Industrial Psychiatry Journal

REVIEW ARTICLE
Year
: 2020  |  Volume : 29  |  Issue : 2  |  Page : 191--199

Influence of Esports on stress: A systematic review


Thamilselvan Palanichamy1, Manoj Kumar Sharma2, Maya Sahu3, DM Kanchana4,  
1 Assistant Professor, Department of Psychology, PSG College of Arts and Sciences, Coimbatore, Tamil Nadu, India
2 Professor, Department of Clinical Psychology, Service for Healthy Use of Technology Clinic, NIMHANS, Bengaluru, Karnataka, India
3 Department of Nursing, NIMHANS, Bengaluru, Karnataka, India
4 Consultant Psychologist, KPS Institute of Mental Health and Psychological Sciences, Coimbatore, Tamil Nadu, India

Correspondence Address:
Dr. Manoj Kumar Sharma
Professor, Department of Clinical Psychology, Services for Healthy Use of Technology (SHUT) Clinic, NIMHANS Centre for Well-Being, NIMHANS, Bengaluru, Karnataka
India

Abstract

Esports is an electronic sport known as competitive video gaming, which has seen tremendous growth over the past few years. Unlike traditional sports such as hockey, baseball, and soccer, Esports is an interconnection of multiple platforms, computing, gaming, and media into a sport event. A systematic review was conducted to collate and review all the research studies concerning Esports from a health perspective and analyze various physical and psychological distress regarding Esports. Relevant published papers were identified through the electronic databases Google Scholar, PubMed, and Research Gate. As a result of the systematic research review, seven articles were identified that investigated three major domains (i) Esports and physical issues, (ii) Esports and psychological distress, and (iii) Esports and addiction. The result indicated that Esports excessive play and its competitive nature lead to physical and psychological problems. Physical issues include eye fatigue, blurry vision, low back pain, tension headache, wrist pain, hand pain, and poor posture while gaming. Psychological issues include depression, anxiety, apathy, uncooperative attitude, tense, sleep disturbances, mental distress, aggressive affect and behaviors, distress in social life, and emotional disturbances. The studies also found that long hours of online gaming was associated with the presence of depression, social phobia, obsession–compulsion, interpersonal sensitivity, hostility, phobic anxiety, paranoid ideation, psychoticism attention-deficit hyperactivity disorder, and gaming addiction. This review draws insight into the problematic side of Esports and suggested that future studies must focus on the interventions to deal with the negative impact of Esports.



How to cite this article:
Palanichamy T, Sharma MK, Sahu M, Kanchana D M. Influence of Esports on stress: A systematic review.Ind Psychiatry J 2020;29:191-199


How to cite this URL:
Palanichamy T, Sharma MK, Sahu M, Kanchana D M. Influence of Esports on stress: A systematic review. Ind Psychiatry J [serial online] 2020 [cited 2021 Apr 21 ];29:191-199
Available from: https://www.industrialpsychiatry.org/text.asp?2020/29/2/191/311148


Full Text



Esports is a form of competition where human–computer interfaces mediate the inputs of players and teams.[1] Esports is being broadcasted through live-streaming platforms with a hundred million players participating in it. Esports has become a multibillion-dollar business[2] with a global audience of 453 million in 2019.[3] These events have considerable prize money of 100–200 million[4] dollars that lure significant amateur players to pursue it professionally. The first esports event happened in 1972 at Stanford University where students competed in video games' space war. Esports origin relies heavily on launching the worldwide web in 1989, and on the early 1990s software and hardware technologies with network and multiplayer functions. Esports began in the early 1990s, and it became increasingly popular during this decade, the number of players growing considerably.[5] It is growing every year.

