Valmaggia, Lee, Millan, Galderisi, Balottin, Ricca and McGuire2017b).
Preliminary findings from a longitudinal study in an FEP clinic in Quebec, indicate high gaming engagement in this population, with 37.12% playing video games several times a week, and GD prevalence (7.04%) more than doubling that of the general population (3.03%) (Huot-Lavoie M et al. Reference Huot-Lavoie, Desmeules, Corbeil, Béchard, Brodeur, Essiambre, Thériault, Anderson, Bachand, Haider, Abdel-Baki, Khazaal, Giroux, Demers and Roy2024). GD may complicate FEP presentation, as its core features – social withdrawal and reduced motivation for other activities – mimic negative symptoms of psychosis, potentially leading to under-recognition in clinical settings.
In order to help these patients this paper aims to 1) summarize current knowledge on the co-occurrence of GD and FEP, 2) identify barriers to GDs recognition and management in early psychosis care, and 3) propose strategies for integrating GD assessment and treatment into early psychosis intervention. To achieve this, both GD and SUD literature will be used. Applying lessons from SUD interventions, targeted GD interventions within early psychosis care frameworks may enhance functional outcomes and recovery.
Gaming disorder and psychosis: current evidence
Despite increasing recognition of GD’s clinical implications, research on its co-occurrence with psychotic disorders remains limited. A resent scoping review shows that the available literature only consists of case reports and cross-sectional studies, precluding a definitive establishment of temporality between GD and psychotic disorders, let alone elucidating potential causal mechanisms (Huot-Lavoie et al. Reference Huot-Lavoie, Gabriel-Courval, Béchard, Corbeil, Brodeur and Massé2023). Preliminary evidence suggests a bidirectional relationship, with dynamic fluctuations in both psychotic symptoms and gaming behaviors over time.
Some cases document psychotic episodes coinciding with increased gaming behavior in young adults (Angane et al. Reference Angane, Keshari, Mane and Nayak2021, Rizzo et al. Reference Rizzo, Della Villa and Crisi2015), while others report psychosis onset following abrupt cessation of excessive gaming in the same population (Ghosh & Sarkhel, Reference Ghosh and Sarkhel2018, Paik et al. Reference Paik, Oh and Kim2014), mirroring patterns in SUDs, where both excessive consumption and withdrawal can trigger psychotic episodes (Donoghue et al. Reference Donoghue, Doody, Murray, Jones, Morgan, Dazzan, Hart, Mazzoncini and MacCabe2014, Di Forti et al. Reference Di Forti, Sallis, Allegri, Trotta, Ferraro, Stilo, Marconi, La Cascia, Reis Marques, Pariante, Dazzan, Mondelli, Paparelli, Kolliakou, Prata, Gaughran, David, Morgan, Stahl, Khondoker, MacCabe and Murray2014, Addington & Addington, Reference Addington and Addington2007, Fruensgaard, Reference Fruensgaard1976).
A recent case series by Ricci et al. (Reference Ricci, De Berardis, Maina and Martinotti2023) described two individuals presenting with both psychotic symptoms and GD, in whom antipsychotic treatment led to symptomatic improvement in both conditions (Ricci et al. Reference Ricci, De Berardis, Maina and Martinotti2023). However, larger prospective studies are needed to clarify the nature, directionality, and clinical significance of this interaction.
Potential benefits of video game use
Generational biases, such as “juvenoia,” may contribute to the negative framing of gaming, as emerging technologies and cultural trends are often met with skepticism by older generations (Finkelhor, Reference Finkelhor2011). Discourse surrounding video games frequently emphasizes their addictive potential, yet cultural attitudes toward gaming vary widely. In some societies, particularly those that celebrate e-sports, gaming is regarded as a prestigious and skill-based activity. Acknowledging these diverse perspectives is essential for a balanced consideration of gaming’s potential benefits.
A systematic review reported that therapeutic video game can improve cognitive and social functioning to a degree comparable to established cognitive remediation therapies for psychotic disorders (Quiles & Verdoux, Reference Quiles and Verdoux2023). While promising, the evidence remains methodologically heterogeneous, necessitating further research (Quiles & Verdoux, Reference Quiles and Verdoux2023). Beyond structured interventions, gaming may serve as an adaptive coping strategy for individuals with psychotic disorders. Self-stigma – the internalization of negative societal perceptions of mental illness – is linked to increased social withdrawal, depressive symptoms, and anxiety. One study suggests that video game engagement may mitigate these symptoms in individuals with psychotic disorders experiencing self-stigma (Chang et al. Reference Chang, Chang, Hou, Lin and Griffiths2021).
