Internet gaming addiction

LEIGH HOLMAN, PH.D., LPCS, RPTS, NCC, SCS

AMHCA DIPLOMATE AND CMHC

PRESIDENT-ELECT INTERNATIONAL ASSOCIATION OF ADDICTION & OFFENDER COUNSELORS

Internet Gaming Addiction

Typology

70% prefer online games to offline games (DePrato et al., 2010)

Online gamers are more likely to demonstrate problematic use (Griffiths, Davies, & Chappell, 2004; Griffiths & Meredith, 2009); Rehbein, Psych, Kleimman, Mediasci, & Mossle, 2010).

Online Typically played simultaneously by players Players can communicate with one another in real time Players can cooperate or compete at will Do not have predetermined end point No real loss, and tasks can be repeated several times Competing leads to immediate social comparison (Griffiths, 2010; Kim & Kim, 2010) Social nature results in more time spent playing

Offline Usually played alone Well-defined start and finish point Goals are usually achieved by the players themselves without external help from any

other player.

History

1970s: MUDS (Multi-User Domains) (Bartle, 2003; Barnett & Coulson, 2010). Text based virtual worlds Several players present at the same time Use imaginations rather than graphics Created real-time chat, interaction between players, parallel

activities, cooperation, competition, social comparison1986: Suggested term: “Video game addiction” 1989: Comparison to SUD: “Computer dependency” 1994: Arcade video game dependency conceptualized

as pathological gambling in the DSM-III

History (Cont.)

1996: “Internet addiction disorder” described in first issue of CyberPsychology & Behavior

2000: First study of online gaming addiction 2004: Release of World of Warcraft – 12 million players

(peak) 2008: Special issue in IJMHA on video game addiction 2009: Internet addiction critiqued in several psychiatry

journals 2010: First randomized controlled trial of IA treatment 2012: Proposed inclusion of Internet Use Disorder

History (Cont.)

MMOGs or MMOs (Massively Multiplayer Online Games) 100s or 1000s of players People play simultaneously in the same online world, not in an

individual copy of it Can only be played through an internet connection (Barnett &

Coulson, 2010). MMOGs most complex (more people and synchronic spaces

and MOGs are simpler (no synchronic spaces & only 4-16 players)

Types of Games (Cyber Junkies, Roberts)

Puzzle Games: deal with logic, language, trivia, mindless repetition, and visual-spatial skills

– no themes or characters Addiction Risk: 2

Physical Simulations: help remedy physical inactivity – Dance Dance Revolution or Guitar Hero –

recommend all homes with video game system have at least one physical game

Addiction Risk: 2 Old School Games

Nintendo64, Playstation1, Sega’s Dreamcast Cartoonlike characters in mazes, races, and battles Families & friends can play together Some fantasy role-playing games (Legends of Zelda) and first person shooter

games (GoldenEye 007) low potential for addiction Addiction Risk: 3


Educational Games May offer very accurate historical representations and give players an in-depth

education on historical periods Addiction is increased when the educational component is combined with other

gaming elements (role play or real-time strategy) Addiction Risk: 4

Mange and Control Games (God Games) The Sims Life Simulation Model- make all housing, finance, food intake, and

relationship decisions of the characters in the game. Roller Coaster Tycoon, player makes decisions to construct, maintain and grow

an amusement park. Black and White – players take on role of a god and act to influence the lives of a

group of islanders Usually have no win-or-loose scenario User does not directly control the characters Opportunity to exert complete dominance over people and places in the game Addiction Risk: 5


Shoot ‘Em Up and Adventure Games Deepening sense of connectedness to the characters they control. Higher levels of realism equal heightened sensory stimulation Unceasing potential for new missions and adventures ensures that

players do not quickly tire of these games First-Person Shooter (FPS) Games

Public enemy number one – high levels of violence – M-rated A player’s view is the same as in real-life – 3D cyberworld Require a high level of concentration & quick reflexes Virtual death awaits Make their way through mazes, cities, or battlefields to search out and

destroy their enemies Counter-Strike, Halo, Call of Duty Form Clans and meet online for team battles Addiction Risk: 7


Shoot ‘Em Up and Adventure Games Real-Time Strategy (RTS) Games

Building a civilization & amassing technology to advance to higher levels of development

Prepare an army for war RTS players control and entire battlefield as well as make overall

strategic decisions Multitasking skills, manages economy, controls armies, and may keep

peasants happy or face revolt Gateway Games Can be played alone or with others Players who derive satisfaction from the online multiplayer feature of

these games often crave greater interaction and connection with other players than RTS games can supply.

