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The common-sense model of illness suggests that mental representations of health threats may affect one’s behavioral reactions to them and health status. Internet gaming disorder is a newly defined mental disorder. Illness representations of internet gaming disorder may affect one’s risk of internet gaming disorder. In turn, symptoms of internet gaming disorder may affect one’s perceptions of the disorder.
This study aimed to investigate the relationships between illness representations and symptoms of internet gaming disorder in college students.
A 1-year longitudinal study was conducted with a convenience sample of Chinese college students (n=591; 342/591, 57.9% female).
Of the participants, 10.1% (60/591) and 9.1% (54/591) were classified as having probable internet gaming disorder at baseline (T1) and follow-up (T2), respectively. The correlations between some dimensions of illness representations regarding internet gaming disorder (ie, consequence, timeline, personal control, treatment control, and concern) at T1 and symptoms of internet gaming disorder at T2 and between symptoms of internet gaming disorder at T1 and the dimensions of illness representations at T2 (ie, consequence, timeline, personal control, and emotional response) were statistically significant. The cross-lagged model fit the data well ((χ2/
Individuals with more severe symptoms of internet gaming disorder had more pessimistic perceptions about the disorder. Such cognitive perceptions may affect one’s emotional and behavioral reactions towards the disorder (eg, greater levels of depression and low self-control intention) and should be modified by educational programs and psychological interventions.
Internet gaming is the most common leisure activity among young people in East Asian countries, including China [
Prevalence rates of IGD vary widely across studies, ranging from 0.7% to 15.6% [
The lay understanding of a potential health threat (ie, illness representations) may influence individuals’ responses to it (eg, IGD). The common-sense model (CSM) of illness [
Illness representations of IGD may affect one’s risk of IGD. People with unfavorable illness representations of IGD (eg, perceiving and worrying about severe consequences of IGD) may be less likely to have IGD. It may be because such people are more likely to regulate their internet gaming behaviors, prevent themselves from excessive internet gaming and IGD, or make an effort to reduce their IGD symptoms. Although related studies are limited, CSM can be used to support our hypothesis theoretically, which postulates that both cognitive representations and emotional representations of the illness can affect coping and appraisal of a disease, which in turn determine health-related outcomes [
However, IGD symptoms may increase the levels of unfavorable representations of IGD. It may be because people with greater symptoms of IGD may have experienced negative consequences of IGD or had trouble with regulating their internet gaming behaviors, thus enhancing their unfavorable representations of IGD, while those with no or minimal symptoms of IGD have not experienced negative consequences of IGD or may not necessarily think about IGD negatively [
This 2-wave longitudinal study aimed to understand how young people cognitively and emotionally perceive IGD as a disorder and health threat (ie, illness representations). In addition, the study investigated the relationships between such perceptions and symptoms of IGD in a population of Chinese college students. It was hypothesized that (1) unfavorable illness representations (eg, severe consequence) of IGD at baseline (T1) would predict low levels of IGD symptoms at follow-up (T2); however, (2) low levels of IGD symptoms at baseline (T1) would predict high levels of unfavorable illness representations of IGD at follow-up (T2).
This longitudinal study adopted a convenience sample recruited from 2 universities in China. The inclusion criteria of this study included (1) being a first-year college student, (2) being willing to participate in the baseline and follow-up studies, and (3) playing internet games in the past year. The exclusion criterion was being a non-Chinese speaker. Data from the participants who completed the 2-wave surveys were reported in this study (n=591). As shown in
Background characteristics of the participants (n=591).