Esports and video gaming: Excessive video games' use is the common feature between esports players and game addict teenagers. Professional gamers can play video games more than 22 h/week,[6] and 30% of teenagers interested in esports are playing video games for more than five hours a day.[7] Physical activities make people happier by increasing their serotonin levels, but playing computer games for a long time may trigger depression and social problems such as decreased academic achievement with conduct problems.[8]

Esports and psychopathology

Gender and game types are essential factors in esports athletes' mental health. Adolescent boys with Internet gaming disorder have higher rate of anxiety, depression, and alexithymia. In adolescent girls with Internet gaming disorder, depression manifest at higher rate than anxiety and alexithymia. Multiplayer online battle areas games have shown to regulate emotions, whereas massively multiplayer online role-playing games appear to be associated with mood and behavior disturbances.[9] A survey conducted for 1928 Norwegian adolescents aged 13–17 years and measured video game usage, video game addiction, depression, heavy episodic drinking, academic achievement, and conduct problems. This survey indicated that video game addiction was related to depression, lower academic achievement, and conduct problems, but the time spent on a video game was not related to any of the studied adverse outcomes.[10] Similarly, academic performance is correlated negatively with playing video game time from an educational point of view.[11] Various kinds of video games affect differently to an individual's mental health. For example, violent video games become the outlet of anger and frustration for adolescent boys.[12] Fantasy games with unrealistic characters make teenagers act similarly. Importantly, when teenagers play games for an excessive amount of time, the person may exhibit pathological symptoms, and addicted teenagers loneliness, anxiety, and depression.[13]

Esports and sports

There are many similarities between sports and esports. They both provide entertainment to the audience viewing the game, as they are both competitive environments that provide displays of skill and prowess and are designed in a very similar way.[14] Esports has many traditional sport components, including players, teams, managers, leagues, competitions, marquee events, endorsement deals, player transfer fees, college scholarships, and a dark side to match-fixing, doping, and gender-related disputes.[15] Certain underlying psychological similarities are observed between esports and established sports as athletes from both domains need a high level of sustained attention and have to make important decisions under time constraints. Several global esports organizations like the International E-Sports Federation also exist to provide an institutional basis for regulation and stabilization of rules that may validate esports games as a recognized professional sport.

Esports and public health perspective: From a public health perspective, concern only arises when engagement in gaming is excessive, and the aim is to minimize harm for both the players and viewers. In the most recent iteration of the Diagnostic Statistical Manual of Mental Disorders – V (DSM – V) (2013), Internet gaming disorder was included in the appendix as a condition warranting further research. In June 2018, the WHO included the gaming disorder as a mental health condition in the ICD-11.[16],[17] Gaming disorder is generally characterized by not able to control over gaming, increased priority is given to gaming when compare to daily routine and the presence of negative consequences. It results in significant impairment in personal, family, social, educational, occupational, or other important functioning areas. The inclusion of gaming as a mental condition prompted health professionals to explore esports activities and their role in contributing toward problematic gaming. The rise of professional gaming has led to an increase in esports. The term stress has been used to express “environmental demands encountered by individuals.”[18] As esports athletes compete in highly pressurized and competitive environments comparable to more traditional sports, stress likely exists in an esports performance environment. Another study identified the mental skill and techniques used by the esports player to achieve optimal performance in a highly competitive gaming environment. For successful performance, esports player needs to know about video games, think strategically, make fast and smart decisions, be motivated to keep moving forward, avoid being distracted, cope adaptively with harassment, and maintain a positive attitude. If the esports player needs to achieve optimal performance, the player should adapt to their opponents, communicate properly with the teammates, and trust their skills. This study also identified the possible barriers of performance, such as confidence issues, inadequate coping strategies with anxiety, past achievements and mistakes, harassment, lack of self and team development, and difficulty in separating life and gaming. Some psychological skill involved in esports includes a high level of sustained attention, planning, working memory, and inhibition to control the impulses. All these factors do contribute to or affect the psychological state of players.[19] Another exploration about the mindset of winning players and teams in Esports suggest that up to 50% of performance improvement link to mental preparedness and a player's state of mind.[20] Research has identified that elite athletes are under intense pressure to succeed and face various demands in performing in an elite environment.[21],[22],[23] Researchers have investigated these demands principally using qualitative methods to interview elite participants about the specific stressors, they face when performing. For example, in an interview of 20 Australian University athletes to understand their stressors, they combined elite sport participation in higher education. The findings revealed a range of stress that included schedule clashes, financial pressure, and coaches' inflexibility.[24] Another study interviewed five high-level League of Legends players about psychosocial factors in competitive esports and found many obstacles prevented optimal performance.[19] These obstacles included pressure of competing, being harassed by others, and negative communication during performance Esports players are competing in increasingly pressurized environments. Stress is likely to impact performance in such an environment negatively. The present review aimed to develop and enhance an understanding of psychological issues among esports players. Even Esports popularity, only a few studies investigated the gamers' health profile (physical and psychological).

