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Table of Contents
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 45-48

Stress and Gaming: Biopsychological Understanding among Medical Graduates

1 Department of Neurochemistry, National Institute of Mental Health and Neuro Sciences, (NIMHANS) Bengaluru, Karnataka, India
2 Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, (NIMHANS) Bengaluru, Karnataka, India
3 SS Institute of Medical Sciences and Research Centre, Davangere, Karnataka, India

Date of Submission13-Aug-2020
Date of Decision03-Dec-2020
Date of Acceptance03-Dec-2020
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Manoj Kumar Sharma
Service for Healthy Use of Technology (SHUT) Clinic, Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_70_20

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Background: Video games are seen as a modality to manage stress. The study examined the role of playing violent gaming on stress. Materials and Methods: The observational design was used for the assessment of stress among 04 medical undergraduates in the age group of 18 years to 20 years. Salivary cortisol and stress subscale of Depression, Anxiety, and Stress scale were used to assess stress. Results: Salivary cortisol and psychological scale findings revealed the presence of higher stress among violent game players. Conclusions: The findings imply the need to evolve emotional regulation approaches for management of stress among gamers.

Keywords: Biopsychological, emotional regulation, gaming, salivary cortisol

How to cite this article:
Ravish H, Sharma MK, Anand N, Vashisht A. Stress and Gaming: Biopsychological Understanding among Medical Graduates. World Soc Psychiatry 2021;3:45-8

How to cite this URL:
Ravish H, Sharma MK, Anand N, Vashisht A. Stress and Gaming: Biopsychological Understanding among Medical Graduates. World Soc Psychiatry [serial online] 2021 [cited 2023 May 29];3:45-8. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/1/45/315126

  Introduction Top

Video games are an interactive medium and its interactive nature has facilitated users to engage in gaming activity. The nature of online gaming interaction also has an impact on the users appraisal of experiences. It also contributes toward interactive stress, where user experiences stress due to his or her presence in the virtual environment, the reception of visual and auditory sensory inputs, and the associated past experiences and memories.[1] When the video games were compared in terms of content, it was found that graphically realistic violent games increased heart rate, while a nonviolent game decreased heart rate during gameplay.[2] Whereas playing nonrealistic or puzzle games were not associated with any significant changes in psychophysiological parameters.[3] Video games are not unidimensional in their effects on emotional expression. Even the same video game can be associated with positive and negative cognitions and emotions simultaneously.[4] Reviews on emotion regulation have also demonstrated the role of video games in the promotion of positive emotional feelings or appraisal before or during gameplay.[5],[6]

There is a need to understand the effects of playing violent games on stress. In the present study, we assessed the effects of violent games genre on stress among players seeking treatment for gaming at tertiary specialty clinic.

  Materials and Methods Top


Four participants in the age group of 18–20 years were selected among the clients attending tertiary specialty clinic for management of technology addiction using intervention design from education Institutes based in Bengaluru, Karnataka, India. Their informed consent for the study was obtained. The present work has received approval from the Institute ethics committee.


Background data sheet

It was prepared by the investigator to collect information about demographic variables.

The Internet Gaming Disorder Scale – Short-Form (IGDS9-SF) assesses the severity of Internet Gaming Disorder (IGD) and its detrimental effects by examining both online and/or offline gaming activities occurring over a 12-month period. The scale comprises nine items corresponding to the nine core criteria defined by the DSM-5. This scale has a good reliability (Internal Consistency = 0.96) and adequate Validity [confirmatory factor analysis; comparative fit index = 0.964; Tucker–Lewis index = 0.952; RMSEA =0.054 [90% confidence interval]).

Depression, Anxiety, and Stress Scale (DASS)-21:[7] It is a short form of DASS. The scale has three subscales: depression, anxiety, and stress. It is made up of 21 items on 4-point Likert type scale, 0 being not at all applied to me and 3 being applied to me very much or most of the time. Each subscale consists of 7 items.


Four medical undergraduates in the age group of 18–20 years were matched for playing multiple player battle royal game. They differed in terms of their duration of play at the time of assessment of cortisol values. First subject, 18-year-old male started playing the game for recreational purpose for the past 6 months. His playing time never exceeded beyond 1 h per day. The parents came to learn about his excessive gaming interest through his excessive mobile use and insisted him to seek treatment. The team players used to be his close friends. He did not report any psychosocial dysfunctions as well as psychiatric morbidities. He did not meet the criteria for gaming disorder on Internet Gaming Disorder Scale-Short-Form (IGDS9-SF) (<5 yes on IGDS9-SF) and was in the normal gaming range and stress category (score of 07). Second subject, 18-year-old male playing games for the past 12 months. His playing time used to vary from 3 to 5 h per day. The family reported dysfunctions in his psychosocial domains, especially, irregular sleeping patterns and lack of interest in other offline activities. He did not meet the criteria for gaming disorder (<5 yes on IGDS9-SF). He was in the mild stress category (score of 12). He did not have any other psychiatric morbidities. Third subject, a 19-year-old male playing games for the past 2 years. He wanted to build up his career in gaming. He had a history of participation in gaming tournaments. His playing time used to vary from 8 to 10 h per day. He met the criteria for gaming disorder (more than 5 yes on the Internet Gaming Disorder Scale – Short-Form (IGDS9-SF)). He was in the moderate stress category (score of 20). He stopped attending college for the past 12 months. The other psychosocial dysfunctions included increased expression of anger, decreased interest in academics and offline leisure activities, and irregular sleeping patterns. Fourth subject, a 19 years male playing games for the past 3 years, with increased gaming for the past 2 years. He spent 8–14 h a day on either playing games or streaming, watching YouTube and shows. He met the criteria for gaming disorder (more than 5 years on IGDS9-SF) and was in the moderate stress category (score of 21). He did not meet criteria for any other significant psychiatric morbidity.