Addiction Risk: 7


Shoot ‘Em Up and Adventure Games Adventure and Role Playing Games (RPGs)

Contains many gateway games because players seem to quite easily move to more addictive MMORPGs

Draw discovery-oriented players and those motivated by role playing

Fantasy character embarks on a quest that progresses through many trials and obstacles, usually toward a goal

In some games there is no ultimate goal, no win-or-loose scenario, but rather simply an opportunity to exist as the character

A player’s choices help shape the direction of the game – appeals to control-oriented gamers

Examples: Legend of Zelda, Final Fantasy. Anmd Warhammer Addiction Risk: 8


MMORPGs Board with life Control an avatar, choose the race, class, and sometimes profession Interact with each other in persistent worlds that operate 24 hours a

day Join clans and guilds of like-minded avatars – cooperate on quests

and adventures & chat through headsets Bond that transcends previous relationships May think about the game constantly May shift perception from fantasy to reality Relationships, career, family may all suffer Rune Scape: 10 million active users – most use a free version -

Addiction Risk: 7 World of Warcraft: 9 million users internationally – pay $13-

$15/month w/ first month free - Addiction Risk: 10

6 technical and design characteristics of MMOS (Chan & Vorderer, 2006)

Persistence the game world may change between sessions because it exists even

when the player isn’t present.Physicality

Realistic world with consistent set of rulesAvatar-Mediated Play

Use of an avatar character to interact with others and the game world – usually has characteristics/skills that the gamer wants to have but doesn’t in real life

Vertical Game Play Even when the highest level is attained, players remain in the game

world and complete more challenges or participate in social activitiesPerpetuity

Game never endsSocial Interaction

Cooperation and rivalry between players is an essential part of the game

3 Major Groups of MMOs & Other (Nagygyogy et al., 2012; Rice, 2006)

79% have a clear preference for type of game, which may indicate the type of game meets certain needs the gamer has

Massively Multiplayer Online Role-Playing Games (MMORPGs) Traditional role-playing games Players control avatar – virtual self Choose a profession that determines their role and abilities Through fulfilling different tasks or missions in the game, the avatars develop & acquire precious

objects that lead to the differentiation status between avatars (Leveling Up) Massively Multiplayer Online First Person Shooter (MMOFPSs)

Skill-demanding action games Players control a single avatar from a first-person perspective Rely on reaction time and attention Several cooperation & competition (individual and group) opportunities

Massively Multiplayer Online Real-Time Strategy (MMORTSs) Player oversees large troups &/or territories in a virtual world, engage in battles, or conclude

alliances with other players Players establish status in the game world and gain esteem through successes

Other online games Sport, racing, music/rhythm games Multiplayer online social games or turn-based strategy games Attract fewer players Many more female players

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

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

1. Tolerance Increasing amounts of time are required to achieve the former effects

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 models

Porter 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 Models Problematic Online Game Use model (Kim & Kim, 2010)

5 dimensions: euphoria, health problems, conflict, failure of self-control, and preference of virtual relationship

Demetrovics et al. (2012) Integrative Approach 6 Dimensions: preoccupation, overuse, immersion, social

isolation, interpersonal conflicts, and withdrawal

Issues with Research

No consistency in literature on gaming addiction: Theory Conceptualization Screening and Assessment Measures Methodology Population Sampling

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

Screening and Assessment

Many scales developed out of scales used for other behavioral addictions such as Internet Addiction without consideration for unique aspects of gaming.

Many have ambiguous or questionable psychometrics.

Because of continued differences regarding what constitutes problematic gaming, scales may measure different things.

Screening & Assessment Issues

Review of all studies published 2001-2012

Search logic: (pathology* OR problem* OR addict* OR compulsive OR dependent*) AND (video OR computer) gam*

Academic Search Premier (967 results), PubMed (235 results), PsychINFO (957 results), Science Direct (1677 results), and Web of Science (284 results)

Studies were not necessarily excluded on the basis of methodological shortcomings. However, a study was excluded if: instrument name was not identified, a composite measure was used, case note material or anecdotal evidence not published in English or Dutch.

•TOTAL: 18 instruments across 63 studies


Instrument analysis

Review framework: Cicchetti's (1994) and Groth-Marnat's (2009) criteria JARS criteria

Psychometric information: components (i.e., underlying theoretical construct), dimensionality, validity (convergent, predictive, and criterion), reliability (internal consistency, inter-rater), availability of normative and prevalence data. Practical considerations: number of items, administration time, reading age level, item sensitivity, time-scale, diagnostic categories, country of origin, language versions.