Preliminary qualitative data suggest that some patients engage in gaming to manage anxiety associated with positive psychotic symptoms (Huot-Lavoie et al. Reference Huot-Lavoie, Béchard, Corbeil, Roy, L’Heureux, Salvini, Lehoux, Essiambre, Thériault, Brodeur, Demers, Khazaal and Roy2025). As one participant described, “During my psychotic episodes, gaming helped me stay focused on a single task, allowing me to ignore what I was hearing or seeing. As soon as I sensed the first signs, like dizziness or voices, I would start playing as a preventive measure.” (Qualitative data from an ongoing study funded by the Canadian Institutes of Health Research (Grant # 509922) and the Fonds de Recherche du Québec – Société et Culture (Grant# 2024-0UER-339171)).
While excessive gaming may precipitate psychotic episodes in some cases, GD may also emerge as an adaptive strategy for coping with self-stigma or symptom regulation. Addressing GD in FEP requires a harm-reduction approach, prioritizing digital well-being over strict abstinence (Vanden Abeele, Reference Vanden Abeele2020).
Challenges in addressing gaming disorder in first-episode psychosis
Early psychosis management prioritize stabilizing psychotic symptoms through pharmacological and psychosocial interventions, often leading to under-recognition of co-occurring conditions like GD. Once acute stabilization is achieved, it is essential to assess and manage comorbidities that may mimic or exacerbate residual symptoms, as this is critical for optimizing recovery (Corbeil et al. Reference Corbeil, Bérubé, Artaud and Roy2021a).
Barriers to engagement in mental health care
Sustained engagement in mental health care remains a significant challenge in addressing GD in FEP. A core feature of psychotic disorders is impaired awareness of illness (Mcevoy et al. Reference Mcevoy, Johnson, Perkins, Lieberman, Hamer, Keefe, Tohen, Glick and Sharma2006, Parellada et al. Reference Parellada, Boada, Fraguas, Reig, Castro-Fornieles, Moreno, Gonzalez-Pinto, Otero, Rapado-Castro, Graell, Baeza and Arango2011, Abdel-Baki et al. Reference Abdel-Baki, Ouellet-Plamondon and Malla2012, Doyle et al. Reference Doyle, Turner, Fanning, Brennan, Renwick, Lawlor and Clarke2014), a difficulty also observed in GD (Jeong et al. Reference Jeong, Yim, Lee, Lee, Potenza, Kwon, Koo, Kweon, Bhang and Choi2018). Whether these awareness deficits are linked or coincidental in patients with both conditions remain unclear, but they complicate structured follow-up and long-term recovery.
Social and environmental factors, including unstable housing and financial insecurity, often take priority, leading to GD being overlooked (Conus et al. Reference Conus, Lambert, Cotton, Bonsack, McGorry and Schimmelmann2010, González-Blanch et al. Reference González-Blanch, Gleeson, Koval, Cotton, McGorry and Alvarez-Jimenez2015). These barriers are particularly pronounced in early psychosis, when functional impairments are most severe (Abdel-Baki et al. Reference Abdel-Baki, Ouellet-Plamondon and Malla2012).
Additionally, substance use is a well-established predictor of treatment disengagement in FEP, further complicating the establishment of stable therapeutic relationship (Stowkowy et al. Reference Stowkowy, Addington, Liu, Hollowell and Addington2012, Doyle et al. Reference Doyle, Turner, Fanning, Brennan, Renwick, Lawlor and Clarke2014). The absence of family involvement has also been linked to higher dropout rates and poorer engagement with mental health services (Doyle et al. Reference Doyle, Turner, Fanning, Brennan, Renwick, Lawlor and Clarke2014, Abdel-Baki et al. Reference Abdel-Baki, Ouellet-Plamondon and Malla2012, Mascayano et al. Reference Mascayano, van der Ven, Martinez-Ales, Henao, Zambrano, Jones, Cabassa, Smith, Yang, Susser and Dixon2021). Family beliefs about mental illness and its treatment play a critical role in shaping patients’ perception of their disorder and motivation to engage in care (Franz et al. Reference Franz, Carter, Leiner, Bergner, Thompson and Compton2010, Lester et al. Reference Lester, Marshall, Jones, Fowler, Amos, Khan and Birchwood2011).
A strong therapeutic alliance is pivotal for treatment adherence (O’Brien et al. Reference O’Brien, Fahmy and Singh2009, Day et al. Reference Day, Bentall, Roberts, Randall, Rogers, Cattell, Healy, Rae and Power2005, Lacro et al. Reference Lacro, Dunn, Dolder, Leckband and Jeste2002). However, establishing this alliance in early psychosis is challenging. Only 14.2% of patients develop a good therapeutic alliance within the first month of treatment, increasing to just 29.8% at six months (Frank & Gunderson, Reference Frank and Gunderson1990). Therefore, prioritizing therapeutic relationship building is essential for mitigating disengagement and supporting long-term recovery (Frank & Gunderson, Reference Frank and Gunderson1990).