 Methods



Aim

This study aimed to review all the recent research studies concerning Esports from a health perspective.

PICO guidelines followed for the systematic review.

P – Population/patient = Human participants

I – Intervention = NIL

C – Comparator/control = NIL

O – Outcome = Esports and health issues (physical and psychological)

The systematic review was conducted based on the preferred reporting item for systematic review and meta-analysis (PRISMA) and PICO guidelines.[25]

Database searched

Studies were identified by searching the three research engines such as PubMed, Google Scholar, and Research Gate. Since esports is a relatively understudied area, the keywords such as Esports, stress, and addiction used to search articles in the research engines.

Inclusion criteria

The data collection included all the studies published between 2017 and 2020. The assessments of psychological issues in esports, empirical studies, inclusive of game players between 14 and 25 years, studies published in the peer-reviewed journal, and studies published in English were included in the systematic review.

Exclusion criteria

Dissertations, pilot/protocol/prototype studies, and studies published in a language other than English were excluded.

Technology-assisted search and screening

Rayyan software used to screen database.[26] Those articles that did not meet the inclusion criteria were excluded. Cross-referencing of the excluded and selected studies were done by consenus of the co-authors.

Study selection and data extraction

A total of 20 papers reviewed as a result of the article's search. Identified studies reviewed independently for eligibility in a two-step process: first screening was performed based on the title and abstract, and then, full texts accessed for a second screening. At both the stages, data was extracted based on the inclusion criteria [Figure 1].{Figure 1}

 Results



All papers used for this review based their findings on online/video games dating from 2017 till date. Twenty-two papers screened through the search terms used in the databases. Papers selected for current review: Seven papers met the inclusion criteria for the current review to explore the Esports and stress. Two papers reported the physical stress and Esports and two papers reported the psychological stress and esports and three papers on Esports and addiction [Table 1].{Table 1}

Seven studies were selected, and these studies comprised three main topics such as (i) Epsorts and physical issues, (ii) Esports and psychological distress, and (iii) Esports and addiction. These studies used online survey method with followings guidelines.

Was the research question or objective in the paper clearly stated?Was the study population clearly specified and defined?Was 50% the participation rate of eligible persons ensured?Were the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?Whether sample size justification, power description, or variance and effect estimates providedFor the analyses in this paper, were the exposure (s) of interest measured before the outcome (s) being measured?Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it exist?For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?Was the exposure (s) assessed more than once over time?Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?Were the outcome assessors blinded to the exposure status of participants?Was loss to follow-up after baseline 20% or less?Were critical potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure (s) and outcome (s)?

[Table 2]: Given the studies's nature, most of the studies were in the category of reasonable or fair, though few components were not reported in the studies.{Table 2}

Esports and physical issues

The early studies revealed that Esports might lead to several types of physical issues. The most commonly reported complaints of esports athletes are eye fatigue. Greater than twenty-five percent of collegiate sports athletes report practicing for more than five hours day. During practice, athletes fix their eyes on a computer screen for a long period of time.[27] Thus, many Esports athletes have computer vision syndrome, characterized by blurry vision, low back pain, and tension headache. This condition found in 90% of individuals using a computer for more than 3 h/day.[33]

A survey of 65 collegiate Esports players from nine universities across the USA and Canada inquired about gaming and lifestyle habits and musculoskeletal complaints due to esports competition. The result of the study revealed those players practicing between 3 and 10 h/day and the most reported complaints were eye fatigue (56%), followed by neck and back pain (42%) and also Esports athletes prone to have wrist pain (36%) and hand pain (32%).[28] Similarly, 35% of collegiate Esports athletes reported neck pain or back pain while gaming.[31]