Background characteristics | Participants, n (%) | ||
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Female | 342 (57.9) | |
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Male | 249 (42.1) | |
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Urban | 304 (51.4) | |
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Rural | 287 (48.6) | |
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Yes | 288 (48.7) | |
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No | 303 (51.3) | |
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0-7 | 264 (44.6) | |
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>7 to 14 | 181 (30.7) | |
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>14 to 21 | 85 (14.3) | |
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>21 | 67 (11.4) | |
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Anesthesia | 84 (14.2) | |
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Forensic Medicine | 87 (14.7) | |
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Stomatology | 165 (27.9) | |
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Chinese Medicine | 137 (23.1) | |
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Psychology | 118 (20.0) |
The baseline survey (T1) was conducted during the first year of college study of the participants, while the 1-year follow-up survey (T2) was conducted during their second year of college study. In the absence of any teacher, the surveys were conducted in classroom settings. A research assistant with 2 years of experience in data collection and who majored in psychology assisted with data collection and answered any questions during the survey. The participants were assured that participation was voluntary and refusals would have no negative consequences. Data confidentiality was guaranteed, and only the researchers could access the data. Student IDs were used for data matching. Researchers were not able to access students’ names or other identifying information. All participants were briefed on the purpose of the study and provided their informed consent to participate in this anonymous survey. They were also provided with information of local psychological services in case it was needed. The study procedures were carried out in accordance with the Declaration of Helsinki. Ethical approval was obtained from the affiliated university of the corresponding author.
The Brief Illness Perception Questionnaire (B-IPQ) was used to assess the participant's cognitive and emotional perceptions of IGD (
IGD symptoms were assessed using the 9 diagnostic criteria proposed in the DSM-5 (
Descriptive statistics of and Pearson’s correlation analyses between the continuous variables of each dimension of B-IPQ and IGD were performed using SPSS 25.0 (IBM Corp, Armonk, NY). The level of statistical significance was set at .05. Furthermore, the cross-lagged model regarding the relationships between all the dimensions of B-IPQ and the IGD score was performed by structural equation modeling using SPSS Amos 25. Latent variables of B-IPQ were created with the scores of each dimension of B-IPQ being used as observed variables. The variables at the same time point were covariated. The goodness-of-model fit was assessed using the Chi-square:degrees of freedom (χ2:df) ratio, CFI, RMSEA, and SRMR. A χ2:df ratio ≤3, CFI ≥.90, RMSEA ≤.08, and/or SRMR ≤.08 would indicate acceptable model fit [
As shown in
However, the percentages of item agreement increased at T2. To be specific, 43.0% (254/591) of the participants perceived that IGD would severely affect his or her life; 25.5% (151/591) believed that IGD would last forever; 60.3% (356/591) of the participants indicated that IGD would lead to severe symptoms; and 74.0% (437/591) would be concerned about IGD. Although 68.7% (406/591) perceived personal control over IGD, more than half of the participants believed that treatment of IGD could control the disease (333/591, 56.3%) and felt that they understood IGD (308/591, 52.1%). More than half (308/591, 52.1%) indicated that they would develop negative emotions due to IGD.
Number of participants who endorsed each item of the Brief Illness Perception Questionnaire (B-IPQ; score ≥6) at T1 (baseline) and T2 (1-year follow-up; n=591).
B-IPQ items | T1, n (%) | T2, n (%) |
Item 1: consequences | 121 (20.4) | 254 (43.0) |
Item 2: timeline | 120 (20.3) | 151 (25.5) |
Item 3: personal control | 338 (57.2) | 406 (68.7) |
Item 4: treatment control | 241 (40.8) | 333 (56.3) |
Item 5: identity | 271 (45.9) | 356 (60.3) |
Item 6: concern | 343 (58.1) | 437 (74.0) |
Item 7: comprehension | 268 (45.3) | 308 (52.1) |
Item 8: emotional response | 220 (37.2) | 308 (52.1) |
Of the participants, 10.1% (60/591) and 9.1% (54/591;
As shown in
Correlations between Brief Illness Perception Questionnaire (B-IPQ) dimensions and internet gaming disorder (IGD) symptoms at T1 (baseline) and T2 (1-year follow-up).