Pharmacological treatment challenges in FEP patients
While pharmacological treatments are essential in FEP, they may contribute to the development of behavioral addictions such as GD. Aripiprazole, a third-generation antipsychotic, has been associated with problem gambling, possibly due to its partial agonism at dopamine D3 receptors (Corbeil et al. Reference Corbeil, Corbeil, Dorval, Carmichael, Giroux, Jacques, Demers and Roy2021b, Williams et al. Reference Williams, Lee, Ewah and Neelam2024, Gatto & Aldinio, Reference Gatto and Aldinio2019, Seeman, Reference Seeman2015). Antidepressants and psychostimulants (e.g., amphetamines, methylphenidate), when used in individuals with bipolar or schizoaffective disorder, can precipitate manic episodes, which may potentially present as increased engagement in gaming and gambling (Gitlin, Reference Gitlin2018, Perugi et al. Reference Perugi, Vannucchi, Bedani and Favaretto2017).
Additionally, the striatal dopaminergic blockade induced by antipsychotics may contribute to dysphoria, which is associated with reduced treatment adherence and an increased propensity for substance use – and potentially behavioral addictions – as a form of self-medication (Awad et al. Reference Awad, Hogan, Voruganti and Heslegrave1995, Chue, Reference Chue2006, Trifilieff & Martinez, Reference Trifilieff and Martinez2014, Thompson et al. Reference Thompson, Urban, Slifstein, Xu, Kegeles, Girgis, Beckerman, Harkavy-Friedman, Gil and Abi-Dargham2013, Yakovenko et al. Reference Yakovenko, Clark, Hodgins and Goghari2016).
The use of performance-enhancing substances, primarily stimulant-based, to sustain prolonged gaming sessions is widespread, further exacerbating GD and amplifying associated physical and mental health risks (Burleigh et al. Reference Burleigh, Griffiths, Sumich, Stavropoulos and Kuss2019, Ip et al. Reference Ip, Urbano, Caballero, Lau, Clauson, Torn, Palisoc and Barnett2021, Słyk et al. Reference Słyk, Zarzycki, Grudzień, Majewski, Jasny and Domitrz2023, Ream et al. Reference Ream, Elliott and Dunlap2011, Lakhan & Kirchgessner, Reference Lakhan and Kirchgessner2012).
Given these complexities, a comprehensive approach to GD management in FEP patients must integrate pharmacological considerations, substance misuse, and behavioral addictions to ensure effective and holistic care.
Challenges related to GD diagnosis
A major challenge in diagnosing GD is the low rate of help-seeking within this population. Unlike SUD, where physical signs of intoxication or withdrawal are externally observable, GD lacks overt symptoms, making it less apparent to clinicians and families.
Many individuals experiencing psychological distress may also perceive gaming as more beneficial than professional intervention (van der Schyff et al. Reference van der Schyff, Amon, Ridout, Forsyth and Campbell2023, von der Heiden et al. Reference von der Heiden, Braun, Müller and Egloff2019), while others may conceal problematic gaming behaviors to avoid losing a primary coping strategy (Chang & Lin, Reference Chang and Lin2019, Schneider et al. Reference Schneider, King and Delfabbro2018). Additionally, increased gaming hours have been linked to lower help-seeking efficacy, suggesting that gaming can serve as an avoidant behavior that further deters healthcare engagement (van der Schyff et al. Reference van der Schyff, Amon, Ridout, Forsyth and Campbell2023). GD itself reinforces gaming as a dominant activity, leading individuals to prioritize it over other aspects of daily life, including seeking professional support.
In the context of FEP, these challenges are compounded by existing barriers to care engagement, further complicating GD recognition and treatment. Moreover, negative symptoms such as avolition, anhedonia, and social withdrawal may be attributed solely to psychosis, despite potentially arising from problematic gaming behaviors. This overlap increases the risk of both misdiagnosis and underdiagnosis in early psychosis settings, further delaying appropriate intervention.
Availability and scope of gaming disorder screening tools
Accurately diagnosing GD remains challenging due to its evolving conceptualization. The use of multiple definitions over the years have hindered the establishment of a gold-standard measurement approach, contributing to limited clinician awareness of formal diagnostic guidelines (Castro-Calvo et al. Reference Castro-Calvo, King, Stein, Brand, Carmi, Chamberlain, Demetrovics, Fineberg, Rumpf, Yücel, Achab, Ambekar, Bahar, Blaszczynski, Bowden-Jones, Carbonell, Chan, Ko, de Timary, Dufour, Grall-Bronnec, Lee, Higuchi, Jimenez-Murcia, Király, Kuss, Long, Müller, Pallanti, Potenza, Rahimi-Movaghar, Saunders, Schimmenti, Lee, Siste, Spritzer, Starcevic, Weinstein, Wölfling and Billieux2021, King et al. Reference King, Billieux, Carragher and Delfabbro2020a, King et al. Reference King, Chamberlain, Carragher, Billieux, Stein, Mueller, Potenza, Rumpf, Saunders, Starcevic, Demetrovics, Brand, Lee, Spada, Lindenberg, Wu, Lemenager, Pallesen, Achab, Kyrios, Higuchi, Fineberg and Delfabbro2020b).