Playing video games longer than 3 hours is associated with shoulder pain and is likely a result of poor posture while gaming[34] because, it requires quick, repetitive movements involving the fingers, hands, and wrists. These repetitive movements lead to hypertrophy of the flexor tendons in the carpal tunnel and an increased cross-sectional area and swelling ratio in the median nerve.[35]

Esports athletes were practicing between 3 and 10 h/day to master his or her sport. When individuals remained seated in a position for >3 h, it negatively affected their peripheral and central vascular health.[36]

A comparative study that included 52 professionals and nonprofessional esports athletes with the Internet gaming disorder revealed differences in brain structure and function. In addition, they increased gray matter volume in the anterior cingulate gyrus, which is responsible for regulating addictive behaviors, in professional esports athletes compared with people with the Internet gaming disorder. Moreover, people with the Internet gaming disorder had increased gray matter volume in the thalamus, responsible for conditioned responses and associated with the stimulus-reward pathway.[37]

[Table 3] reported that Esports might lead to various physical issues such as blurry vision, low back pain, neck pain, and tension headache.{Table 3}

Esports and psychological distress

Esports not only leads to physical issues, but it may also lead to adverse psychological effects. Playing video games for a long time in daily life causes social, emotional, and mental problems such as depression and aggression. So uncontrolled and excessive play of video games can cause social and emotional problems.[38]

A study at the University of Chichester examined esports professionals' psychological challenges when competing in a primary contests. A study at the University of Chichester examined esports professionals' psychological challenges when competing in major contests. Esports players faced different types of stress factors, including communication problems and concerns with competing in front of a live audience, mirroring the mental conditions experienced by pro athletes, including footballers and rugby stars in high-profile tournaments. Similarly, excessive video game playing was related to social life distress, disturbance occupational activities, and academic performance among high school students, college students, and adults.[39]

In a survey of 276 students enrolled in ninth through twelfth grades in the International Schools in Buraidah, Al-Qassim, it is determined that addiction to video games was strongly associated with psychological distress, and also female gender, higher screen time, and shorter sleep hours were found as other significant correlates.[40]

Esports has become an ever-increasing part of many adolescents' day to day lives. The relationship between computer games and aggression in adolescents with mental health was explored and found that computer games increase adolescent aggression and decrease mental health.[41] Similar results found that the addictive behavior of excessive gaming is interrelated with aggressive behavior.[42] Similarly, a study based on the Affective Aggression Model revealed that exposure to violent video games would increase aggressive behavior in both the short-term and long-term duration.[43]

The experimental research showed that playing violent video games produces a higher level of aggressive cognitions, aggressive affect, physiological arousal, and aggressive behavior (short term) than nonviolent video games.[44] Similarly, other researchers assessed whether violent video games increase physical aggression over time in both high (United States) and low (Japan) violent cultures. The study revealed that habitual violent video games play in the school age-predicted later aggression, even after controlling for gender and previous aggressiveness in each sample. This shows that playing violent video games is a significant risk factor for later physically aggressive behavior. This violent video game effect on youth generalizes across very different cultures.[45]

Esports and addiction

Game addiction is a major problem for society to deal with, and there will be harmful psychosocial consequences. Scientists have started viewing video gaming as a pathological issue.[46] Teenagers with addictive behaviors may be evolving into aggressive, uncooperative, apathetic, and tense personalities.[47]

The participation rates and demographic characteristics of esports spectators whose gambling were assessed through an international online survey (n = 582), and the sample highlighted the prevalence of young, often underage, males in esports-related gambling activities. Participation in gambling and gambling-like activities was 67%, with rates of problematic and potentially problematic gambling in the sample being 50.34%. The result revealed that increased gambling is associated with increased spectating of esports. Similarly, a study using an international online survey (n = 613) revealed that esports' consumption had a moderate relationship with video game-related gambling, online gambling, and problem gambling.[32]