Variable | Consequence-T1 | Timeline-T1 | Personal control-T1 | Treatment control-T1 | Identity-T1 | Concern-T1 | Comprehension-T1 | Emotional response-T1 | Consequence-T2 | Timeline-T2 | Personal control-T2 | Treatment control -T2 | Identity-T2 | Concern-T2 | Comprehension-T2 | Emotional response-T2 | IGD symptoms-T1 | IGD symptoms-T2 |
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1 | 0.61 | 0.08 | 0.19 | 0.47 | 0.25 | 0.13 | 0.40 | 0.19 | 0.13 | 0.00 | –0.04 | 0.12 | 0.13 | 0.15 | 0.18 | 0.23 | 0.16 |
—a | <.001 | .33 | .02 | <.001 | <.001 | .12 | <.001 | .03 | .13 | .99 | .63 | .17 | .13 | .09 | .04 | .01 | .07 | |
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0.61 | 1 | –0.11 | 0.06 | 0.18 | –0.03 | 0.03 | 0.19 | 0.22 | 0.30 | –0.13 | –0.05 | 0.00 | –0.08 | –0.06 | 0.07 | 0.29 | 0.27 |
<.001 | — | .20 | .51 | .03 | .75 | .69 | .02 | .01 | <.001 | .15 | .56 | .98 | .37 | .53 | .45 | <.001 | <.001 | |
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0.08 | –0.11 | 1 | 0.49 | 0.38 | 0.36 | 0.36 | 0.29 | –0.07 | –0.25 | 0.17 | –0.03 | –0.09 | –0.11 | 0.08 | –0.10 | –0.17 | –0.15 |
.33 | .20 | — | <.001 | <.001 | <.001 | <.001 | <.001 | .40 | <.001 | .06 | .76 | .31 | .23 | .36 | .23 | .02 | .08 | |
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0.19 | 0.06 | 0.49 | 1 | 0.54 | 0.52 | 0.31 | 0.47 | 0.07 | –0.03 | –0.01 | 0.27 | 0.03 | 0.11 | 0.02 | –0.04 | –0.03 | –0.02 |
.02 | .51 | <.001 | — | <.001 | <.001 | <.001 | <.001 | .42 | .73 | .92 | <.001 | .77 | .20 | .80 | .67 | .75 | .79 | |
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0.47 | 0.18 | 0.38 | 0.54 | 1 | 0.58 | 0.39 | 0.48 | 0.29 | 0.07 | –0.01 | –0.05 | 0.08 | 0.11 | 0.15 | 0.15 | 0.06 | 0.05 |
<.001 | .03 | .00 | <.001 | — | <.001 | <.001 | <.001 | <.001 | .44 | .88 | .57 | .37 | .22 | .10 | .08 | .36 | .57 | |
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0.25 | –0.03 | 0.36 | 0.52 | 0.58 | 1 | 0.51 | 0.53 | 0.33 | 0.00 | 0.09 | 0.16 | 0.10 | 0.23 | 0.21 | 0.27 | –0.09 | –0.03 |
<.001 | .75 | <.001 | <.001 | <.001 | — | <.001 | <.001 | <.001 | .96 | .31 | .07 | .28 | .01 | .02 | <.001 | .29 | .77 | |
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0.13 | 0.03 | 0.36 | 0.31 | 0.39 | 0.51 | 1 | 0.39 | 0.21 | 0.05 | 0.12 | 0.09 | 0.00 | 0.16 | 0.27 | 0.21 | –0.14 | –0.02 |
.12 | .69 | <.001 | <.001 | <.001 | <.001 | — | <.001 | .02 | .60 | .17 | .34 | .99 | .07 | <.001 | .02 | .10 | .86 | |
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0.40 | 0.19 | 0.29 | 0.47 | 0.48 | 0.53 | 0.39 | 1 | 0.27 | 0.18 | 0.06 | 0.17 | 0.13 | 0.13 | 0.15 | 0.17 | 0.06 | 0.10 |
<.001 | .02 | <.001 | <.001 | <.001 | <.001 | <.001 | — | <.001 | .05 | .13 | .06 | .14 | .16 | .10 | .05 | .48 | .24 | |
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0.19 | 0.22 | –0.07 | 0.07 | 0.29 | 0.33 | 0.21 | 0.27 | 1 | 0.62 | 0.05 | 0.28 | 0.49 | 0.43 | 0.39 | 0.53 | 0.17 | 0.25 |