While various screening tools exist for assessing gaming behavior (e.g. Internet Gaming Disorder Scale -9 (IGDS9-SF), their applicability for longitudinal follow-up in clinical settings remains underexplored (King et al. Reference King, Chamberlain, Carragher, Billieux, Stein, Mueller, Potenza, Rumpf, Saunders, Starcevic, Demetrovics, Brand, Lee, Spada, Lindenberg, Wu, Lemenager, Pallesen, Achab, Kyrios, Higuchi, Fineberg and Delfabbro2020b). Most GD-specific tools are designed for general populations and do not account for the cognitive and symptomatic features unique to individuals with psychotic disorders (King et al. Reference King, Chamberlain, Carragher, Billieux, Stein, Mueller, Potenza, Rumpf, Saunders, Starcevic, Demetrovics, Brand, Lee, Spada, Lindenberg, Wu, Lemenager, Pallesen, Achab, Kyrios, Higuchi, Fineberg and Delfabbro2020b). Although some instruments align with ICD-11 criteria (Paschke et al. Reference Paschke, Austermann and Thomasius2020, Zhang et al. Reference Zhang, Luo, Hao, Cao, Yuan and Liao2022, Müller et al. Reference Müller, Wegmann, Oelker, Stark, Müller, Montag, Wölfling, Rumpf and Brand2022), they have limited clinical applicability and remain understudied. Critically, no GD measurement scales have been validated for individuals with psychotic disorders, raising concerns about their accuracy and reliability in FEP (Huot-Lavoie et al. Reference Huot-Lavoie, Gabriel-Courval, Béchard, Corbeil, Brodeur and Massé2023).
Cognitive and symptomatic barriers to accurate measurement
Patients with psychotic disorders often experience cognitive impairments, including deficits in working memory, processing speed, executive functioning, and attentional control. These challenges can hinder engagement with standard screening tools, leading to inconsistent or unreliable responses (Barch & Sheffield, Reference Barch and Sheffield2014).
Screening tools like the IGDS9-SF, which require abstract thinking, may be particularly problematic for individuals with psychosis-related cognitive impairments (Zhang et al. Reference Zhang, Li, Stone, Woodberry, Seidman, Tang, Guo, Zhuo, Qian, Cui, Zhu, Jiang, Chow, Tang, Li, Jiang, Yi, Xiao, Wang and van Amelsvoort2015, Müller et al. Reference Müller, Wegmann, Oelker, Stark, Müller, Montag, Wölfling, Rumpf and Brand2022, Zanelli et al. Reference Zanelli, Mollon, Sandin, Morgan, Dazzan, Pilecka, Reis Marques, David, Morgan, Fearon, Doody, Jones, Murray and Reichenberg2019). Simplifying language, providing clear examples, and integrating visual aids could improve comprehension and response accuracy.
An optimal screening tool should also account for impaired awareness of illness and the risk of symptom misattribution between GD and psychotic disorders (e.g., avolition, social withdrawal). Differentiating these overlapping symptoms by assessing them within their specific clinical context would enhance diagnostic precision.
These challenges highlight the urgent need for validated GD screening tools tailored for individual with FEP. Incorporating adaptations that address cognitive deficits, insight-related impairments, and symptoms overlap is essential to improving diagnostic accuracy and ensuring appropriate clinical interventions.
Challenges related to treatment of patient living with both GD and FEP
Systematic reviews on GD treatment consistently identify cognitive–behavioral therapy (CBT) as the most widely implemented approach (Costa and Kuss Reference Costa and Kuss2019, King et al., Reference King, Delfabbro, Wu, Doh, Kuss, Pallesen, Mentzoni, Carragher and Sakuma2017, Lampropoulou et al., Reference Lampropoulou, Siomos, Floros and Christodoulou2022, Stevens et al., Reference Stevens, King, Dorstyn and Delfabbro2019, Xu et al. Reference Xu, Wu, Geng, Wang, Guo, Song, Liu, Deng, Zhang and Potenza2021, Zajac et al., Reference Zajac, Ginley, Chang and Petry2017, Zajac et al., Reference Zajac, Ginley and Chang2020, Khazaal et al., Reference Khazaal, Billieux, Achab, Simon, Dufour and Benyamina2024). Core components often include psychoeducation, increased awareness of internet use, gradual reduction of gaming time, development of cessation strategies, cognitive restructuring to address maladaptive thoughts, and relapse prevention (Torres-Rodríguez et al. Reference Torres-Rodríguez, Griffiths, Carbonell and Oberst2018, Lampropoulou et al., Reference Lampropoulou, Siomos, Floros and Christodoulou2022).
