Personality and Internet Gaming Disorder: a Systematic Review of Recent Literature

Abstract

Purpose of Review
In this study, we present a systematic review of empirical studies that have addressed the relationship between Internet gaming disorder (IGD) and personality in the last 10 years (2007–2016). A systematic search of scientific literature identified 27 peer-reviewed empirical studies that examined the relationship between IGD and personality dimensions.

Recent Findings
The findings of recent empirical studies suggest that IGD is linked to a wide range of personality traits, domains, and disorders.

Summary
Although some personality factors such as high neuroticism, high impulsivity, and high aggressiveness emerged quite consistently as significant predictors of IGD across the studies, the overall result of this systematic review showed that different personality traits (more frequently, in combination) may play a pivotal role in the acquisition, development, and maintenance of IGD. Therefore, further research is needed to understand whether specific patterns of personality traits may predispose people to IGD.

Full text

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Current Addiction Reports
e-ISSN 2196-2952
Curr Addict Rep
DOI 10.1007/s40429-017-0159-6
Personality and Internet Gaming Disorder:
a Systematic Review of Recent Literature
Alessia Maria Gervasi, Luana La Marca,
Antonino Costanzo, Ugo Pace, Fanny
Guglielmucci & Adriano Schimmenti

1 23
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TECHNOLOGY ADDICTION (J BILLIEUX, SECTION EDITOR)
Personality and Internet Gaming Disorder: a Systematic Review
of Recent Literature
Alessia Maria Gervasi
1
&Luana La Marca
2
&Antonino Costanzo
2
&Ugo Pace
2
&
Fanny Guglielmucci
3
&Adriano Schimmenti
2
#Springer International Publishing AG 2017
Abstract
Purpose of Review In this study, we present a systematic re-
view of empirical studies that have addressed the relationship
between Internet gaming disorder (IGD) and personality in the
last 10 years (2007–2016). A systematic search of scientific
literature identified 27 peer-reviewed empirical studies that
examined the relationship between IGD and personality
dimensions.
Recent Findings The findings of recent empirical studies sug-
gest that IGD is linked to a wide range of personality traits,
domains, and disorders.
Summary Although some personality factors such as high
neuroticism, high impulsivity, and high aggressiveness
emerged quite consistently as significant predictors of IGD
across the studies, the overall result of this systematic review
showed that different personality traits (more frequently, in
combination) may play a pivotal role in the acquisition, devel-
opment, and maintenance of IGD. Therefore, further research
is needed to understand whether specific patterns of personal-
ity traits may predispose people to IGD.
Keywords Internet gaming disorder .Video game addiction .
Personality .Personality traits .Systematic review
Introduction
In the context of scientific debate about the nature of problem-
atic Internet use, it has been shown that different Internet ser-
vices and applications may have some addictive properties [1,
2••]. This is reflected in empirical research related to compul-
sive buying on the Internet, excessive social networking,
watching online pornography, online gambling, and online
computer gaming [3]. It is noteworthy that increasing scien-
tific reports have begun to focus on the preoccupation some
people develop with certain aspects of the Internet, and online
games in particular, in part as a result of the inclusion of
Internet gaming disorder (IGD) among the conditions for fur-
ther study in the last edition of the Diagnostic and Statistical
Manual of Mental Disorders [4]. Criticisms have been
expressed about the consistency and validity of the diagnosis
[1,5•,6,7], including the tendency of researchers to compen-
sate for a lack of theoretical conceptualizations and clinical
evidence related to the disorder by adapting criteria of addic-
tive disorders (e.g., substance abuse), with the assumption that
a conceptual overlap or similarity exists [6–9]. In fact, some
scholars have observed that excessive Internet gamers display
symptoms related to their gaming behaviors that are similar to
those of people suffering from substance use disorder, such as
playing compulsively, frequent and obsessive thoughts re-
garding the game to the exclusion of other interests, social
isolation, psychological discomfort when gaming is reduced,
reduction of social, recreational, work, educational, house-
hold, and/or other activities, disregard about one’s own and
others’needs because of the behavior, withdrawal when
pulled away from gaming, and persistent and recurrent online
activity resulting in clinically significant impairment or dis-
tress [10,11].Therefore, excessive Internet gaming behaviors
are increasingly recognized as an issue of psychological and
psychiatric relevance, due to the potentially negative effect of
This article is part of the Topical Collection on Technology Addiction
*Adriano Schimmenti
adriano.schimmenti@unikore.it
1
Department of Social Sciences, University of Verona, Verona, Italy
2
Faculty of Human and Social Sciences, UKE –Kore University of
Enna, Cittadella Universitaria, SN/R14, 94100 Enna, Italy
3
Department of Psychology, University of Turin, Turin, Italy
Curr Addict Rep
DOI 10.1007/s40429-017-0159-6
Author's personal copy

excessive Internet gaming on multiple domains of functioning
[7,12–15]. In this respect, it is possible that the scientific
debate resulting from the inclusion of IGD diagnosis and its
criteria in the Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (DSM-5) may help researchers to over-
come the relevant methodological weaknesses of extant quan-
titative and clinical studies on problematic Internet gaming [7,
16–18].
A number of factors have been identified that may contrib-
ute to an increased vulnerability for developing IGD [19].
Among these factors, research suggests that personality traits
may have a critical role in predisposing certain people to de-
veloping IGD [20••,21,22,23•]. Personality traits can be
conceived as habitual patterns of attitude, behavior, emotion,
and thought; these patterns are relatively stable over time,
differ across individuals, and influence behavior [24]. A com-
bination of dysfunctional and/or maladaptive personality traits
may also result in personality disorder [4]. In this article, we
present a systematic review of the empirical studies that have
linked personality traits and disorders to IGD symptoms in the
last 10 years (2007–2016). Our choice to systematically re-
view only articles published after 2006 is justified by the fact
that online gaming has evolved with the development of tech-
nologies. Thus, we thought it was inappropriate to include
research that was older than 10 years, as the inclusion of this
research might have led to misleading or even non-extant
conclusions.
Method
Search Strategies
A systematic search strategy was used to identify relevant
studies. Research was conducted between November 2016
and January 2017, and included studies published in the last
10 years (January 2007–December 2016). Studies were iden-
tified by searching the following databases: MEDLINE/
PubMed and PubMed Central, Scopus (Elsevier), ProQuest
Psychology Journal, SpringerLink and SpringerLink Open
Access, Directory of Open Access Journals, Taylor &
Francis Online, Karger Journals, SAGE Journals,
PsycArticles, and PsycINFO.
