What can qualitative research tell us about Gaming Disorder?

Thanks for the revisions! The authors have satisfactorily addressed all issues/suggestions I made point-to-point, and I have no further comments on the protocol.  

Thank you once again for the opportunity to review this revised report. 

I am happy with the revisions that have been made, and impressed in particular with the time and care you have taken to consider their fundamental assumptions and theoretical framework. I think the project has improved greatly as a result of this. 

You may find that the distinction between online and offline games as a way to handle the historical breadth of the material you cover is still too coarse. As you move into the era of MMORPGs running concurrently with simple games and a multitude of game play styles, you might find that the qualitative data itself suggests that different gamers and different gaming/games present a more complex picture than is represented in some of the quantative data. Case studies are excellent for showing this. If this is the case, the field of game studies will of course be most useful.

I don't think anything needs to be revised at this stage, that's a note for the future as you assess the data.

I believe this report is ready for publication / submission.

Thanks for the invitation to review this protocol.

The study showed great endeavor trying to rule out the underlying characteristics of gaming disorder (GD), by synthesizing evidence from case studies. I believe this would help finding some phenomena in GD hindered by the group level studies and provide important insights for the diagnosis and intervention of GD, on an individual level.

Overall, the protocol appears thorough and well-planned, with clear objectives and methods. Below are some comments that I hope could help the authors to improve the study:

1. The introduction mentions pivotal theories such as the "Coping model," "Value fulfillment theory," and "Theory of cultural dissonance," but detailed explanations of these frameworks are deferred until much later in the document (lines 269~278). This delayed exposition disrupts the narrative flow and may confuse readers unfamiliar with these concepts. It would be beneficial to integrate a concise overview of these theories early in the introduction to anchor the subsequent analysis and discussion. 

2. The protocol acknowledges the role of culture in GD; however, the discussion on cultural impacts seems to be limited to cultural dissonance. For instance, Olson et al. (2022) highlights that cultural tightness and other cultural dimensions significantly influence GD prevalence and societal perceptions. Expanding the discussion to include these aspects could provide a more comprehensive view of how cultural factors shape gaming behavior and disorder manifestations globally. Additionally, explicating how these cultural factors will be assessed or coded in the study could offer a clearer roadmap for analysis.

3. The diversity in game types and their potential differential impact on GD could be considered. There are currently a large variety of games, including but not restrict to: RPG games, MOBA games, strategy games, gambling games, etc. Acknowledging this variety and discussing how the study might consider these differences could enrich the understanding of GD's complexity. This consideration is crucial, as the addictive potential and player engagement mechanisms can vary significantly across game types, influencing the reasons for dependency and the manifestation of disorder symptoms. 

4. While the study employs multiple theoretical frameworks, the operational definitions and criteria for applying these theories to the analysis are vague. A more detailed description of how each theory will be used to interpret data would enhance the protocol's rigor. For instance, specifying indicators or manifestations within the data that would signify alignment with each theoretical model would clarify the analytical process. This precision will help ensure consistency in data interpretation and enhance the study's replicability and validity.

Overall, this protocol is already quite clear and informative. Enhancing theoretical clarity, incorporating broader cultural and game-type considerations, and detailing methodological specifics would substantially strengthen the study's framework and potential impact. 

Thank you for the opportunity to review this report. 

Overall I believe this is an important and timely review, with the potential to illuminate what is a messy but important part of the field of research into (Internet) Gaming Disorder. Some small tweaks to this proposal and the research design could improve the quality of your work. 

I have a number of comments that I hope will be helpful in the preparation of your review, and I will list them according to line number:

61: The DSM has moved to a numbered convention (no longer Roman numerals) I.e. DSM-5-TR

68-70: Not a single problem, but many problems. Not just raised by this author either, this is a consistently raised conceptual issue - I discuss it in my thesis if you're after an overview: https://www.researchgate.net/publication/334670305_Internet_Gaming_Disorder_Fact_or_Fantasy_A_conceptual_analysis_of_a_new_psychiatric_classification​ 

70-71: Meaning unclear, consider re-writing this sentance. 

73-74: There are plenty of sound models, but none are agreed upon (I.e. the problem is a lack of consensus, rather than a lack of models). Perhaps re-word to reflect this.

75-76: This sentance, and actually the whole paragraph needs a re-think. It needs to be linked to your overall theory and the last sentance of the previous paragraph if it's to be included. My suggestion would be to cut the whole paragraph, or to be more clear that you're only giving the reader a 'taster' of the field, because it's a bit cut and paste. 

107: "few would disagree" is an argument by authority (logical fallacy). You can, and have, made the same point without the fallacy, so delete that phrasing and re-word.

126-127: Repeat of previous point about prevalence, which you questioned.

168: Sub-type Internet Gaming Disorder should be included.

180: Would it make greater conceptual sense to constrain your search historically? This is my most substantive feedback. Given the heterogeniety of the data, particulalrly the further you go back, and the changes to games, it seems odd to survey the entireity of the gaming era. I would suggest at the very least constraining to the beginning of the rise of MMOGs and/or the Internet. Otherwise you're comparing apples with pears. Some justifications for the time-period you cover needs to be given. 

186-187: This is going to be very difficult to define. What exactly categorises a gambling game? There are games that are explicitly gambling, yes. But what about games that have gambling tasks at the core of their game play (such as Diablo)? How would you code those? You'll need to have a think about this. 