 Discussion



The present review studies showed the impact of increased Esports on psychological well-being, physical stress, and addiction. In a cross-sectional online survey of 165 multiplayer online battle arena, gamers revealed that a higher level of playtime was associated with poor psychological well-being.[48] The studies have corroborated the association of long hours of online gaming and the presence of depression, social phobia, obsession–compulsion, interpersonal sensitivity, hostility, phobic anxiety, paranoid ideation, and psychoticism ADHD and Internet addiction. The gender difference observed for expression of social anxiety.[49],[50],[51] Similar findings have been reported using video game use questionnaire and symptom checklist scale-90 that reported a nonspecific relationship between various domains of psychopathology and video game use in general and problem video game use in particular.[52]

Competition is related to psychophysiological stress response and it is a key aspect of esports. The esports in competitive settings is related to physiological or psychological stress based on the systematic literature review. A total of 17 studies were reviewed and the result shows that five studies on stress in competitive setting demonstrated no hormonal reaction, one study reported an increase in anxiety levels in the winners as well as increase cortisol levels from baseline to postgame, and two studies found an activation of the sympathetic nervous system. These stresses in some of the cases do manifest as aggression.[53] Although the research is available in gaming and psychological distress, empirical work must assess the psychological issues and their impact on esports players [Table 3].[54]

Strengths and limitations

A comprehensive and systematic approach to have a detailed review of each full-text article. The attempt was made to reduce the risk of bias. Rayyan software, the PICO, and PRISMA guidelines used to minimize error. The limitation of this review is the availability of a limited number of databases meeting the inclusion criteria.