We used a three-step literature search. First, we used a
combination of the keywords “personality”OR “trait”AND
“Internet gaming”OR “online gaming”to identify the relevant
studies. For the publication year, we selected the period be-
tween 2007 and 2016 as an additional criterion.
Secondly, a database search was performed using the
names of the authors of all the articles identified in the first
step. Finally, reference lists of articles selected were manually
checked for any studies not retrieved by the automatic litera-
ture search. Article eligibility was independently evaluated by
AC, AMG, and LLM. Any discrepancy regarding the
inclusion/exclusion of articles was discussed within the re-
search group up until an agreement was reached.
Selection Criteria
This systematic review is in compliance with the PRISMA
(Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) guidelines for the search, systematization,
and reporting of systematic reviews [25]. Progressive exclu-
sion was performed by reading the abstract and, finally, the
full text. Including criteria were (a) published within the given
time interval (2007–2016); (b) articles in English language;
(c) articles published in peer-reviewed journals; and (d) arti-
cles focusing on personality traits and disorders associated
with IGD. Newspaper articles and dissertations were excluded
from the analysis. The database search resulted in a total of
503 articles. Duplicate articles resulted in a total of 17.
Another 461 articles were excluded based on full-text evalu-
ation, because they either: (a) analyzed Internet use as a
whole, rather than Internet gaming behaviors, and/or (b) ex-
amined online video game activity but not personality traits,
and/or (c) focused on the psychosocial outcomes and mental
health of gamers rather than on IGD, and/or (d) examined
neurobiological correlates of IGD, and/or (e) were literature
reviews. Two additional articles were identified through a
manual search. The 27 articles resulting from electronic and
manual literature searches underwent close scrutiny, data ex-
traction, and qualitative analysis. The entire article selection
procedure is displayed in Fig. 1.
Data Analysis
Data analysis was carried out by considering the aims of the
studies, the methodologies employed, and the results. Coded
data included authors of the article, year of publication, sam-
ple characteristics (age, gender, country), personality variables
investigated, IGD and personality measures, and the main
findings of the study.
Results
In this section, we summarize the results of our review. We
reviewed the findings for personality dimensions, traits and
disorders examined in their relationship with IGD, including
personality domains of the “Big Five”model [26], sociability,
self-directedness, cooperativeness, impulsivity, self-regula-
tion, aggressiveness, interpersonal dependency, narcissism,
and clusters of personality disorders. A brief description of
each investigated personality variable is provided in Table 1.
For clarity of presentation, we separated the constructs to be
studied into different categories, but as it is known in the
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literature [27–29] and as Table 1illustrates, many of these
constructs are often interrelated. Table 2summarizes the re-
sults of the review.
Big Five Dimensions
The Big Five model of personality conceives of personality as
a result of the interactions among five broad personality di-
mensions, namely, neuroticism, openness to experience, con-
scientiousness, extraversion, and agreeableness [26]. The the-
oretical framework provided by the Big Five model has gen-
erated several studies in video game-related research.
Mehroof and colleagues [19] suggested that neuroticism
may be important in the acquisition, development, and main-
tenance of IGD. These authors found in a sample of students
that neuroticism predicted their measure of online gaming
addiction. Similarly, Montag and colleagues [20••] showed
in a large and ecologically valid sample of first-person shooter
video gamers that IGD scores were positively associated with
neuroticism. Cole and Hooley [21] found that players of
massively-multiplayer online (MMO) games with high levels
of problematic Internet use were more neurotic than other
participants. Also, Peters and Malesky [45]foundamoderate
and positive correlation between neuroticism and IGD in
Fig. 1 Flow chart of the search
strategy and selection procedure
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another sample of massive multiplayer online role-playing
game (MMORPG) players of World of Warcraft. In another
study, Müller and colleagues [42] found that personality traits,
and neuroticism in particular, were positively associated with
Internet addiction and computer game addiction scores. In
more detail, they compared four groups of participants in
terms of personality traits: an IGD group (comprising patients
in treatment for IGD), a pathological gambling group (com-
prising patients in treatment for gambling disorder), a clinical
control group (comprising individuals seeking treatment), and
a non-clinical control group (comprising healthy subjects
recruited through local advertisements). Significant differ-
ences among groups emerged in different domains, with a
large effect size for increased neuroticism in the IGD group.
Khazaal and colleagues [23•] found in a large sample of late
adolescents and young adults a positive association between
gaming addiction scores and neuroticism scores. Another
study by Lehenbauer-Baum and colleagues [39]showedthat
addicted gamers displayed more neurotic traits than engaged
gamers, and Li and colleagues [40] found that the “online
game addiction”group in their study showed higher neuroti-
cism scores than the other participants who were not addicted
Tabl e 1 Personality traits and disorders associated with IGD in the research (2007–2016)
Neuroticism (Big Five dimension) describes an overall vulnerability to unpleasant feelings such as anxiety, sadness, nervousness, and a tendency to
worry. It is associated with a predisposition to experiencing negative affects, so that neurotic people react worse to stressors and interpret ordinary
situations as intimidating and minor frustrations as hopelessly difficult.
Openness to experience (Big Five dimension) describes a tendency toward curiosity, creativity, and preference for novelty and variety. People who are
open to experience are intellectually curious, appreciative of art, and sensitive to beauty. They also tend to be more aware of their feelings than closed
people.
Conscientiousness (Big Five dimension) is a tendency to show self-discipline and to act dutifully. People who are high in conscientiousness rely on
organization, tend to work hard, and take a methodical approach to achieving their goals. They are also willing to spend a great amount of time and
effort to succeed.
Extraversion (Big Five dimension) is characterized by the presence of energy, positive emotions, sociability, assertiveness, and the tendency to seek
stimulation in the company of others. Extroverted individuals tend to prefer to be in the presence of other people, and they sometimes engage in
thrill-seeking behavior.
Agreeableness (Big Five dimension) describes a tendency to be cooperative toward others rather than suspicious and antagonistic. People who are
agreeable are also empathetic and altruistic. They tend to seek the best in everyone and they prove to be generous, dependable, honest, and concerned
about the well-being of others.
Sociability is a component of extraversion. It describes the ability to be fond of the company of others. Sociable people are inclined to seek out the
opportunity to have social contact with others. People high in this trait usually communicate their ideas well, are skilled in social interactions, and are
able to resolve conflicts.
