N-acetylcysteine ​​in the treatment of Internet gaming disorder

Internet gaming disorder (IGD) is the persistent and repetitive use of the Internet to engage in video games through a single or multiplayer interface that can lead to significant impairment or distress. With the technological advances of the past decade across portable handheld devices, along with their universal availability, video games have found a new medium in which they can provide instant access to casual and enthusiast users alike. Unfortunately, this greatly increases the likelihood of addiction. IGD shares a similar pathophysiological aetiology to addiction as drug or gambling. However, IGD can be difficult to manage due to easy access to video games and limited understanding of the newly recognized disorder.

This study aims to bridge the knowledge gap related to the limited research on Internet gaming addiction, its implications for human cognitive behavioral performance, and the administration of pharmacotherapy as observed in our patient, who developed IGD, starting with an informal recreational pastime among peers. . This case also highlights the lack of social awareness and the severity attributed to this disorder. Focuses on the use of N-acetylcysteine ​​in the administration in addition to other psychotropic and psychotropic drugs.

an introduction

In the modern world, video games have become a routine part of daily activities as a form of leisure and entertainment. In recent years, many technological innovations have been made in the field of Internet and computer games. These changes have changed the concept of gaming, making it addictive for some. As a result, Internet gaming disorder (IGD) was recently included as a possible diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (APA). [1]. In addition, the World Health Organization (WHO) has recognized the impact of games on public health. Therefore, the diagnosis of “gaming disorder” was mentioned in the eleventh revision of the International Classification of Diseases (ICD-11). [2].

APA defines IGD as persistent and frequent use of the Internet to participate in games resulting in significant impairment. The World Health Organization defines this disorder as impaired gaming control, increased priority given to gaming, and continued gaming despite negative consequences. Gaming behavior pattern results in significant distress or impairment in many areas of functioning, including, but not limited to, personal, family, social, educational, and occupational. This disorder includes both online and offline, digital, or video games. Online games, such as multiplayer online role-playing games (MMORPG), where Internet users interact with each other, are highly addictive. [3].

Neurobiological findings suggest that pathological gambling and drug addiction share a common pathophysiology. There has been a shift in gambling from traditional casinos to online gambling. Online gambling is promoted and advertised via social media and email marketing. Moreover, the frequent use of online devices for stock market gambling and bitcoin trading has been observed [4]. Online games like MMORPG are the most addictive. IGD may also be associated with such addiction-related findings. The prevalence of IGD is estimated to be between 1.2% and 5.5%.

In addition, one in ten teenagers who play video games can have problems using games [5]. Thus, more treatments are needed to prevent or treat diseases associated with this addiction. N-acetylcysteine ​​(NAC) is a glutamine drug that has been discovered as a treatment option to reduce clinical symptoms among addictive or addictive individuals. [6]. If the pathophysiology of gaming addiction is similar, similar treatment and intervention may also be beneficial.

We present the case of a college student exhibiting symptoms of IGD and associated addictive behavior. In our case, we review the use of the NAC protocol as an intervention for the treatment of IGD, as glutamine drugs have shown potential in the treatment of substance use disorder and pathological gambling.

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A 19-year-old college student was brought to the outpatient department by his parents complaining of excessive time spent playing video games. According to the parents, he has been playing a game for 12-14 hours a day for the past three months during the coronavirus 2019 pandemic while in isolation in his bedroom. Report disruption of the sleep cycle, irregular meal timing, and neglect of self-care and personal hygiene. He was irritable and verbally aggressive when faced with gaming mania. He has stopped showing interest in his routine, extracurricular and athletic activities and has received frequent complaints from his teachers about his poor academic performance lately.

He was introduced to online video games by his peers two years ago. I initially started playing for one to two hours on weekdays and five to six hours during the weekend. When the desire to play with massive success in games (eg rewards, unlocking achievements, winning periods, etc.) No symptoms of depression, anxiety, or psychosis were observed with no known family or personal history of psychiatric illness or any substance use disorder.