A structured treatment model for problematic internet use, including GD, has been developed and evaluated by Dufour et al. (Reference Dufour2023) in outpatient addiction services (Dufour et al. Reference Dufour2023). This intervention consists of eight key stages: 1) behavioral activation; 2) understanding technology use motivations; 3) enhancing motivation for change; 4) improving control over technology use; 5) emotion regulation; 6) problem-solving; 7) strengthening social relationships; and 8) skill consolidation. The approach adapts CBT principles to GD by addressing in-game cognitive, emotional, and behavioral experiences, reinforcing self-regulation strategies, and identifying relapse-risk situations (Taquet & Hautekeete, Reference Taquet and Hautekeete2013).
Despite these promising treatment models, no intervention has been specifically designed for individuals with psychotic disorders. Adapting existing approaches is crucial to address engagement difficulties, psychotic symptoms – including negative symptoms that limit motivation – and cognitive impairments that may affect adherence and therapeutic outcomes.
What we learned from substance use disorders
Managing co-occurring addictions in individuals with FEP requires nuanced, patient-centered approaches, and empathy. Clinical guidelines for SUD management in FEP provide valuable insights that can inform GD care (Hughes et al. Reference Hughes, Crlenjak, Hetrick, Nicoll, Elkins, Cementon and Leceister2015, Laboratory, 2019).
Assessment challenge
Substance use assessments are recommended upon admission to early psychosis services (Hughes et al. Reference Hughes, Crlenjak, Hetrick, Nicoll, Elkins, Cementon and Leceister2015, Laboratory, 2019). However, the acute phase of psychosis is often marked by significant distress and instability, leading patients to underreport or withhold information regarding substance use. Ongoing monitoring beyond initial stabilization is essential to identify emerging addiction patterns and evaluate intervention effectiveness.
Cognitive impairments commonly observed in psychotic disorders pose significant obstacles to accurate assessment. A gradual, paced approach can help mitigate these challenges, allowing patients to process information incrementally. Normalizing hesitation, fostering a safe, trusting environment encourage honest disclosure (Hughes et al. Reference Hughes, Crlenjak, Hetrick, Nicoll, Elkins, Cementon and Leceister2015).
A multimodal strategy – incorporating standardized screening tools, diagnostic interviews, self-report measures, and collateral information from family members – provides a comprehensive understanding of substance use behaviors. Structured self-monitoring further empowers patients to track usage patterns, recognize triggers, and actively engage in treatment (Hughes et al. Reference Hughes, Crlenjak, Hetrick, Nicoll, Elkins, Cementon and Leceister2015, Orygen, 2016, Stavely, Reference Stavely2013).
Engagement challenge
While patients may accept antipsychotic treatment, they often remain ambivalent about addressing addictions. The Stage of Change models provide a framework for tailoring interventions based on an individual’s motivational stage and its principles apply equally to behavioral addictions like GD (Hughes et al. Reference Hughes, Crlenjak, Hetrick, Nicoll, Elkins, Cementon and Leceister2015, Barrowclough et al. Reference Barrowclough, Haddock, Wykes, Beardmore, Conrod, Craig, Davies, Dunn, Eisner, Lewis, Moring, Steel and Tarrier2010).
Telemedicine, brief digital contacts (e.g., text messaging, email), and flexible outreach (e.g., community follow-ups and reminders) can sustain engagement and interdisciplinary coordination (Alameda et al. Reference Alameda, Golay, Baumann, Morandi, Ferrari, Conus and Bonsack2016, D’Arcey et al. Reference D’Arcey, Collaton, Kozloff, Voineskos, Kidd and Foussias2020, Vignapiano et al. Reference Vignapiano, Monaco, Panarello, Landi, Di Gruttola, Malvone, Martiadis, Raffone, Marenna, Pontillo, Di Stefano, D’Angelo, Steardo and Corrivetti2025).
A non-judgmental and empathic approach that normalizes struggles, alongside family involvement when possible, also contribute in reducing stigma and improves treatment adherence and outcomes (Tait et al. Reference Tait, Birchwood and Trower2003, Doyle et al. Reference Doyle, Turner, Fanning, Brennan, Renwick, Lawlor and Clarke2014, Van Dorn et al. Reference Van Dorn, Swanson, Elbogen and Swartz2005, Gaebel et al. Reference Gaebel, Zäske and Baumann2006, Galanis et al. Reference Galanis, Weber, Delfabbro, Billieux and King2023, Hughes et al. Reference Hughes, Crlenjak, Hetrick, Nicoll, Elkins, Cementon and Leceister2015, Orygen, 2016).
