Leigh Holman, Ph.D., LPCS, RPTS, NCC, SCSAmhca Diplomate and CMHC

President-Elect International Association of Addiction & Offender Counselors

Diagnostic ConsiderationsInternet Gaming Addiction

Conflict Over what constitutes Problematic Online Gaming?

Video games as the starting point for examining the characteristics of a specific pathology (Charlton & Danforth, 2007; Griffiths, 2005; Griffiths & Meredith, 2009; Peters & Malesky, 2008).

VS.

Internet is the main platform that unites different addictive activities, including online games (Van Rooij, Schoemakers, Vermulst, Van den Eijnden, & Van de Mheen, 2011; Young, 2009).

Griffiths, 2010) Video Game Addiction Theory

Indicators of High Engagement (Charlton & Danforth, 2007, 2008)

1. Salience• Gaming becomes the most important activity in the

person’s life and dominates his/her thinking, feelings (i.e. cravings), & behavior

• Preoccupation & Cognitive Distortions• Deterioration of Socialized Behavior

2. Mood Modification Gamers report both an arousing ‘buzz or high” and Distressing tranquilizing feeling of “escape or

numbing”3. Tolerance• Increasing amounts of time are required to achieve

the former effects

Griffiths, 2010) Video Game Addiction Theory

Central Role in Addiction (Charlton & Danforth, 2007, 2008)

4. Withdrawal Symptoms Unpleasant feeling states or physical effects when

not gaming or reduced time gaming Shakes, moodiness, irritability

5. Conflict• Interpersonal conflict with important relationships• Conflict with time spent on other activities (hobbies,

work, school, social life)• Intra-psychic conflict – feelings of loss of control

6. Relapse Tendency for repeated reversions to earlier patterns

of gaming after abstinence or control has been established

Other modelsPorter et al. (2010)

Excessive use of one/more video games resulting in a preoccupation with and a loss of control over playing video games, and resulting negative psychosocial and/or physical consequences

Integrated ModelsProblematic Online Game Use Model (Kim & Kim,

2010)5 dimensions: euphoria, health problems, conflict, failure of

self-control, and preference of virtual relationshipDemetrovics et al. (2012) Integrative Approach

6 Dimensions: preoccupation, overuse, immersion, social isolation, interpersonal conflicts, and withdrawal

Issues with ResearchNo consistency in literature on gaming

addiction:TheoryConceptualizationScreening and Assessment Measures MethodologyPopulationSampling

International Prevalence Rates

Prevalence

Meta-analysis: About 3% of the general population meet addiction criteria

Limited evidence suggests that most addicts (about 80%) stay addicts for at least 2 years in the absence of treatment

Prevalence rates vary according to: Type of digital technology activity

How addiction is assessed (measurement) Demographic factors Cultural context (Far East Asian > Western) Country

Recruitment and sampling method psychiatric sample vs. community sample;

self-selection vs. random selection Type of video game typically played ↑among online video games, especially MMORPGs

DSM-5“Internet gaming has been reportedly defined as

an “addiciton” by the Chinese government, and a treatment system has been set up. Reports of treatment of this condition have appeared in medical journals, mostly from Asian countries and some in the United States” (APA, p. 796).

DSM-5 Workgroup:Reviewed more than 240 articlesSome behavioral similarities were found between

SUDs and Internet Gaming Disorder including: tolerance, withdrawal, repeated unsuccessful attempts to cut back or quit, and functional impairment

Literature doesn’t use a standard definitionNeed epidemiologic studies to determine prevalence,

clinical course, possible genetic influence, and potential biological factors base don fMRI data

DSM-5“a pattern of excessive and prolonged Internet

gaming that results in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of substance use disorders.

Typically play for 8-10 hours per day and at least 30 hours per week.

Experience agitation and anger if they cannot playNeglect norlmal work/school/relationship

obligationsSeparate from gambling disorder involving the

Internet

DSM-5Essential Feature: “persistent and recurrent

participation in computer gaming, typically group games, for many hours. . . Involve competition etween groups of players (often in different global regions, so that duration of play is encouraged by the time-zone independence) participating in complex structured activities that include a significant aspect of social interactions during play” (APA, p. 797)

Team or social aspects are a key motivationCriteria is adapted from studies published in

China

DSM 5 Section III: Internet Gaming Disorder

Proposed Criteria:

Persistent and recurrent use of Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by 5 or more of the following in a 12 month period:

1.Preoccupation with Internet games.

2.Withdrawal symptoms when Internet gaming is taken away.

3.Tolerance: the need to spend increasing amounts of time engaged in internet games.

4.Unsuccessful attempts to control the participation in Internet games.

5.Loss of interests in previous hobbies & entertainment as a result of, and with the exception of, Internet games.

6.Continued excessive use of Internet games despite knowledge of psychosocial problems.

7.Has deceived family members, therapists, or others regarding the amount of Internet gaming.

8.Use of Internet games to escape or relieve a negative mood.

9.Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games.

DSM 5 Section III: Internet Gaming DisorderSpecify Severity:

MildModerateSevere

Depends on how much the disorder is causing distress or functional impairment in normal activities the client should be involved in.

Mild: exhibit fewer symptoms and less disruption

Severe: generally more time spent on the computer and more severe impact on functioning at work or school and in disruption in significant relationships

Diagnostic ConsiderationsThe criteria in Section III should be used to

determine if the client fits within these diagnostic criteria first.

Since Section III diagnosis cannot be used as a diagnosis, consider using: Other Specified Obsessive Compulsive Disorder, Internet Gaming

Risk & Prognostic FactorsEnvironmental:

Computer availabilityInternet connectionSpeculation that helicopter parenting or very

controlled home environments might generate higher risk situations

Genetic & Physiological:Adolescent males at higher riskAsian environmental and/or genetic

background is a risk factor suggested by literature, but clear evidence isn’t available

Differential Diagnosis

Internet use that is excessive but doesn’t involve playing online games is not the same.