 Conclusion



Over the past few years, the popularity of Esports events has grown enormously. This kind of event typically involves professional video game players competing in multiplayer video game competitions. The present study collated all the recent empirical studies that intend to assess the health issues (physical and psychological) in Esports and revealed that excessive Esports play causes social, emotional, addiction, and psychological problems such as depression and aggression. From the studies reviewed, assessing it is seen that the survey method was used for the negative consequences of gaming. Regarding future research directions, health issues, their relationship with nature of games, duration of play, and the interventions to deal with the Esports negative impact needed to be explored. There is a need to provide psychological as well as physical skills training like positive self-talk, breathing techniques, skills to avoid physical distress, and imagery to improve focus and encouraging their use during Esports competitions to regulate emotions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Hamari J, Sjöblom M. What is eSports and why do people watch it? Internet Res 2017;27. DOI:10.1108/IntR-04-2016-0085.
2Gupta N. Building A Career In eSports: What Does It Take to Build One and How Much Can I Earn? Available from: https://zuuonline.sg/career/building-a-career-in-e-sports-what-does-it-take-to-build-one-and-how-much-can-i-ear. [Last accessed on 2020 Jul 20].
3Global eSports Market Report. Available from: https://strivesponsorship.com/2019/06/18/newzoo-global-esports-market-report-2019/. [Last accessed on 2020 Jul 20].
4Chung T, Sum S, Chan M, Lai E, Cheng N. Will esports result in a higher prevalence of problematic gaming? A review of the global situation. J Behav Addict 2019;8:384-94.
5Jonasson K, Thiborg J. Electronic sport and its impact on future sport. Sport Soc 2010;13:287-99.
6Chappell D, Eatough V, Davies MN, Griffiths M. EverQuest-It's just a computer game right? An interpretative phenomenological analysis of online gaming addiction. Int J Ment Health Addict 2006;4:205-16.
7Eventbrite E Sport Study; 2015. Available from: https://www.impulsegamer.com/eventbrite-esports-study-reveals-the-impact-of-live-events-on-gamer-play-and-spending-behaviour/. [Last accessed on 2020 Jun 14].
8Brunborg GS, Mentzoni RA, Melkevik OR, Torsheim T, Samdal O, Hetland J, et al. Gaming addiction, gaming engagement, and psychological health complaints among Norwegian adolescents. Media Psychol 2013;16:115-28.
9Bonnaire C, Baptista D. Internet gaming disorder in male and female young adults: The role of alexithymia, depression, anxiety and gaming type. Psychiatry Res 2019;272:521-30.
10Brunborg GS, Mentzoni RA, Frøyland LR. Is video gaming, or video game addiction, associated with depression, academic achievement, heavy episodic drinking, or conduct problems? J Behav Addict 2014;3:27-32.
11Anand V. A study of time management: The correlation between video game usage and academic performance markers. Cyberpsychol Behav 2007;10:552-9.
12Greitemeyer T. Everyday sadism predicts violent video game preferences. Pers Individ Dif 2015;75:19-23.
13Sarda E, Bègue L, Bry C, Gentile D. Internet gaming disorder and well-being: A scale validation. Cyberpsychol Behav Soc Netw 2016;19:674-9.
14Michaluk T. Changes in the meaning of physicality in modern sport-from disabled sports to e-sport. Physiother Fizjoterapia 2012;20:3-9.
15Jenny SE, Manning RD, Keiper MC, Olrich TW. Virtual (ly) athletes: Where eSports fit within the definition of “Sport”. Quest 2017;69:1-8.
16World Health Organization. Gaming Disorder. Available from: http://www.who.int/features/qa/gaming-disorder/en/. [Last accessed on 2019 Apr 08].
17World Health Organization. WHO Releases New International Classification of Diseases (ICD 11). Available from: http://www.who.int/news-room/detail/18-06-2018-who-releases-new-international-classification-ofdiseases-(ICD-11). [Last accessed on 2019 Apr 08].
18Fletcher D, Hanton S , Mellalieu SD An organisational stress review: Conceptual and theoretical issues in competitive sport. In: Literature reviews in sport psychology, Edited by: Hanton S, Mellalieu SD. 321–374. Hauppauge, NY: Nova Science; 2006.
19Himmelstein D, Liu Y, Shapiro JL. An exploration of mental skills among competitive league of legend players. Int J Gaming and Computer-Mediated Simulations 2017;9:1-21.
20Andrejkovics Z. The Invisible Game: Mindset of Winning Team (Esports & Competitive Gaming, Dota 2, League of Legends, CS:GO); 2016. p. 124-60.
21Thelwell RC, Weston NJ, Greenlees IA, Hutchings NV. Stressors in elite sport: A coach perspective. J Sports Sci 2008;26:905-18.
22Weston NJ, Thelwell RC, Bond S, Hutchings NV. Stress and coping in single-handed round-the-world ocean sailing. J Appl Sport Psychol 2009;21:460-74.
23Arnold R, Fletcher D. A research synthesis and taxonomic classification of the organizational stressors encountered by sport performers. J Sport Exerc Psychol 2012;34:397-429.