Cooperativeness is a component of agreeableness. It concerns the degree to which a person is generally agreeable in his or her relations withother people.
People who are cooperative usually show high empathy and social tolerance, and they are ready to share with others a common purpose.
Self-directedness refers to self-determination. It is positively associated with conscientiousness and is inversely related to neuroticism. It represents the
ability to regulate and adapt one’s own behaviors in order to achieve personal goals. Self-directedness is also conceptually related to locus of control,
so that low self-directedness is associated with external locus of control, whereas high self-directedness is associated with internal locus of control.
Impulsivity is a multifactorial construct that involves a tendency to display behavior characterized by little or no reflection, forethought, and/or
consideration of the consequences. It can be conceived as a combination of distinct psychological components that are strictly related to the
overarching dimension of impulsivity, such as urgency (the tendency to experience strong reactions, frequently in situations of negative affect), lack of
premeditation (the tendency to disregard the consequences of an act before engaging in that action), lack of perseverance (a difficulty remaining
focused on goal achievements), and sensation seeking (a tendency to pursue sensory pleasure and excitement, by the readiness to take risks). Other
multifactorial models of impulsivity have highlighted the components of cognitive impulsiveness (the inability to focus on tasks), motor
impulsiveness (acting on the spur of the moment), non-planning (acting without self-control), or the difference between functional impulsivity (a
tendency to make quick in times when this cognitive style is beneficial for decisions) and dysfunctional impulsivity (a tendency to act with less
forethought and an inability to both delay gratification and to control one’s own behavior despite the negative consequences).
Self-regulation describes the ability to control impulses, thoughts, feelings, and behaviors. This ability allows individuals to manage and adaptively
respond on emotional and cognitive levels to changes in external and internal stimuli.
Aggressiveness describes the tendency to harm oneself, other persons, or objects. It is often related to impulsivity and feelings such as anger, hate, and
inferiority. Aggressive people are more likely to engage in violent behaviors.
Interpersonal dependency describes how affective responses, cognition, motivation, and actual patterns of behavior are affected by relationships to
others, and how people relate with others.
Narcissism describes a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. Narcissistic people have an
excessive need for admiration by others, and a sense of superiority and entitlement, so that they tend to consider themselves better than others, to
exaggerate their skills, to excessively praise their successes, and to expect special treatment by others.
Cluster C personality disorders (DSM-5 mental disorders) include the avoidant, dependent, and obsessive-compulsive personality disorders. These three
personality disorders share pervasive patterns of inflexible thoughts and behaviors resulting in social awkwardness and social withdrawal due to
unprocessed feelings of inadequacy and relational fears.
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Tab l e 2 Empirical studies examining the relationship between personality and Internet gaming disorder
First author Sample
N
Sample characteristics Mean age Country Personality
variables
IGD measure Personality
measure
Relationships between IGD and personality
variables (main findings)
Billieux (2011)
[30]
54 Regular player of MMORPGs (100%
males)
23.43
(SD = 5.08)
Switzerland Impulsivity IAT UPPS-P Associations. High urgency was the only facet of
impulsivity that significantly predicted
problematic engagement in MMORPGs
(β= .45, p< .01).
Billieux (2015) [8] 1057 Online gamers (87.7% males, 12.3%
females)
26.01
(SD = 7.96)
France,
Switzerland,
Belgium
(2.46% other
countries)
Impulsivity IAT UPPS-P Differences between groups. Differences among
problematic gamers found. Unregulated
escapers: high impulsivity and low sensation
seeking; Unregulated achievers: high on all
impulsivity facets; Hardcore gamers: high
levels of sensation seeking and the urgency
dimension of impulsivity, but also high
perseverance and high premeditation.
Sensation seeking
Blinka (2016) [31] 1463 Online gamers (90.8% males, 9.2%
females)
24.40
(SD = 6.48)
Czech Republic
and Slovak
Impulsivity AEQ DII Associations. Dysfunctional impulsivity
positively predicted IGD scores (β=.25).
Braun (2016) [32] 2891 Adults (83.7% males, 16.3% females)
(78% gamers,16% gaming addicts, 6%
non-gamers)
23.20
(SD = 5.99)
Online survey Neuroticism AICA-S
gaming
BFI-S Associations. IGD scores positively correlated
with neuroticism (r= .12), and negatively
correlated with extraversion (r=−.14) and
conscientiousness (r=−.25).
Extraversion
Conscientiousness
Agreeableness Differences between group. Higher neuroticism
and lower extraversion in gaming addicts.
Higher neuroticism in gaming addicts and
non-gamers. No significant differences
between non-gamers, regular gamers, and
gaming addicts for agreeableness.
Choi (2014) [33] 60 Patients and controls 25% Internet gaming
disorder, 25% gambling disorder, 25%
alcohol use disorder, 25% healthy
controls
20.80
(SD = 5.09)
South Korea Impulsivity IAT BIS-11 Differences between groups. Total impulsivity
scores higher in IGD and alcohol use disorder
groups than in other groups. Cognitive
impulsivity lower in the IGD group than that in
the gambling disorder group, but motor and
non-planning impulsivity higher in the IGD and
alcohol use disorder groups than in the
gambling disorder group.
Cole (2013) [21] 163 Adult online gamers (56.4% males, 40%
females, 3.6% unreported)
27.3
(SD = 9.1)
Online survey Neuroticism GPIUS NEO-PI-R Differences between groups. MMO gamers
showed more neuroticism and less extraversion
and conscientiousness than other participants in
the study.
Extraversion
Conscientiousness
Collins (2012) [22] 225 Adults (57.3% males, 42.7% females) 10%
problematic MMORPG player, 19%
non-problematic MMORPG players,
71% non-players
26.55
(SD = 9.48)
UK Agreeableness PVP IPIP Differences between groups. Self-regulation,
dysfunctional impulsivity, and agreeableness
decreased in problematic MMORPG players
compared to non-problematic gamers. Physical
and verbal aggression increased in problematic
MMORPGs players, while impulsivity,
functional impulsivity, and agreeableness
scores were lower in the same problematic
players compared to non-players.