.03 | .01 | .40 | .42 | <.001 | <.001 | .02 | <.001 | — | <.001 | .53 | <.001 | <.001 | <.001 | <.001 | <.001 | .05 | <.001 | |
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0.13 | 0.30 | –0.25 | –0.03 | 0.07 | 0.00 | 0.05 | 0.18 | 0.62 | 1 | –0.12 | 0.20 | 0.42 | 0.22 | 0.13 | 0.40 | 0.38 | 0.45 |
.13 | <.001 | <.001 | .73 | .44 | .96 | .60 | .05 | <.001 | — | .17 | .02 | <.001 | .01 | .12 | <.001 | <.001 | <.001 | |
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0.00 | –0.13 | 0.17 | –0.01 | –0.01 | 0.09 | 0.12 | 0.06 | 0.05 | –0.12 | 1 | 0.51 | 0.23 | 0.41 | 0.32 | 0.22 | –0.30 | –0.19 |
.99 | .15 | .06 | .92 | .88 | .31 | .17 | .13 | .53 | .17 | — | <.001 | .01 | <.001 | <.001 | .01 | <.001 | .05 | |
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–0.04 | –0.05 | –0.03 | 0.27 | –0.05 | 0.16 | 0.09 | 0.17 | 0.28 | 0.20 | 0.51 | 1 | 0.33 | 0.49 | 0.22 | 0.32 | –0.10 | –0.01 |
.63 | .56 | .76 | <.001 | .57 | .07 | .34 | .06 | <.001 | .02 | <.001 | — | <.001 | <.001 | .01 | <.001 | .24 | .90 | |
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0.12 | 0.00 | –0.09 | 0.03 | 0.08 | 0.10 | 0.00 | 0.13 | 0.49 | 0.42 | 0.23 | 0.33 | 1 | 0.52 | 0.32 | 0.59 | 0.06 | 0.16 |
.17 | .98 | .31 | .77 | .37 | .28 | .99 | .14 | <.001 | <.001 | .01 | <.001 | — | <.001 | <.001 | <.001 | .06 | .06 | |
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0.13 | –0.08 | –0.11 | 0.11 | 0.11 | 0.23 | 0.16 | 0.13 | 0.43 | 0.22 | 0.41 | 0.49 | 0.52 | 1 | 0.40 | 0.57 | –0.12 | –0.05 |
.13 | .37 | .23 | .20 | .22 | .01 | .07 | .16 | <.001 | .01 | <.001 | <.001 | <.001 | — | <.001 | <.001 | .16 | .55 | |
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0.15 | –0.06 | 0.08 | 0.02 | 0.15 | 0.21 | 0.27 | 0.15 | 0.39 | 0.13 | 0.32 | 0.22 | 0.32 | 0.40 | 1 | 0.31 | –0.05 | 0.05 |
.09 | .53 | .36 | .80 | .10 | .02 | <.001 | .10 | <.001 | .12 | <.001 | .01 | <.001 | <.001 | — | <.001 | .58 | .60 | |
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0.18 | 0.07 | –0.10 | –0.04 | 0.15 | 0.27 | 0.21 | 0.17 | 0.53 | 0.40 | 0.22 | 0.32 | 0.59 | 0.57 | 0.31 | 1 | 0.08 | 0.06 |
.04 | .45 | .23 | .67 | .08 | <.001 | .02 | .05 | <.001 | <.001 | .01 | <.001 | <.001 | <.001 | <.001 | — | .35 | .49 | |
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0.23 | 0.29 | –0.17 | –0.03 | 0.06 | –0.09 | –0.14 | 0.06 | 0.17 | 0.38 | –0.30 | –0.10 | 0.06 | –0.12 | –0.05 | 0.08 | 1 | 0.54 |
.01 | <.001 | .02 | .75 | .36 | .29 | .10 | .48 | .05 | <.001 | <.001 | .24 | .06 | .16 | .58 | .35 | — | <.001 | |
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0.16 | 0.27 | –0.15 | –0.02 | 0.05 | –0.03 | –0.02 | 0.10 | 0.25 | 0.45 | –0.19 | –0.01 | 0.16 | –0.05 | 0.05 | 0.06 | 0.54 | 1 |
.07 | <.001 | .08 | .79 | .57 | .77 | .86 | .24 | <.001 | <.001 | .05 | .90 | .06 | .55 | .60 | .49 | <.001 | — |
aNot applicable.