24Cosh S, Tully PJ. Stressors, coping, and support mechanisms for student athletes combining elite sport and tertiary education: Implications for practice. Sport Psychol 2015;29:120-33.
25Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. J Clin Epidemiol 2009;62:e1-34.
26Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan – A web and mobile app for systematic reviews. Syst Rev 2016;5:210.
27DiFrancisco-Donoghue J, Balentine J, Schmidt G, Zwibel H. Managing the health of the eSport athlete: An integrated health management model. BMJ Open Sport Exerc Med 2019;5:e000467.
28Rudolf K, Bickmann P, Froböse I, Tholl C, Wechsler K, Grieben C. Demographics and Health Behavior of Video Game and eSports Players in Germany: The eSports Study 2019. Int J Environ Res Public Health 2020;17: 1870.
29Kocadağ M. Investigating psychological well-being levels of teenagers interested in esport career. Res Educ Psychol 2019;3:1-10.
30DiFrancisco-Donoghue J, Balentine JR. Collegiate eSport: Where Do We Fit In? Curr Sports Med Rep 2018;17:117-8.
31Macey J, Hamari J. Investigating relationships between video gaming, spectating esports, and gambling. Comput Hum Behav 2018;80:344-53.
32Macey J, Hamari J. eSports, skins and loot boxes: Participants, practices and problematic behaviour associated with emergent forms of gambling. New Media Soc 2019;21:20-41.
33Mashalla YJ. Impact of computer technology on health: Computer vision syndrome (CVS). Med Pract Rev 2014;5:20-30.
34Sekiguchi T, Hagiwara Y, Yabe Y, Tsuchiya M, Itaya N, Yoshida S, et al. Playing video games for more than 3 hours a day is associated with shoulder and elbow pain in elite young male baseball players. J Shoulder Elb Surg 2018;27:1629-35.
35Toosi KK, Hogaboom NS, Oyster ML, Boninger ML. Computer keyboarding biomechanics and acute changes in median nerve indicative of carpal tunnel syndrome. Clin Biomech (Bristol, Avon) 2015;30:546-50.
36Credeur DP, Miller SM, Jones R, Stoner L, Dolbow DR, Fryer SM, et al. Impact of prolonged sitting on peripheral and central vascular health. Am J Cardiol 2019;123:260-6.
37Han DH, Lyoo IK, Renshaw PF. Differential regional gray matter volumes in patients with on-line game addiction and professional gamers. J Psychiatr Res 2012;46:507-15.
38Lemmens JS, Valkenburg PM, Peter J. Development and validation of a game addiction scale for adolescents. Media Psychol 2009;12:77-95.
39Hart GM, Johnson B, Stamm B, Angers N, Robinson A, Lally T, et al. Effects of video games on adolescents and adults. Cyberpsychol Behav 2009;12:63-5.
40Saquib N, Saquib J, Wahid A, Ahmed AA, Dhuhayr HE, Zaghloul MS, et al. Video game addiction and psychological distress among expatriate adolescents in Saudi Arabia. Addict Behav 2017;6:112-7.
41Grüsser SM, Thalemann R, Griffiths MD. Excessive computer game playing: Evidence for addiction and aggression? Cyberpsychol Behav 2006;10:290-2.
42Anderson CA, Dill KE. Video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. J Pers Soc Psychol 2000;78:772.
43Adachi PJ, Willoughby T. The effect of violent video games on aggression: Is it more than just the violence? Aggress Violent Behav 2011;16:55-62.
44Anderson CA, Sakamoto A, Gentile DA, Ihori N, Shibuya A, Yukawa S, et al. Longitudinal effects of violent video games on aggression in Japan and the United States. Pediatrics 2008;122:e1067-72.
45Lemmens JS, Bushman BJ, Konijn EA. The appeal of violent video games to lower educated aggressive adolescent boys from two countries. Cyberpsychol Behav 2006;9:638-41.
46Boxer P, Groves CL, Docherty M. Video games do indeed influence children and adolescents' aggression, prosocial behavior, and academic performance: A clearer reading of ferguson (2015). Perspect Psychol Sci 2015;10:671-3.
47Goh C, Jones C, Copello A. A further test of the impact of online gaming on psychological wellbeing and the role of play motivations and problematic use. Psychiatr Q 2019;90:747-60.
48Wei HT, Chen MH, Huang PC, Bai YM. The association between online gaming, social phobia, and depression: An internet survey. BMC Psychiatry 2012;12:92.
49Kim NR, Hwang SS, Choi JS, Kim DJ, Demetrovics Z, Király O, et al. Characteristics and psychiatric symptoms of internet gaming disorder among adults using self-reported DSM-5 criteria. Psychiatry Investig 2016;13:58-66.
50González-Bueso V, Santamaría JJ, Fernández D, Merino L, Montero E, Ribas J. Association between internet gaming disorder or pathological video-game use and comorbid psychopathology: A comprehensive review. Int J Environ Res Public Health 2018;15:668.
51Starcevic V, Berle D, Porter G, Fenech P. Problem video game use and dimensions of psychopathology. Int J Ment Health Addict 2011;9:248-56.
52Leis O, Lautenbach F. Psychological and physiological stress in non-competitive and competitive esports settings: A systematic review. Psychol Sport Exerc 2020;51:101738.
53Smith MJ, Arnold R, Thelwell RC. “There's no place to hide”: Exploring the stressors encountered by elite cricket captains. J Appl Sport Psychol 2018;30:150-70.
54Bányai F, Griffiths MD, Király O, Demetrovics Z. The psychology of esports: A systematic literature review. J Gambl Stud 2019;35:351-65.