Aggression GME
Impulsivity BPAS
Self-regulation DII-S
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Tab l e 2 (continued)
First author Sample
N
Sample characteristics Mean age Country Personality
variables
IGD measure Personality
measure
Relationships between IGD and personality
variables (main findings)
Collins (2013) [34] 416 Adults (62.5% males, 37.5% females) 65%
non-problematic video game players,
18% problematic video game players,
17% non-gamers
27.3 years
(SD = 8.48)
UK, USA,
Australia,
Spain
(17.9% other
countries)
Extraversion GAS EPQ-R-S Differences between groups. No significant
differences across groups (non-problematic
video game players, problematic video game
players, and non-gamers) in extraversion.
Festl (2012) [35] 4382 Online gamers (13% adolescents, 43%
young adults, 44% adults)
37.8
(SD = 9.80)
Germany Sociability GAS GSE Differences between groups. Sociability decreased
and aggressive tendencies increased among
adolescents with problematic game use.
Aggression AQ
Gentile (2011) [2] 2998 Children and adolescent students (72.7%
males, 27.3% females) 48% in primary
schools, 52% in secondary schools
11.2
(SD = 2.06)
Singapore Impulsivity PVG BIS-11 Associations. A longitudinal growth model
showed that increased impulsivity fostered the
development, maintenance, and worsening of
pathological gaming among participants.
Jiménez-Murcia
(2014) [36]
193 Gambling disorder patients (86.5% males,
13.5% females): 62.69% non-video
game users; 22.27% video game users;
15.04% video game addicts
42.4
(SD = 13.4)
Spain Self-directedness VDT TCI Differences between groups. Self-directedness
decreased among video game users and video
game addicts.
Associations. Lower self-directedness scores
uniquely predicted IGD scores (β=−.97,
p<.01).
Khazaal (2016)
[23•]
5983 Young adults (55.5% French-speaking,
44.5% German-speaking)
20.0
(SD = 1.2)
Switzerland Neuroticism GAS ZKPQ-50-cc Associations. IGD scores were positively
associated with neuroticism (r=.24)and
negatively associated with sociability
(r=−.20) in the French-speaking community.
In the German-speaking community, IGD
scores were positively associated with
neuroticism (r= .23) and aggression (r=.15)
and negatively associated with sociability
(r=−.10). No significant associations were
found between sensation seeking and IGD
scores.
Sociability BSSS
Aggression
Sensation seeking
Kim (2008) [37] 1471 Online gamers (82.7% males,17.3%
females)
21.30
(SD = 4.96)
South Korea Narcissism GAS NPDS Associations. Narcissistic personality traits
(β= .19, p< .001) and aggressiveness
(β= .16, p< .001) positively predicted IGD
scores.
Aggressiveness
Lehenbauer-Baum
(2014) [38]
577 Online gamers (77.1% males, 22.9%
females)
24.38
(SD = 1.89)
Germany,
Austria,
Switzerland
Agreeableness WoW
questionnaire
BFI-10 Differences between groups. Significant
differences between addicted and engaged
players, with addicted players reporting higher
scores on agreeableness and conscientiousness.
Conscientiousness
Lehenbauer-Baum
(2015) [39]
682 Online gamers (84.9% males, 15.1%
females)
23.26
(SD = 5.98)
Germany,
Austria,
Switzerland
Neuroticism GAS BFI-10 Differences between groups. Addicted gamers
reported lower scores than engaged gamers on
agreeableness, conscientiousness, and
neuroticism.
Agreeableness
Conscientiousness WoW
questionnaire
Li (2016) [40] 654 Students (45.6% males, 54.4% females)
4.8% addict gamers, 95.2% non-addict
gamers
20.29
(SD = 1.39)
China Neuroticism OGCAS EPQ-RS Differences between groups. The IGD group
scored higher on neuroticism than other
participants.
CIAS
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Tab l e 2 (continued)
First author Sample
N
Sample characteristics Mean age Country Personality
variables
IGD measure Personality
measure
Relationships between IGD and personality
variables (main findings)
Martín-Fernández
(2016) [41••]
59 Patients (96.6% males, 3.4% females) 14.83
(SD = 1.45)
Spain Cluster C
personality
Clinical
interview
Kiddie-sads Descriptive. 11% of those with a diagnosis of
Internet gaming disorder showed Cluster C
personality disorders in comorbidity.
Mehroof (2010)
[19]
123 Students (58.5% males, 41.5% females) 21.95
(SD = 4.1)
UK Neuroticism GAS SCS Associations. Sensation seeking (β=1.04,
p< .001), neuroticism (β=2.04p< .01), and
aggression (β=.21;p< .01) positively
predicted IGD scores.
Sensation seeking BPAQ
Aggression AISS
EPQ-R-S
Montag (2011)
[20••]
610 Online gamers—students (97% males, 3%
females)
19.32
(SD = 4.40)
Germany Neuroticism IAT NEO-FFI Associations. IGD scores were positively
correlated with neuroticism (r= .33) and
aggression (r= .30) and were negatively
correlated with extraversion (r=−.15),
openness to experience (r=−.12),
agreeableness (r=−.27), conscientiousness
(r=−.35), self-directedness (r=−.48), and
cooperativeness (r=−.30, p<.01).
Participants with IGD showed higher
self-directedness (β=−.32; p< .01) and
lower consciousness (β=−12; p<.01) than
the other participants.
Extraversion TCI
Openness to
experience
ANPS
Agreeableness
Conscientiousness
Cooperativeness
Aggression
Self-directedness
Müller (2014) [42] 404 Adolescent and young adult men (Internet
gaming disorder group 28.46%; clinical
control group 18.31%; pathological
gambling group 30.19%; non-clinical
control group 23.04%)
22.90
(SD = 6.13)
Germany Neuroticism AICA-S NEO-FFI Differences between groups. The IGD group
showed higher neuroticism and openness to
experiences, and lower conscientiousness and
extraversion than the other groups.
Extraversion
Conscientiousness
Openness to
experiences
Associations. Neuroticism (β=.25,p< .001)
and conscientiousness (β=−.39; p< .001)
predicted IGD scores.
Müller (2016)
[43•]
699 Adults (97.9% males, 2.1% females)
(Internet addiction group 32.49%;
gambling disorder group 33.33%;
control group 20.35%; specific control
group for Internet addiction 13.83%)
26.0
(SD = 8.69)
Germany Sensation seeking AICA-C SSS-V Differences between groups. Addicted gamers and
gamblers reported lower scores in sensation
seeking.