Integrating addiction treatment into an early intervention in psychosis program
Managing co-occurring SUD and FEP within fragmented clinical settings is largely ineffective (Mueser & Gingerich, Reference Mueser and Gingerich2013, Ridgely et al. Reference Ridgely, Goldman and Willenbring1990, Laboratory, 2019). Disconnected psychiatric and addiction treatments contribute to poor follow-through on referrals to external services, inadequate communication between care teams, and high dropout rates (Mueser & Gingerich, Reference Mueser and Gingerich2013, Ridgely et al. Reference Ridgely, Goldman and Willenbring1990, Laboratory, 2019). To overcome these barriers, integrated treatment frameworks are essential.
The role of early intervention in psychosis programs
Early intervention in psychosis (EIP) programs are specialized, evidence-based services designed to detect and treat FEP at its earliest stages. EIP teams – comprising psychiatrists, nurses, social workers, occupational therapists, psychologists, and pharmacists – deliver individualized care that integrates both clinical and psychosocial dimensions (Orygen, 2016, Stavely, Reference Stavely2013). By addressing barriers like prolonged duration of untreated psychosis and fragmented service delivery, EIP significantly improves patient trajectories through coordinated multidisciplinary care (Malla et al. Reference Malla, Iyer, McGorry, Cannon, Coughlan, Singh, Jones and Joober2016). Extensive evidence supports the effectiveness of EIP, demonstrating that timely, holistic interventions lead to substantial improvements in clinical outcomes, functional recovery, and overall quality of life (Correll et al. Reference Correll, Galling, Pawar, Krivko, Bonetto, Ruggeri, Craig, Nordentoft, Srihari, Guloksuz, Hui, Chen, Valencia, Juarez, Robinson, Schooler, Brunette, Mueser, Rosenheck, Marcy, Addington, Estroff, Robinson, Penn, Severe and Kane2018).
Incorporating SUD treatment within EIP
Given the high prevalence of SUD in FEP, integrating addiction expertise within EIP programs is becoming standard practice, ensuring the integrate management of both conditions (Laboratory, 2019, Orygen, 2016, sociaux, 2017, Dixon et al. Reference Dixon, Dickerson, Bellack, Bennett, Dickinson, Goldberg, Lehman, Tenhula, Calmes, Pasillas, Peer and Kreyenbuhl2010). Integrated treatment models demonstrate superior outcomes compared to non-integrated approaches. For instance, in integrated care groups, work or school participation increased by 21%, compared to 7% in community-treated groups (McFarlane et al. Reference McFarlane, Levin, Travis, Lucas, Lynch, Verdi, Williams, Adelsheim, Calkins, Carter, Cornblatt, Taylor, Auther, McFarland, Melton, Migliorati, Niendam, Ragland, Sale, Salvador and Spring2015). Integrated care also improves symptom management, functional recovery, and treatment adherence (Fusar-Poli et al. Reference Fusar-Poli, McGorry and Kane2017a).
Drawing from empirical evidence and clinical guidelines, EIP programs must embed addiction treatment as a core component of care, providing comprehensive support for individuals with dual diagnoses.
Integration of GD intervention in EIP programs
Building on insight from managing co-occurring SUD and FEP, there is growing recognition of the need to integrate behavioral addiction interventions, particularly GD, into EIP programs. While integrated care models for SUD have demonstrated clear benefits, the role of GD within this framework remains underexplored. Given its classification as a behavioral addiction and its potential impact on psychosocial functioning, incorporating GD assessment and treatment within EIP programs is both clinically relevant and necessary.
The following section presents a preliminary clinical model for integrating GD management into EIP programs. It outlines specific strategies to address the previously highlighted challenges, enhancing screening, follow-up, and therapeutic engagement, while identifying critical knowledge gaps that must be addressed to optimize care for individuals with both conditions. By adopting a more integrated approach, EIP programs can more effectively meet the needs of patients struggling with both psychotic and behavioral addictions.
Proposed clinical management of GD in EIP programs
This clinical framework builds on existing interventions for SUD in FEP and is informed by clinical and research experiences following the implementation of a GD screening protocol within an ongoing longitudinal study (Huot-Lavoie et al. Reference Huot-Lavoie, Corbeil, Béchard, Brodeur, Desmeules and Thériault2024).
A non-judgmental, patient-centered approach is essential when taking care of individuals with GD and FEP. Early care should prioritize understanding gaming habits, including their personal significance and perceived benefits, to foster engagement and facilitate a nuanced behavioral assessment. Case managers, who maintain continuous patient contact and coordinate care within EIP programs, should play a central role in delivering interventions. Their comprehensive understanding of each patient’s condition enables early detection of problematic gaming behaviors and supports tailored interventions.
Youth-friendly approaches can enhance patient engagement and adherence by aligning treatment environments with younger individuals’ interests and communications styles, ultimately improving treatment participation and outcomes (Orygen, 2016).