On the Mental Status Examination (MSE), the patient appeared sad and withdrawn with minimal verbal interaction. There was no formal intellectual disturbance, delusions, obsessions, or suicidal thoughts. There were no perceptual distortions and no perceptual impairments. However, his addictive video game behavior has impaired his insight and judgment. IGD was assessed using the nine-item IGD scale. He was then diagnosed with IGD based on the MSE scale, DSM-5, and IGD.

Complete blood count, thyroid test, kidney and liver function, as well as urine drug examination showed no abnormalities.

The patient was transferred to a rehabilitation center for three months to provide an instrument-free environment and supportive psychotherapy. Pharmacotherapy consists of NAC 600 mg twice daily to control game cravings, olanzapine 5 mg once daily to control aggressive behavior (eventually diminishing within 1 month and discontinuation), and diazepam 5 mg at bedtime for insomnia.

During the first weeks of rehabilitation, the patient showed no noticeable improvement, with limited insight, was reluctant to share his thoughts, was depressed, and had intermittent crying spells. Withdrawal symptoms of intense cravings, insomnia, frequent headaches, and memories of gaming scenarios while he slept were displayed. After one month, the patient began to demonstrate an understanding of his pathological behavior. His mood and sleep improved, and he reported a decrease in cravings. He began to actively participate in indoor/outdoor activities, became more communicative during treatment, and resumed his academic classes.

During a one-month follow-up, the patient and parents denied witnessing any addiction-seeking behavior or unnecessary immersion in gaming. He uses his mobile smartphone for routine internet and social media use under parental supervision. He continues to take his medication regularly.


When trying to explore how video games can be highly addictive, it is essential to understand how repeated stimulation of neurons from gaming can affect cortical function and cognition. Reduced gray matter volume is observed in the anterior cingulate gyrus, dorsolateral prefrontal cortex, and motor cortex in IGD patients. [7].

Changes in the putamen structure have been reported in patients with IGD. Functional MRI analysis also showed increased activation in the bilateral cingulate cortex, anterior insula, and striatum. [8]. Impaired cognitive control in patients with IGD leading to compulsive gaming behavior may be related to increased striatal size. The amygdala is responsible for controlling emotions, and its impaired function may be associated with an increased focus on emotions and immediate rewards, leading to excessive play.

The mesolimbic dopamine pathway is the intrinsic reward circuit pathway. It includes dopaminergic projections from the ventral tegmental area to the nucleus accumbens and the olfactory tubercle. Similar to substance use disorders, decreased dopamine activity associated with a lack of total reward leads to excessive use of the Internet and gaming [9].

Glutamate is the primary neurotransmitter of the nervous system. Addiction results from a reduced ability to impede the desire to seek out drugs in response to environmental constraints. The proposed mechanism is an alteration of glutamate homeostasis and activation of N-methyl-D-aspartate receptors and dopamine glutamate receptors. In patients with substance abuse, blocking glutamate release inhibits drug-seeking behaviors [10].

Glutamate drugs act concurrently on the dopamine and glutamate systems and help prevent relapse in patients with substance abuse. NAC, a glutamatergic drug, comes from the amino acid L-cysteine ​​and can increase extracellular glutamate levels in the nucleus accumbens. It is effectively used in the treatment of substance use disorder and trichotillomania and may be useful in the treatment of obsessive-compulsive disorder and gambling disorder. Glutamate acts at metabolically directed glutamate receptors and glutamate receptors. NAC may stimulate metabolic inhibitory glutamate receptors, reducing synaptic release of glutamate and helping manage drug addiction and behavior. [11].

There are no long-term follow-up studies for the treatment of IGD. However, early diagnosis of IGD can prevent adverse effects on the functional and social domains of life. Management should be approached with the utmost care because of the potential effects of withdrawal features, anxiety, depression, and negative self-esteem, along with addictive-seeking behavior through other forms of ‘reward’.


This case report highlights the lack of social awareness and understanding and the impact that IGD has on an individual’s life while suggesting the use of NAC as a new treatment approach for IGD. Although the availability of data on the use of NAC in the treatment of addiction, including gambling disorders, is limited, further research could shed light on the potential for its widespread use while highlighting the implications of gaming addiction and its pervasive effects on social and mental health.

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