AICA-S
Nuyens (2016)
[44]
36 Online gamers (84% males, 16% females) 21.35
(SD = 1.89)
Belgium Impulsivity POGQ UPPS-P Associations. Cognitive impulsivity (and no other
impulsivity dimensions) was associated with
IGD preoccupation (r= .41) and immersion
scores (r=.33).
BIS-11
Peters (2008) [45] 196 Online gamers (88.3% males, 11.7%
females)
24.34
(SD = 5.36)
USA Agreeableness WoW NEO-PI-R Associations. IGD scores were negatively
correlated with agreeableness (r=−.30),
positively correlated with neuroticism
(r= .38), and low negatively correlated with
extraversion (r=−.24) and with
conscientiousness (N=145,r=−.289,
p< .001).
Neuroticism AEQ
Extraversion
Conscientiousness
Škarupovà (2016)
[46••]
6730 Online gamers (93.5% males, 6.5%
females)
20.81
(SD = 5.95)
Czech Republic
and Slovak
Interpersonal
dependency
AEQ RPT Associations. Destructive overdependence
(β= .17, p< .01) and dysfunctional
detachment (β= .17, p< .01) positively
predicted IGD scores, while
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Tab l e 2 (continued)
First author Sample
N
Sample characteristics Mean age Country Personality
variables
IGD measure Personality
measure
Relationships between IGD and personality
variables (main findings)
healthy-dependency personality (β=−.13,
p< .01) negatively predicted IGD scores.
Vollmer (2014)
[47]
741 Adolescents (60.2% males, 39.8%
females)
12.89
(SD = 1.05)
Turkey Agreeableness CGA BFI-10 Associations. Extraversion (β=−.10, p< .005)
and agreeableness (β=−15, p< .001)
negatively predicted IGD scores.
Neuroticism
Walther (2012)
[48]
2553 Adolescents and young adults (50.7%
males, 49.3% females)
Not reported
(age
between 12
and
25 years
old)
Germany Impulsivity KFN-CSAS-II IVE Associations. Problematic computer gaming was
associated with higher irritability/aggression
(OR = 1.64) and higher impulsivity (OR 1.79).
Aggression SBB-SSV
Wang (2015) [49] 920 Students (36.6% males, 63.4% females) 15.5
(SD = 1.5)
China Openness IAT BFI-10 Associations. Conscientiousness (β=−.09,
p< .01) and openness to experiences
(β=−.06, p< .05) negatively predicted
Internet gaming disorder scores. No significant
associations found between neuroticism and
IGD scores.
Conscientiousness GAS
Personality measure
AISS Arnett Inventory of Sensation Seeking, ANPS Affective Neuroscience Personality Questionnaire, AQ Aggression Questionnaire, BFI-10 Big Five Inventory with 10 items, BFI-S Big Five Inventory-
Socio Economic Panel, BIS-11 Barratt Impulsiveness Scale, BPAQ Buss-Perry Aggression Questionnaire, BPAS Buss-Perry Aggression Scale, BSSS Brief Sensation Seeking Scale, DII Dickman’s
Impulsivity Inventory, DII-S Dickman’s Impulsivity Inventory Short, EPQ-R-S Eysenck Personality Questionnaire Revised Short Scale, GME Grossarth-Maticek and Eysenck’s, GSE General Self-
Efficacy Expectations Scale, IPIP International Personality Item Pool Big Five Factor Markers questionnaire, IVE Inventory of Impulsivity, Risk Behaviour and Empathy, Kiddie-sad Kiddie-sad present
andlifetimeinterview,NEO-FFI NEO Five-Factor Inventory, NEO-PI-R Revised NEO Personality Inventory, NPDS Narcissistic Personality Disorder Scale, RPT Relationship Profile Test, SBB-SSV
Rating Scale for Oppositional Defiant/Conduct Disorders, SCS Self-Control Scale, SRS Self-Regulation Scale, SSS-V Sensation Seeking Scale-FormV, TCI Temperament and Character Inventory, TCIR
Temperament and Character Inventory-Revised, UPPS-P Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency, ZKPQ-50-cc Zuckerman-Kulhman Personality Questionnaire-50-
CC
IGD measure
AEQ Addiction-Engagement Questionnaire, AICA-C Checklist for the Assessment of Internet and Computer Game Addiction, AICA-S gaming Scale for the Assessment of Internet and Computer Game
Addiction, AICA-S Scale for the Assessment of Pathological Computer Gaming, CGA Computer Game Addiction, GAS Game Addiction Scale, GPIUS Generalized Pathological Internet Use Scale, CIAS
Chinese Internet Addiction Scale, IAT Internet Addiction Test, KFN-CSAS-II Video Game Dependency Scale, OGCAS Online Game Cognitive Addiction Scale, POGQ Problematic Online Game
Questionnaire, PVG Pathological Video Game Use, PVP Problem Video Game Playing Scale, VDT Test de Dependencia de Videojuegos
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to online gaming. In contrast to the majority of the studies, in
which neuroticism was a positive predictor of IGD, two other
major studies reported small or even non-significant associa-
tions between IGD scores and neuroticism. Braun and col-
leagues [32] examined the personality characteristics and
IGD symptoms of gaming addicts, regular gamers, and non-
gamers. They found a positive but weak association between
IGD scores and neuroticism, and an analysis of variance sur-
prisingly showed that non-gamers and gaming addicts had the
highest scores for neuroticism compared to regular gamers.
Wang and colleagues [49] found that neuroticism was not
significantly associated with gaming addiction in a study ex-
amining addictive behaviors in relation to different online ac-
tivities among adolescents.