Assessment of gaming behavior in EIP
Assessing gaming behavior in patients with FEP extends beyond simply documenting screen time; it provides valuable insight into lifestyle, sleep patterns, and social interactions. Understanding gaming motivations and emotional responses can also reveal preserved emotional engagement, even in patients perceived as anhedonic.
The proposed evaluation consists of three distinct phases. The first two phases are conducted by the case manager, who gathers general information about gaming behaviors and their impact on patient functioning. In the final phase, a psychiatrist reviews the collected data and conducts a formal diagnostic interview based on ICD-11 criteria for GD.
Evaluating gaming habits
This evaluation can unfold through informal discussions alongside routine care coordination, fostering a therapeutic alliance and encouraging honest disclosure.
Key components for a comprehensive evaluation:
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• Frequency and duration of gaming sessions, including daytime and nighttime habits. Clinicians may consider inquiring about objective measures of playtime, such as screen time reports or in-game tracking features, to obtain a more accurate assessment of gaming behavior.
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• Online versus offline gaming and the types of interaction they have with other players (e.g., competitive vs collaborative) providing insights into social interactions within gaming environments.
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• Assessment of gaming motives and perceived benefits of gaming.
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• Engagement in gaming-related activities, such as participation in video game streaming platforms, implication in gaming community and loot box purchases which have been associated with increased GD risk (Raneri et al. Reference Raneri, Montag, Rozgonjuk, Satel and Pontes2022, Cabeza-Ramírez et al. Reference Cabeza-Ramírez, Rey-Carmona, del Carmen Cano-Vicente and Solano-Sánchez2022).
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• Impact of gaming and related activities on academic performance, employment, relationships, health, and overall daily-life functioning.
To ensure accurate responses, clinicians should use clear, straightforward language, considering potential impairments in abstract thinking and cognition in FEP. Questions should also help differentiate excessive gaming from GD.
Sample screening questions:
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• Has gaming delayed your schoolwork or job tasks?
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• How does gaming affect your sleep, health, or mood?
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• Have you had conflicts with family or peers over gaming?
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• What other activities or hobbies do you engage in outside of gaming?
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• Are there activities or hobbies you used to enjoy that you no longer do because of gaming?
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• How does gaming affect your daily schedule or routine?
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• Have you tried to reduce or stop gaming? Why?
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• How do you usually feel when you can’t play video game?
Enhancing precision in gaming behavior assessment
Obtaining collateral feedback from family members and caregivers provides a more comprehensive understanding of gaming behaviors. Questions like “Have you noticed changes in the patient’s behavior related to gaming?” or “Have there been conflicts at home concerning video games?” can uncover discrepancies between the patient’s self-reports and external observations. Additionally, inquiring about the perceived consequences of gaming habits on both the patient and their family and how the patient manages and responds to gaming interruptions can provide a more comprehensive understanding of the patient’s gaming patterns and their overall impact. These discussions also offer an opportunity to highlight positive aspects of gaming, such as social connection or stress relief, while educating families on supporting healthy gaming habits and minimizing stigmatization.
Although screening tools are useful adjuncts, existing instruments lack validation in FEP populations. Although new tools such as the ACSID-11 capture the key components of GD assessment based on ICD-11 criteria, their items may be difficult for patients to answer and often require dedicated time to complete, which poses challenges for individuals facing multiple priorities in early intervention settings. To optimize GD screening in FEP care, the following adaptations are recommended:
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• Simplified Language and Instructions: Clear, concise language enhances comprehension in patients with cognitive impairments.
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• Shortened, Focused Questionnaires: Instruments should be reduced to a minimal set of items that directly reflect ICD-11 diagnostic criteria thereby improving feasibility and response reliability without sacrificing diagnostic precision.
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• Incorporation of Visual Aids: Visual supports (e.g., pictograms, graded color scales) can facilitate understanding and engagement in patients with or attentional difficulties, increasing accuracy of self-reports.
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• Flexible Administration: Allowing breaks or splitting assessments into multiple sessions (e.g., 2 – 3 questions at a time during routine follow-up) to minimize fatigue and maximize participation in early intervention settings.
Frequent reassessments are critical to identifying changes in gaming behaviors and differentiating transient patterns from persistent problematic behaviors. Maintaining a gaming journal can serve as a useful self-monitoring tool for patients, fostering greater insight into gaming habits and supporting behavioral self-regulation.
Conducting a diagnostic interview
Following the initial evaluation and screening, a comprehensive psychiatric diagnostic interview conducted by a psychiatrist is essential. By integrating self-reported data, collateral information, and validated screening tools from the previous assessment stages, clinicians can effectively differentiate between normative, hazardous, and pathological gaming behaviors. This structured approach enhances diagnostic precision and facilitates the development of an individualized, evidence-based treatment plan, tailored to the patient’s specific needs.