No two instruments were alike with respect to their profile of diagnostic features

Interpersonal conflict was the only addiction indicator that was assessed across all 18 instruments

Financial conflict not generally assessed

Few instruments assessed use despite harm (SD criterion)

Instruments do not ask: “Do you think you have a problem?”

DSM-IV-TR criteria include the most indicators (13 ind.)

Game Addiction Scale and Young Internet Addiction Test each assess 11 criteria

Only the PVP Scale mapped all criteria of DSM-5 Internet Use Disorder – instruments tended to miss: (i) use despite harm and (ii) deception/secrecy

Improving Measures

Inclusion of items to assess: whether the individual personally believes that their video-gaming behavior is problematic

(i.e., a validity check), an item that asks whether significant others would consider that their video-gaming is

problematic (i.e., a reliability check)

Inclusion of measures to assess co-morbidity

Guidelines for scoring and interpretation

Establishment of norms

Assessing harm/conflict across several domains

Research - No instrument measures all indicators, therefore: •include additional items

Use more than one measure

Gentile (2009)Pathological Gaming Scale

Over time, have you been spending much more time thinking about playing video games, learning about video-game playing, or planning the next opportunity to play?

Do you need to spend more and more time and/or money on video games in order to feel the same amount of excitement?

Have you tried to play video games less often or for shorter periods of time, but are unsuccessful?

Do you become restless or irritable when attempting to cut down or stop playing video games? Have you played video games as a way of escaping from problems or bad feelings? Have you ever lied to family or friends about how much you play video games? Have you ever stolen a video game from a store or a friend, or have you ever stolen money in

order to buy a video game? Do you sometimes skip household chores in order to spend more time playing video games? Do you sometimes skip doing homework in order to spend more time playing video games? Have you ever done poorly on a school assignment or test because you spent too much time

playing video games? Have you ever needed friends or family to give you extra money because you spent too much

money on video-game equipment, software, or game/Internet fees?

Convergent & Divergent Validity

Lemmens et al. (2009)Game Addiction Scale for Adolescents

Salience (GA 1-3)Tolerance (GA 4-6)Mood Modification (GA 7-9)Relapse (GA 10-12)Withdrawal (GA 13-15)Conflict (GA 16-18)Problems (GA 19-21)

Randomly distributed in the scale5 point Likert scaleSecond-order factor structure of 21 item Game Addiction Scale

(N = 351)EFA, Convergent & Criterion Validity

Online Game Addition Diagnostic Scale (Lee & Han, 2007)

Factor 1: Psychological DependenceFactory 2: Daily Life DisorderFactor 3: Interpersonal Relationship Toward OnlineFactory 4: ToleranceFactor 5: Negative Behavior & EmotionsFactor 6: Mental DisorderFactory 7: Physical Disorder

Integrative Approach30 items, EFA, criterion validity

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.

Specify Severity: Mild, Moderate, or Severe

Comorbidity

2x 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.

Etiology

Neurobiological 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

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)

Etiology

Motivational 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

Etiology

Motivation (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

Etiology

Structural 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

Etiology

Structure 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 Time Excessive game play is not a sufficient condition of addiction More time = higher risk

Prevention

Family & friends should initiate direct conversations with problematic players by showing true interest toward the game, the gamer, and everything the gamer likes in the virtual environment.

Facilitates communication and emotional attachment with the user. Parents choose games with children/adolescents Encourage children to play with other real life friends because it helps

develop personal relationships & communication & cooperation skills learned online can be transferred more easily to real-life situations.

Set gaming time together. Follow game manufacturer’s recommendations for monitor brightness,

distance from the monitor, taking short and frequent breaks, and not playing if fatigued.

Gamers need other recreational activities in addition to gaming. Positive effects: increased self-esteem; improved reflexes, reaction time,

memory, logical and strategic thinking, social and communication skills; etc.

(Griffiths, 2003, 2008, 2010; Griffiths & Meredith, 2009)

Treatment

Support forums: Parents & other family members who discuss the nature of the problem, share their

experiences, & support each other Self-help forums (Online Gamers Anonymous) Established & administered by professionals

Specialty Addiction Clinics Improve pro-social skills through social activities & real-life activities that replace time spent

gaming. Psychotherapy to address co-morbid or underlying issues Management skills development to help players control their behavior Support Groups

Couples and/or Family Therapy Medication: Buproprion SR – decrease problem behavior & depression (Han et al., 2011;

Ko et al., 2009; Kuss & Griffiths, 2012). China & South Korea – High Intensity Physical Activity in natural

surroundings

Treatment of Internet Addiction: 2000-2012

Internet gaming addiction

Health & Medicine

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