The cross-lagged model fit the data well (χ2/
Cross-lagged model of Brief Illness Perception Questionnaire (B-IPQ) and internet gaming disorder (IGD) symptoms at T1 (baseline) and T2 (1-year follow-up) with standardized path coefficients.
Factor loadings of Brief Illness Perception Questionnaire (B-IPQ) at T1 (baseline) and T2 (1-year follow-up).
Factor loadings | B | β | Composite reliability | |
Consequence-T1 <--- B-IPQ T1 | 1.00 | .38 | -a | -a |
Timeline-T1 <--- B-IPQ T1 | 1.22 | .34 | 2.42 | .01 |
Personal control-T1 <--- B-IPQ T1 | 1.21 | .47 | 7.09 | <.001 |
Treatment control-T1 <--- B-IPQ T1 | 1.71 | .65 | 8.11 | <.001 |
Identity-T1 <--- B-IPQ T1 | 1.83 | .73 | 9.13 | <.001 |
Concern-T1 <--- B-IPQ T1 | 2.17 | .81 | 8.52 | <.001 |
Comprehension-T1 <--- B-IPQ T1 | 1.45 | .58 | 7.79 | <.001 |
Emotional tesponse-T1 <--- B-IPQ T1 | 1.68 | .68 | 8.19 | <.001 |
Consequence-T2 <--- B-IPQ T2 | 1.00 | .68 | -a | -a |
Timeline-T2 <--- B-IPQ T2 | .61 | .45 | 12.41 | <.001 |
Personal control-T2 <--- B-IPQ T2 | .43 | .33 | 7.25 | <.001 |
Treatment control -T2 <--- B-IPQ T2 | .71 | .48 | 10.19 | <.001 |
Identity-T2 <--- B-IPQ T2 | 1.07 | .74 | 14.13 | <.001 |
Concern-T2 <--- B-IPQ T2 | 1.03 | .73 | 14.43 | <.001 |
Comprehension-T2 <--- B-IPQ T2 | .65 | .48 | 10.27 | <.001 |
Emotional response-T2 <--- B-IPQ T2 | .96 | .76 | 14.80 | <.001 |
aIn the confirmation factor analysis, the loading of this factor was fixed at 1.