191-194: I understand this is constrained by your team, however the exclusion of Chinese data might be something you'll have to address.

228: You've included co-morbidity under descriptive data, but it will certainly appear under reported reasons for seeking help. The complex interplay between gaming and co-morbid disorders will be hard to tease out.

237: Consider the therapeutic value of gaming too, to avoid some of the conceptual errors in the current research which frames gaming as inherently negative. 

298: Your epistemological approach appears to be grounded theory, if I'm not incorrect? Perhaps this could be made more explicit?

363: Handle this with care in terms of lived experience accounts. The language of 'informativeness' could suggest that you're ranking the lived experience of gamers and their distress in terms of their usefullness or importance. I understand you'd be making a more grounded point about relationship to theory, so it'd be important to make that very clear in any reports. I hope that point is salient. 

Excellent work so far, and I look forward to reading the final paper. 

I thank the Recommenders and the Authors for the opportunity to review this stage 1 RR.

I compliment the authors for their relevant efforts in addressing the necessity for qualitative syntheses on gaming disorder (GD). Below are some comments and suggestions that the authors could consider when revising the text. I hope that they will be of help in improving its clarity. Best regards.

I like the authors’ idea of reviewing case reports and agree with them that the study has the potential to make an important contribution to the literature as it is described in the text. Case reports can be highly informative and provide evidence not well captured by other study designs. They can be useful to describe and provide evidence on rare conditions and inspire future investigation by more systematic methods. Indeed, they are helpful especially when no other higher level of evidence is available. 

However, they may be affected by important limitations and bias and thus be hardly representative of the condition under study limiting the findings' generalizability. For instance, case reports that are missing/not published could have told a “different story”. Or, differently, case reports that are published might be a minority and published because of their peculiarity. Furthermore, considering inherent bias in case reports caution is needed when it comes to judgments/recommendations resulting from this body of evidence. The above aspects (high risk of selection bias and low certainty of evidence) could be mentioned/discussed in this stage 1 RR. 

The condition/phenomenon or behavior under study needs to be clarified and a definition for “game-related health problems” provided in the introduction. According to my opinion, it is a bit confusing in its current form. Sometimes “gaming disorder” is used (present in the title of the study but not in the abstract), but other times “game-related health problems” is preferred (reading the abstract the focus seems to be gaming activity in general). The meaning of the latter is wider and can include conditions different from gaming disorder, like excessive gaming, postural or eye problems, overweight, etc. Therefore, they should not be taken as being the same (“gaming disorder – or gaming-related health problems more generally”, line 96). Research questions and methods seem in line with a view of gaming disorder and other related conditions as non-pathological. If the main objective of the study is to question/discuss the validity of the concept of gaming disorder this could be better highlighted in the text (considering the authors' conflicts of interest besides other aspects). To note, the search string mainly includes terms related to addiction/disorder. 

Regarding the abstract, I feel that something is missing, such as what is expected from this study, why we need it, and what it could add to the current knowledge. 

In the introduction, the authors discuss the concept of gaming disorder as a coping mechanism serving self-regulation (lines 74-83). However, conceptually, this does not exclude the validity of the GD category. This discussion might benefit from the inclusion of the “syndrome model of addiction” (Shaffer et al) and the “self-medication hypothesis” (Khantzian).  

According to my opinion, a point that needs to be considered among the study limitation and potential bias is the fact that only reports of treatment-seeking individuals will be considered. This could favor the findings supporting the view of "gaming disorder as a coping strategy" because highly impaired cases could be excluded (they might not seek help). Therefore, the findings of this study would not be representative or generalized to gaming disorder but only to a specific subgroup.

Lines 230: The authors could include a description of how and based on which characteristics were those specific models selected among different models of GD. It is not clear why a model related to psychopathology (e.g., syndrome model, self-regulation hypothesis) is not examined.

Line 308, Informativeness: The authors might want to mention the available tools that inspired their tool. They could also consider the recommendations of Murad et al 2018 (10.1136/bmjebm-2017-110853). Indeed, Murad et al. identified a useful domain that could be considered for evaluating methodological quality, i.e., selection (Does the patient(s) represent(s) the whole experience of the investigator (centre) or is the selection method unclear to the extent that other patients with similar presentation may not have been reported?). Furthermore, the use of summary score (line 359) leads to considering equally informative all items when some of them may be more important. Have the authors thought about the use of "an overall judgment" of informativeness?

Minor suggestions:

A reference for the data provided on line 42 could be added. 

Lines 107-110: The search term strategy used could be reported. Using the search terms "game addiction" OR "gaming disorder" I found no more than 40 meta-analyses, and if reviews were included the results were 226. For clarity (based on the items retrieved), "meta-analyses" could be moved after "reviews".

After reading the introduction, I wonder whether there is a real need to use the word "meta-synthesis" rather than "systematic review of qualitative studies". From the text, it is not clear what meta-synthesis refers to.

Coding: will agreement between coders be examined?

When is COI considered present? Additional information could be included when mentioning COIs.

Lines 267, RQ1.3: What about descriptions that could fit more than one category (e.g., bidirectional relationships)?

Line 388: Why para-exploratory instead of exploratory (i.e., what does para- add to the meaning)?