The findings on the relationships between the other Big
Five domains and IGD symptoms were mixed. In their already
mentioned study, Montag and colleagues [20••] found that
IGD scores were negatively associated with extraversion,
openness to experience, agreeableness, and conscientious-
ness, with low conscientiousness emerging in regression
models as a significant predictor of Internet addiction scores
among gamers. In the study by Wang and colleagues [49], low
conscientiousness and low openness to experiences were sig-
nificantly associated with gaming addiction. Müller and col-
leagues [42] found instead that participants displaying IGD
showed lower extraversion and conscientiousness but higher
openness to experience compared to the pathological gam-
bling group. However, in Müller and colleagues’study, only
low conscientiousness and high neuroticism predicted the
scores for Internet and gaming addiction. Braun and col-
leagues’study [32] suggested that gender differences may
help understand these conflicting results: they found in a
German adult sample that openness to experiences statistically
interacted with gender, so that male gamers showed lower
openness to experience than non-gamers, whereas female
gamers showed significantly higher scores for openness to
experience than non-gamers. Also, in their study, excessive
gamers reported significantly lower scores on extraversion
and conscientiousness than non-gamers and regular gamers,
while they did not find significant differences between non-
gamers, regular gamers, and excessive gamers for agreeable-
ness. Yet, Collins and colleagues [22] found that agreeable-
ness decreased in problematic MMORPG players with respect
to both non-problematic MMORPG players and non-players,
and Vollmer and colleagues [47] found that agreeableness,
together with extraversion, negatively predicted online gam-
ing addiction scores in a sample of adolescents. Also, Peters
and Malesky [45] found in a sample of players of World of
Warcraft low to moderate negative correlations between on-
line gaming addiction scores and agreeableness, conscien-
tiousness, and extraversion, and Lehenbauer-Baum and col-
leagues [39] found that addicted gamers reported lower scores
in comparison to healthy-engaged gamers [50]inthe
dimensions of agreeableness and conscientiousness.
However, a year before this, Lehenbauer-Baum and
Fohringer [38] published another study in which an opposite
pattern of associations emerged, with addicted players show-
ing higher rather than lower scores inthe dimensions of agree-
ableness and conscientiousness. In this context, two other
studies are relevant: Cole and Hooley [21] found that gamers
with higher IGD symptoms scored lower on conscientious-
ness and extraversion than their counterparts, who did not
show significant IGD symptoms. Conversely, Collins and col-
leagues [34] did not find significant differences among three
groups of adolescents (non-problematic video game players,
problematic video game players, and non-gamers) with re-
spect to extraversion.
Sociability, Self-Directedness, and Cooperativeness
Several personality features have been explored in relation to
IGD. Some of these personality features can be conceived as
specific traits within the Big Five model of personality, and
among these are sociability, cooperativeness, and self-
directedness.
In the study by Montag and colleagues [21], Internet ad-
diction scores among gamers were negatively correlated with
both self-directedness and cooperativeness, with low self-
directedness explaining most of the variance in Internet addic-
tion scores. Festl and colleagues [35] found among German
adolescent gamers that social competence and social integra-
tion were negatively related to game addiction scores, with
low sociability specifically linked to problematic gaming.
Likewise, Khazaal and colleagues [23•] found a negative as-
sociation between sociability and gaming problems. Finally,
Jiménez-Murcia and colleagues [36] found in a group of video
game users and video game abusers that low levels of self-
directedness uniquely predicted IGD scores.
Impulsivity and Sensation Seeking
Several studies [8,22,27,31,33] showed that there are sig-
nificant overlaps between personality dimensions and impul-
sivity components. For example, the urgency component and
the inability to delay gratification are related to neuroticism;
lack of premeditation, lack of perseverance, and dysfunctional
impulsivity are related to low consciousness; moreover, sen-
sation seeking and dysfunctional impulsivity are also connect-
ed with extraversion. The findings on the relationship between
impulsivity and IGD suggest that specific facets of impulsivity
maybelinkedwithIGD.
Among the few findings against this assertion, the prob-
lematic group of MMORPG players in Collins and col-
leagues’[22] study scored significantly lower in dysfunctional
impulsivity than non-problematic MMORPG players and
even non-players. Conversely, Blinka and colleagues [31]
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found a moderate and positive association between dysfunc-
tional impulsivity and online gaming addiction scores in a
large sample of MMO gamers. In their study, regression anal-
yses showed that dysfunctional impulsivity was a significant
predictor of gaming addiction. Similarly, in a previous study
examining the psychological predictors of problematic in-
volvement in MMORPGs, Billieux and colleagues [30]found
that high urgency was a significant predictor of problematic
engagement in the game. Moreover, in another study, Billieux
and colleagues [8]examinedalargesampleofonlinegamers,
and found that impulsivity was related to problematic gaming.
They identified through cluster analysis three subtypes of
problematic online gamers: unregulated escapers were charac-
terized by high impulsive traits but low levels of sensation
seeking; unregulated achievers were high on all impulsivity
facets (urgency, lack of premeditation, lack of perseverance,
sensation seeking); hardcore gamers showed a contrasting but
interesting profile characterized by high levels of sensation
seeking and urgency and at the same time high levels of pre-
meditation and perseverance. Nuyens and colleagues [44]ex-
plored impulsivity in multiplayer online battle arena (MOBA)
gamers and found that cognitive impulsivity was associated
with problematic online gaming. Previously, Choi and col-
leagues [33] examined differences in impulsivity among indi-
viduals diagnosed with IGD, gambling disorder (GD), alcohol
use disorder (AUD), and controls. The IGD and AUD groups
scored significantly higher on total impulsivity than the other
groups, with increased scores in motor and non-planning im-
pulsivity among Internet gamers further explaining the differ-
ences between patients with IGD and pathological gamblers.
Also, Walther and colleagues [48] found in a large sample of
students that high levels of impulsivity consistently predicted
IGD. However, stronger evidence for the relationship between
impulsivity and IGD is a 2-year prospective study by Gentile
and colleagues [2••], who showed through a 2-year longitudi-
nal study that high impulsivity is a risk factor for becoming a
pathological gamer among children and adolescent students.
Sensation seeking is a personality feature that has been
clearly linked with impulsivity [27], but it is often studied as
a stand-alone construct in research. In Mehroof and Griffiths’
[19] study, sensation seeking showed a predictive association
with online gaming addiction scores among students. In con-
trast, Muller and colleagues [43•] compared patients with
gambling disorder, patients with IGD, and healthy controls,
and they found that sensation seeking was surprisingly lower
in addicted gamers and pathological gamblers than in controls.
Moreover, the study by Khazaal and colleagues [23•] did not
show significant associations between gaming addiction
scores and sensation seeking. However, with respect to these
latter studies, it may be useful to observe that the measures
used to assess sensation seeking may not be particularly ap-
propriate for IGD research, as the used scales were developed
to address the more action-based component of sensation
seeking (e.g., through extreme sports) rather than the compo-
nent of psychological and sensory excitement, which may be
more relevant to Internet gamers.
Self-Regulation and Aggressiveness
As already mentioned, personality dimensions and traits may
be closely related and sometimes overlap [51]. As such, im-
pulsivity and sensation seeking show positive relationships
with aggressiveness and low capacities for self-regulation
[52]. In fact, people who are highly impulsive often fail to
regulate painful or otherwise negative feelings, and some of
them are also prone to a host of high-risk behaviors character-
ized by poor self-control and by elements of aggressiveness
[53].