Integrating gaming disorder evaluation into patient follow-up
GD evaluations should be integrated into standard care protocols and conducted at regular intervals throughout a patient’s EIP journey. Similar to other addictions, systematic assessments every 3 to 6 months facilitate continuous monitoring, enabling timely identification of problematic behaviors. Gaming habits should also be reassessed during significant life transitions (e.g., loss of employment or enrollment in an academic program) to evaluate their impact on daily functioning. In addition, reassessment is warranted after medication changes, as certain psychotropic agents have been linked to increased vulnerability to addictive behaviors. Embedding GD assessments within routine clinical practice ensures that interventions evolve alongside recovery. The development and validation of GD scales tailored to FEP populations will significantly enhance diagnostic accuracy, support progress monitoring, and guide interventions over time.
Integrating gaming disorder treatment into EIP programs
Building on our clinical experience with the structured treatment model for problematic internet use developed by Dufour et al. (Reference Dufour2023), GD management in FEP requires a flexible, patient-centered approach that prioritizes engagement, motivation, and individualized care. Case managers should deliver adaptable interventions, including home-based care when necessary, while accommodating patient absences and gradually incorporating GD-specific strategies.
The treatment approach should integrate key therapeutic components, such as behavioral activation, understanding technology use motivations, enhancing motivation for change, improving control over technology use, emotion regulation, problem-solving, strengthening social relationships, and skill consolidation.
Although no medication is currently approved specifically for the treatment of GD, several agents have been explored. Systematic reviews suggest potential benefit from bupropion and selective serotonin reuptake inhibitors such as escitalopram, based on their prior use in other behavioral addictions, including compulsive buying and pathological gambling (Lampropoulou et al. Reference Lampropoulou, Siomos, Floros and Christodoulou2022, Greenfield, Reference Greenfield2022, Chang et al. Reference Chang, Chang, Yang and Tzang2022, Zajac et al. Reference Zajac, Ginley and Chang2020). However, available studies are few, with small samples, short treatment durations, and limited randomized controlled trials and notably have not examined patients with psychotic disorders. Consequently, the level of evidence remains low, precluding regulatory approval or the establishment of practice guidelines. Theoretical models also raise the possibility that addictolytic agents such as N-acetylcysteine or naltrexone may target shared neurobiological pathways, but these remain speculative.
In clinical practice, pharmacological strategies for GD are best considered within a multimodal framework that also incorporates psychotherapeutic interventions and the management of psychiatric comorbidities. In the context of FEP, particular attention must be given to the overall medication regimen, as antipsychotics and adjunctive treatments may influence vulnerability to addictive behaviors as described in the Pharmacological Treatment Challenges in FEP Patients section. Regular reassessment of both therapeutic benefits and potential risks is therefore essential to ensure safe and effective integration of GD care within early intervention programs.
The unique context of FEP treatment necessitates aligning GD interventions with the patient’s priorities, introducing them at clinically appropriate moments without overshadowing other urgent treatment needs. Additionally, simplified content, structured sessions, and reinforcement of key concepts over time enhance treatment accessibility and adherence. Group interventions within EIP programs can further normalize gaming discussions, reduce stigma, and provide valuable insight into gaming behaviors. Peer support workers can play a key role in this process by sharing lived experiences and fostering engagement. A harm-reduction approach that emphasizes digital well-being over abstinence may offer more sustainable long-term recovery outcomes (Huot-Lavoie et al. Reference Huot-Lavoie, Béchard, Corbeil, Roy, L’Heureux, Salvini, Lehoux, Essiambre, Thériault, Brodeur, Demers, Khazaal and Roy2025). Embedding GD treatment within EIP programs ensures that gaming behaviors are addressed holistically within psychotic disorder care, promoting viable coping mechanisms and improved psychosocial outcomes.
Conclusion
Integrating a comprehensive GD care model within EIP programs is essential for early identification and intervention, preventing complications that may obscure the clinical presentation of psychosis. A patient-centered approach, embedded within routine care, aligns with recovery-oriented practices and supports individuals in achieving balanced, fulfilling lives.
There is an urgent need for GD screening and treatment models tailored to individuals with FEP. Effective interventions must address the unique cognitive, emotional, and social challenges of this population to ensure accurate identification and optimal management of GD. Developing such models will enhance individual outcomes while expanding our understanding of how behavioral addictions intersect with psychotic disorders.
Recognizing and addressing GD is not only essential for comprehensive care but also represents a cornerstone of modern psychiatry, ensuring that clinical practice remains responsive to the evolving realities of patients’ lives in an increasingly digital world.
Financial support
MHL is also supported by the Frederick Banting and Charles Best Canada Graduate Scholarship Doctoral Awards from the Canadian Institute of Health Research (FID-172598) and by Mitacs Grant (IT34510). The funders played no role in the redaction of this article, and we have no restrictions regarding the submission of this manuscript for publication.
Competing interests
The authors declare none.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
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