This study adopted a longitudinal design and conducted cross-lagged modeling analyses to demonstrate the relationship between illness representations of IGD and IGD symptoms. The results showed that only IGD symptoms at T1 predicted high levels of unfavorable illness representations at T2. Thus, hypothesis (2) was supported but not hypothesis (1). Indeed, people with greater IGD symptoms may be more likely to experience negative consequences of IGD in their daily life. For example, people with excessive and addictive use of internet games may suffer from mental and emotional disorders (eg, depression, anxiety, social anxiety, suicidal ideation), loneliness, interpersonal conflicts, and lack of offline social connection or support (eg, [
Correlation analyses showed significant correlations between greater consequence, higher timeline, and low personal control at T1 and high levels of IGD symptoms at T2; in turn, IGD symptoms at T1 were also significantly correlated with these perceptions at T2, which seem to suggest longitudinal and interactive relationships between these perceptions and IGD. Other significant correlations included the correlations between negative emotional response at T1 and IGD symptoms at T2, between IGD symptoms at T1 and treatment control at T2, and between IGD symptoms at T1 and concern at T2. Similar correlations between these dimensions of illness representations and IGD symptoms were also found at the same time point. Not all the correlations were statistically significant. Since the dimensions represent different perceptions of a disease and some perceptions may be particularly relevant to the disease, it is reasonable that not all the dimensions of illness representations of IGD were significantly correlated with IGD symptoms. Consistently, the recent cross-sectional study also reported that only timeline cyclical, personal control, illness coherence, and emotional representations were significantly correlated with IGD symptoms [
It is interesting to find that the percentages of item agreement for each dimension of illness representations significantly increased at T2 compared with T1. A plausible explanation for this increase may be that both international and local societies have started to emphasize the adverse consequences of excessive use of the internet and video games in recent years. For example, the World Health Organization defined IGD as a mental disorder in 2018 [
The prevalence of IGD found in our study is consistent with another study with Chinese college students (10.3%) [
The levels of illness representations of IGD changed significantly over time, while IGD did not change largely. It seems contradictory to our assumptions regarding their associations. One plausible explanation may be that although the protective factors of IGD (ie, unfavorable illness representations) increased over time, there may exist increasing independent risk factors (eg, daily life stress and academic stress) among the participants that could increase their risk of IGD or moderate the effect of illness representations on IGD. Future studies should investigate both risk and protective factors of IGD to better understand the change in IGD symptoms over time. These perceptions may have great effects on mental health and behavioral outcomes. For example, pessimistic views of IGD, such as low treatment control, may reduce ones’ help-seeking intention; a perception of low personal control may lead to anxiety and low self-efficacy. Future studies should test these mental health and behavioral outcomes.
This study represents the first longitudinal study testing the relationships between illness representations and symptoms of IGD. It is also the first attempt at understanding illness representations of IGD among young people who are a group at high risk of IGD [
Limitations of this study include the use of self-report measures, a nondiagnostic tool for IGD, and a small convenience sample. These might have affected the prevalence of IGD. The sample may differ from other populations considering some important demographic characteristics, such as age, educational level, majors, and regions. For example, the study only included medical students who might have extraordinary capabilities to assess their own health and possible threats of a disease. Thus, their perceptions of IGD may be different from other populations’ perceptions. Second, although the conduct of surveys within classroom settings helped to guarantee the survey’s quality, it might come with some limitations such as social pressure to participate. Third, only a 1-year follow-up was conducted. More waves and longer years of follow-up are warranted to better understand the stability of and changes in IGD and its consequences. Fourth, this study used the short version of IPQ. Although this version is more feasible in longitudinal surveys, future studies may use the long version of IPQ to validate our findings and test the reliability of each dimension of IPQ. Also, it was the first to use the B-IPQ in the context of IGD. Future studies should validate this scale well in the context of IGD. B-IPQ and IGD explained a relatively low amount of variance for each other. Future studies should include more potential important variables in the cross-lagged model. Fifth, it is worth noting that this study only investigated illness representations among gamers. Such perceptions may be different from those of nongamers [
The findings suggest that illness representations of IGD increased over time and the level of IGD symptoms might affect ones’ illness representations of IGD. Based on the CSM, these illness representations may further influence gamers’ mental health, coping strategies, and behaviors related to the illness (eg, self-management, help-seeking). Future research may examine how illness representations of IGD would influence mental health and behavioral outcomes. Educational programs and psychological interventions are warranted to reduce the over-pessimistic perceptions about IGD based on the CSM structure and the self (eg, low personal control over IGD) among the gamers.
Measures.
Brief Illness Perception Questionnaire
comparative fit index
common-sense model
Diagnostic and Statistical Manual of Mental Disorder
International Classification of Diseases
internet gaming disorder
root mean square error of approximation
standardized root mean square residual
None declared.