Collins and colleagues [22] found that aggressiveness cor-
related positively with scores on problematic video gaming.
Moreover, in their study, the problematic group of gamers
showed significantly lower scores in self-regulation than the
non-problematic group and scored significantly higher in
physical aggression and verbal aggression than non-players.
Also, Mehroof and Griffiths [19] showed that aggressiveness
was a good predictor of online video game addiction.
Similarly, the study of Kim and colleagues [37] on online
game users suggested that IGD could be predicted on the basis
of higher aggressiveness scores. Walther and colleagues [48]
also found that high levels of aggressiveness predicted IGD,
and Montag and colleagues [21]found positive associations
between Internet addiction scores and aggressiveness among
first-person shooter video game players. Moreover, Festl and
colleagues [35] found among German gamers that problemat-
ic game use was associated with aggressive tendencies
(whether physical or anger-related), and Khazaal and col-
leagues [23•] found a significant, albeit weaker, association
between gaming addiction scores and aggressiveness.
Other Personality-Related Constructs
The results obtained from systematic review showed that other
personality-related constructs, such as interpersonal depen-
dency, narcissism, and personality disorders, may play a piv-
otal role in the acquisition, development, and maintenance of
IGD.
Škarupová and Blinka [46••] showed in relation a large
sample of online gamers that IGD scores were negatively
associated with healthy dependency, whereas the associations
between IGD and the negative dimensions of interpersonal
dependency—destructive overdependence and dysfunctional
detachment—were positive.
A study by Kim and colleagues [37] explored the relation-
ship between online game addiction and narcissistic personal-
ity traits in a sample of MMORPG players. In this study,
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higher narcissistic personality traits predicted the severity of
online game addiction.
Finally, we found only one article that examined the rela-
tionship between IGD and diagnosed personality disorders.
Martin-Fernandez and colleagues [41••] described the profiles
of 59 Spanish patients from a hospital unit. Of these patients,
11% presented comorbidity with cluster C (including
avoidant, dependent, and obsessive) personality disorders.
Discussion
This systematic review illustrated the associations between
personality features and IGD. The relationship between IGD
symptoms and the Big Five model of personality has been
extensively investigated, and this model has been considered
of particular relevance for the understanding of the online
game addiction process [37]. Regarding neuroticism, the find-
ings are quite consistent and mirror results of research on
problematic Internet use, suggesting that a high level of neu-
roticism is involved in a maladaptive use of the Internet [19,
20••,40,49]. For people who are high in this personality trait,
it is possible to conceptualize problematic online gaming as a
maladaptive coping strategy that may serve to reduce tension
(i.e., as a mood modifier) [43•,51] and/or to overcome nega-
tive life events [54–59].
With respect to the other Big Five domains, low agreeable-
ness seems to also play a relevant role in IGD. This finding is
consistent with considerations reported by many scholars [10,
20••,36,42] that decreased agreeableness indicates a higher
tendency toward competition than toward cooperation.
Computer games often demand high competitiveness to
achieve game success, which might reinforce the gaming be-
havior. However, in some games such as MMORPGs, it is
also crucial to cooperate with others. Thus, findings of the
studies linking agreeableness to IGD should be observed in
relation to their related results on extraversion. In fact, the
effects of decreased agreeableness might be regarded in the
same light as decreased extraversion for the development of
problematic Internet gaming. Perhaps, as a consequence of
impaired social participation in the real world, some gamers
might become aware of other people creating distance.
Lacking close social boundaries could motivate the gamer to
search for social contacts in virtual environments. Moreover,
less extroverted people may compensate for loneliness
through activities such as playing computer games, but they
may also use games to express themselves and their feelings
better in a controlled virtual context that allows them to main-
tain the desired distance from other people. Thus, despite the
fact that several studies [19,20••,42]havehypothesizedthat
introverted people usually have a poorer social network and
experience more rejection by peers, there are studies [22,34]
in which no significant differences in extraversion emerged
between players and non-players.
Likewise, several studies [21,42,45,49] discussed how
people scoring low on conscientiousness are less persistent in
pursuing personal aims and often show difficulties organizing
their activities. If gamers with these characteristics find the
environments of computer games particularly attractive, they
might be at greater risk of developing IGD-related problems,
as they do not pay much attention to the duties of everyday
life. Other studies underline that addictive use of gaming may
be influenced by low openness to experience. It might be that
gamers with low openness to experience tend to stick to their
gaming behavior instead of exploring new activities, thus
making low openness to experience even more important for
the maintenance of IGD than for the onset of IGD [20••,49].
All these considerations may explain results concerning
lower levels of sociability, self-directedness, and cooperative-
ness in IGD, which can also result in lower expectations of
self-efficacy, lower life satisfaction, less perceived social sup-
port, and increased feelings of anger as potential conse-
quences [20••,23•,35,36].
In this respect, understanding the role of impulsivity in
online gaming may be an important contribution to the con-
ceptualization of IGD. Literature focusing on addictive behav-
iors suggest that addiction is strictly related to high impulsiv-
ity [59], and the examined studies showed that both impulsiv-
ity and sensation seeking are related to problematic gaming in
some samples [2••,8,31,33,36,44]. The most important
study in this field is that of Gentile and colleagues [2••],
who showed with longitudinal data that impulsivity combined
with other significant risk factors (such as high amount of
gaming, depression, anxiety, and low social competence) in-
creased the risk of pathological gaming, but also that, in a
vicious circle, pathological gaming increased impulsivity
across time. However, despite most of the studies [31,33,
44] showing that higher impulsivity increases the risk of de-
veloping symptoms of IGD, impulsivity is a broad construct,
so it is likely that specific components of impulsivity, such as
high urgency [8], are more relevant for understanding IGD. In
fact, Collins’study [22] found decreased dysfunctional impul-
sivity among gamers; Billieux et al. [8,30]showedthatspe-
cific components of impulsivity may be linked at different
levels to different profiles of problematic gaming. Moreover,
findings on sensation seeking are highly inconsistent, suggest-
ing that problematic gaming may be related to both high [19]
and low [43•] levels of sensation seeking, or may even be
unrelated to such a construct [23•]. A possible explanation
of these conflicting findings is that people who display prob-
lematic gaming have diverse psychological profiles, also with
respect to impulsivity facets [8]. For example, impulsive peo-
ple are very unlikely to excel at some games such as
MMORPGs, and in fact, impulsivity may limit their enjoy-
ment as it may be detrimental to achievement in the game;
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however, other players high in impulsiveness may find it en-
joyable to excessively play in order to overcome their bore-
dom and/or to feel psychologically or physiologically stimu-
lated [60]. In sum, research findings highlight that impulsivity
and its facets are probably involved with IGD, but their spe-
cific contributions need further research.