Gambling using the Internet is not the same.Depression

Social Phobia or other Anxiety

Aspergers or Autism Spectrum Disorder

Comorbidity2x more likely to be diagnosed with ADD/ADHD than

gamers who play recreationally (Batthyany, Muller, Benker, & Wolfling, 2009; Bioulac, Arfi, & Bouvard, 2008; Chan & Rabinowitz, 2006; Gentile et al., 2011; Han et al., 2009).

Depression (Gentile et al., 2011; Peng & Liu, 2010). MMORPG depressive symptoms (sadness, hopelessness,

crying spells, insomnia, concentration problems) are related to habitual computer gaming at night b/t 10-6 (Lemola et al., 2011)

Anxiety & Social Phobia – longitudinal data suggest pathological gamers exhibit higher levels of depression, anxiety & social phobia during follow-up than normal gamers (Gentile et al., 2011), but the relationship may be reciprocal.

EtiologyNeurobiological Aspects:

Cue induced gaming urge activates the same brain regions activated by gambling in pathological gamblers and substance use in substance addicts (Han et al., 2011; Ko et al., 2009).

Working memory may be affected similarly as is in substance dependence (Kim et al., 2012).

Need more studies

Etiology Personality Aspects:

Low Emotional Stability (Charlton & Danforth, 2010; Mehroof & Griffiths, 2010; Nagygyorgy, Mahalik, & Demetrovics, 2012; Peters & Malesky, 2008).

Low Agreeableness (Charlton & Danforth, 2010; Peters & Malesky, 2008). Low Extroversion (Charlton & Danforth, 2010). Neuroticism Amount of time playing – Decreased quality of interpersonal relationships

and increased social anxiety (Lo, Want, & Fang, 2005). Problematic Gaming is negatively correlated with offline social self-efficacy

and positively correlated with online social self-efficacy (Jeong & Kim, 2011, Porter et al., 2010).

Inadequate self-regulation (Seay & Kraut, 2007) Low Self-Esteem ( Ko, Yen, Chen, Chen, & Yen, 2005); Lemmens et al.,

2011) Low Emotional Intelligence (Herodotou, Kambouri, & Winters, 2011) Above Average State Trait Anxiety (Mehroof & Giffiths, 2010) Increased Loneliness (Lemmens et al., 2011; Seay & Kraut, 2007) Narcissistic Personality (Kim et al., 2008) Aggression (Kim et al., 2008; Mehroof & Griffiths, 2010) Lower life satisfaction (Ko et al., 2005; Wang, Chen, Lin, & Want, 2008) Decreased Psychosocial Well-being compared to other gamers (Lemmens

et al., 2011)

EtiologyMotivational Aspects:

Motives play in important role in the development and maintenance of problematic online gaming (Demetrovics et al., 2011; Kuss & Griffiths, 2012)

Bartle (1996) 4 motivational types: achievers, explorers, socializes, & killers of MUD players

Yee (2006) tested Bartle’s model with MMORPG players. Using EFA, identified 10 motivational components that belong to 3 main factors: Achievement: advancement (desire to gain power, progress rapidly &

accumulate in-game symbols of wealth/status), mechanics, and competition;

Social Factor & Discovery: socializing, relationship, and teamwork; Immersion: role-playing, customization, and escapism (use of online

environment to avoid thinking about real-life problems) Demetrovics et al. (2011): Motives for Online Gaming

Questionnaire (MOGQ): 7 factors Social, escapism, coping, fantasy, skill development, recreation, competition

EtiologyMotivation (Cont.) Cyber Junkie by Kevin Roberts

Achievement – increases self-esteem – good at something Escape – emotional escape, interpersonal difficulties Role Playing: “Their online persona often possesses attributes

that they wish they had in real life” (p. 14). “Driven to become someone else, to exist in a different time, or to live lives filled with meaning.” Rely on the game for social interaction.

Control: often products of strict/helicopter parenting - cyber world as a refuge where they have a sense of power and purpose

Aggression: Teabagging – kneeling over an opponent’s on-screen character after you kill them to show dominance & humiliate them – Aggression and anger management issues precede online gaming – a way to act out aggression – generally suffer from emotional avoidance

Discovery: satisfaction comes from finding new twists to a game or uncovering a glitch that no one has yet discovered. Often genius level IQ and underachieving/bored in life/school/job – desire to feel fully alive & game is a substitute

EtiologyStructural Characteristics in Online Gaming:

High degree of realism (realistic sound, graphics, and setting), a rapid absorption rate, character development, the ability to customize the game, multiplayer features, winning and losing features, and ability to save the game at regular intervals viewed as essential by gamers (Weed et al., 2004).

King et al. (2010) Theoretical Model of 5 Structural Features: Social Features: how players communicate, creation of cooperative

& competitive community of players. Manipulation & Control Features: how players interact with and

control in-game properties using a physical control scheme Narrative & Identity Features: how players take on another identity

in the game – sense of self Reward & Punishment Features: how players are reinforced for

skillful play (winning) and punished for loosing – Problem gamers report significantly higher enjoyment of management of in-game resources, earning points, getting 100% in the game, and mastering the game – leveling up (earning meta-game rewards) – fast loading times

Presentation Features: Aesthetics – Realism of sound and look

EtiologyStructure Continued:

Instant but Intermittent Reinforcement (people keep responding in the absence of reinforcement hoping that another reward is just around the corner).

Magnitude of the Reinforcement (high points score for doing something in-game – large rewards lead to fast responding and greater resistance to extinction

Amount of TimeExcessive game play is not a sufficient condition of

addictionMore time = higher risk