Measurement of salivary cortisol

Saliva samples were obtained according to the manufacturer's instructions (DBC KIT). The quantitative assessment of cortisol in saliva was performed using Enzyme-linked immunosorbent assays (ELISA) cortisol under manufacturer's instructions. For the ELISA kit testing procedures, the laboratory or department must have the equipment and supplies. Briefly, an ELISA works by a competitive binding assay. ELISA microplate is cortisol-coated with monoclonal antibodies. Cortisol is applied to microplate wells in saliva samples and a set of criteria (“cold” cortisol). After this, cortisol linked to horseradish peroxidase is added to each well. “Cold” and “hot” cortisol compete for a small number of antibody binding sites and are washed away after an incubation period. Bound “hot” cortisol is measured by its peroxidase enzyme on a substrate (tetramethylbenzadine). The reaction produces a 450 nm color on a plate reader. Color strength represents the amount of peroxidase detected, inversely proportional to the amount of cortisol present.[8] We calculated the intraassay reproducibility recorded as variation coefficients ranging from 0.30% to 1.23%

  Results and Discussion Top

The age of the subjects ranges from 18 to 20 years. Normal range of salivary cortisol is 5-21ng/ml as per kit literature. Pre-cortisol of first and second subject were 12.1ng/ml and 10.2ng/ml respectively i.e. within the normal range. Pre-cortisol of third and fourth subject were 35.2ng/ml and 38.5ng/ml i.e. outside normal reference range. The cortisol difference i.e. delta cortisol is the difference between post session – pre session cortisol. All four subjects had severe delta cortisol i.e. > 13ng/ml. However, HPA activation was more in subjects with normal range pre-cortisol compared to subjects who had elevated pre-cortisol are shown in [Table 1].
Table 1: Pattern of salivary

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This study documents the presence of a higher level of stress among subjects with a history of long duration of playing violent games. The stress levels were high among beginner and regular players which could be because of online teams pressure to excel. [Table 1] The available literature review corroborates with the findings of the present study. This study from available literature assessed different types of stress in 80 players in the age group of 18–30 years.[9],[10] They played the Runner game, Excitement game, Fear game, and Puzzle game. The stress was assessed using salivary cortisol, α-amylase, and brain waves. The findings revealed the salivary α-amylase and salivary cortisol concentration increased significantly after playing the Fear game, Runner game, and Excitement game and decreased significantly after playing the Puzzle game. The brain wave analysis also indicated the presence of high level of stress after playing Fear game than the Excitement game.

These findings contradict the available literature, which indicated the reduction of stress in post gaming conditions or understand it from maladaptive coping perspective. The games were played for management of the stressful situation,[11],[12] also implicated the role of games as coping modality among 60 gamers. Playing video games have been associated with reduced experience of negative emotions such as frustration.[13],[14] It was observed that the greater IGD9-SF score was associated with a greater duration of gaming time per day rather than the total time spent online per day.[15]

Since all the subjects were playing Multiple player battle royal game, it could be because these games allow the players to interact with other gamers in a virtual space as well as the peer pressure to remain in online gaming sessions might be associated with long duration of engagement in games. These platforms keep updating their content to impart uniqueness of gaming experience for the players and provide them with opportunities for in-game progression, in-game socialization and/or avatar development in the game. These unique structural characteristics of multiple player battle royal game act as positive reinforcements for gamers and promote increased frequency and duration of gaming behavior in them.[16],[17]

It was observed that academic stress was the major source of stress among undergraduate medical students. This experience of stressors was associated with indulgence in addictive behaviors.[18] The problematic video gameplay was being seen as a response to life stressors and video gaming was used as a strategy for diversion from the main task or goals.[19] Other studies found the association of problematic gaming with escapism/coping, mechanics, fantasy, and obtaining in-game wealth/achievements as motivations for gaming.[20],[21]

The study has limitations for not assessing the positive emotions among these subjects. There is also methodological justification not to include females because normal levels of cortisol are not the same among pubertal boys and girls. The inclusion of both genders and their comparison in the study would be inappropriate.

There is a need to explore other mental health conditions and assessment of biopsychosocial features within them to determine the obtained relationship among medical students. There is a need to do longitudinal studies to assess the health outcomes of excessive exposure to these violent games. The study also explained the observed manifestation of stressful reactions among gamers who play violent games. There is a need to create awareness among students, teachers, and medical colleges authorities about the harms associated with excessive gaming and the various risk factors for the development of excessive use of gaming. These findings can be used to create awareness as well as for planning emotional regulation intervention and wellness program for medical students. Research has demonstrated the effects of mindfulness-based stress-reduction or meditation techniques, self-hypnosis in helping medical students in managing stress. There is a need to assess the efficacy of other psychological strategies in reducing the distress of medical students.


SATYAM, DST Delhi, India, awarded the grant to Dr. Manoj Kumar Sharma.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Aliyari H, Sahraei H, Daliri MR, Minaei-Bidgoli B, Kazemi M, Agaei H, et al. The beneficial or harmful effects of computer game stress on cognitive functions of players. Basic Clin Neurosci 2018;9:177.  Back to cited text no. 9
Pontes HM, Griffiths MD. Measuring DSM-5 Internet gaming disorder: Development and validation of a short psychometric scale. Comput Hum Behavior 2015;45:137-43.  Back to cited text no. 10
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Király O, Sleczka P, Pontes HM, Urbán R, Griffiths MD, Demetrovics Z. Validation of the ten-item Internet Gaming Disorder Test (IGDT-10) and evaluation of the nine DSM-5 internet gaming disorder criteria. Addict Behav 2017;64:253-60.  Back to cited text no. 16
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  [Table 1]


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