A difficulty with self-regulation could be a general trait that
increases the risk of developing an IGD [61]. Limited self-
regulation abilities often foster compensatory strategies that
allow the individual to cope (albeit dysfunctionally) with neg-
ative affect [55]; in fact, some researchers have proposed that
excessive gaming might be a coping strategy to deal with
temporary or persistent emotional distress [54,56,57,61].
Aggressive tendencies (whether physical or anger-related)
seem also to be linked to IGD. In this respect, there is a quite
high degree of agreement among the studies [19,20••,22,35,
37,47,62]. In fact, research has shown a link between exces-
sive gaming and a liking for game violence [63–65].
However, the directionality and origins of aggression are not
revealed in the examined study. Also, considering the fact that
low agreeableness, low self-directedness, and low self-
regulation seem also to be involved in IGD, it is possible that
more aggressive players can engage in specific online games
(e.g., first-person shooter games) to express, in the safe con-
text of a virtual world, their aggressive impulses without
harming anyone.
A unique finding has emerged from Škarupová and
Blinka’s study [46••], in which the authors suggested that
the negativetraits of destructive overdependence and dysfunc-
tional detachment may predispose some individuals toward
developing addictive use of video games. This finding ex-
pands the literature on IGD and on interpersonal dependency
as a trait [66,67]. The concept of interpersonal dependency is
to some extent similar to the concept of attachment [68], an
inborn motivational system that steers an individual’s attitude
toward a desire for close relationships. Attachment styles have
indeed shown significant associations with problematic
Internet use [59]. In the case of IGD, it is possible that indi-
viduals with problematic interpersonal dependency seek an
escape toward a more detached social environment (dysfunc-
tional detachment), or, on the contrary, they may constantly
seek the social support and recognition of fellow gamers (de-
structive overdependence).
Finally, it is no surprise that the few people with both per-
sonality disorders and IGD observed in Martin-Fernandez and
colleagues’[41••] study displayed mainly Cluster C personal-
ity disorders (avoidant, dependent, or obsessive-compulsive
personality disorders), as Cluster C disorders reflect many
personality traits already discussed, e.g., low extraversion is
a characteristic of avoidant personality, overdependence is a
characteristic of dependent personality, and low openness to
experience is a characteristic of obsessive-compulsive person-
ality. Furthermore, narcissistic personality traits showed
positive associations with IGD [37]. This finding seems to
be inconsistent with a previous report by Niemz and col-
leagues [69], who found that low self-esteem and a negative
evaluation of the self were good predictors of generalized
problematic Internet use and the amount of time spent online.
Moreover, the unique characteristics of MMORPGs may ex-
plain Kim and colleagues’[53] findings of a positive relation-
ship between narcissistic traits and IGD. In MMORPGs,
leveling-up and getting items, recognition, and admiration
from other players could be major attractions for many players
[70]. Thus, for some people with increased narcissistic per-
sonality traits, playing MMORPGs can be reinforcing because
it may bolster self-esteem and provide status and respect.
Limitations of Current Studies and Future
Directions
The results of this review should be considered in light of
limitations of the examined studies. The first limitation relates
to the paucity of studies on IGD as a specific construct, which
did not allow us to disentangle the different conceptualizations
of IGD and the differences in the measurement of both IGD
and personality traits in the various studies. The second limi-
tation is that most of the studies described in this review are
correlational and/or did not control for multiple comparisons,
which strongly limit the possibility ofestablishing causal links
between specific personality traits and IGD. A third problem
arises when considering the age of participants and the com-
position of the samples. Many studies focused on male ado-
lescents and young adults, and often no controls for age, were
applied in the study, which limits the generalizability of our
review to adult people and patients suffering from IGD. A
fourth limitation is that there are clear discrepancies between
the types of gamers in the different studies (e.g., MMORPG
gamers, MOBA gamers, first-person shooter gamers), and
these discrepancies may account for different findings, as dif-
ferent games may attract different types of people with differ-
ent personality characteristics. Finally, although research into
online gaming has steadily increased over the last decade, as
yet, there are few longitudinal studies and studies specifically
examining the relationship between IGD and personality
disorders.
It is also important to note here that our review may be
limited in the following aspects. First, we decided to review
empirical articles published after 2006. This decision likely
allowed us to collect and discuss contemporary research in a
more reliable and valid fashion, but it might also have caused
us to dismiss previous relevant findings, even though we con-
sidered the literature before 2007 in writing our article.
Second, even though we conducted both an electronic and a
manual search to identify relevant articles, it is possible that
other relevant articles have been missed because they were not
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indexed with the selected keywords in the searched database
and were not identified in the manual search.
However, regardless of the limitations of our review and
others’studies, it is evident that further research is needed to
extend and clarify the findings of the examined studies and to
disentangle the role of personality factors in the development
and maintenance of problematic Internet gaming.
Conclusions
IGD is included as a condition for further study in the DSM-5.
It is a relatively novel topic, in relation to which the research
base is constantly developing. Therefore, it is difficult to draw
any definitive conclusion from this review. The findings of the
studies highlight that IGD is linked to a wide range of person-
ality features, and it emerged that each of these personality
dimensions and traits, alone or more frequently in combina-
tion, may play a pivotal role in the acquisition, development,
and maintenance of IGD. In this respect, future research will
be critical for understanding whether the concept of IGD re-
flects a specific and consistent diagnostic entity [5•], and if so,
which pattern (or patterns) of personality traits maypredispose
to it.
Compliance with Ethical Standards This systematic review is in
compliance with the PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) guidelines for the search, sys-
tematization, and reporting of systematic reviews [25].
Conflict of Interest Dr. Alessia Maria Gervasi, Dr. Luana La Marca,
Antonino Costanzo, Dr. Ugo Pace, Dr. Fanny Guglielmucci, and Dr.
Adriano Schimmenti declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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