Gaming Disorder: a Virtual Addiction · VG vs. Sleep • Insufficient sleep strongly predicts depression, anxiety, & suicidality (Matamura ‘14) • IGD triple sleep deprivation
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Gaming Disorder: a Virtual Addiction
Paul Weigle, MD
CT Council on Problem Gambling
Hilton Garden Inn
October 30th, 2019
No Disclosures
The speaker and planners, of
this event have no financial
conflicts of interest in regards
to the content of this program
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Pleasure of pleasures! hot fever of hope and fear! inexpressible unjaded passions! how fiercely beautiful thou art, O Gaming!
Lord Edward Lytton The Last Days of Pompeii, 1836
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder is an official
diagnosis in ICD-11
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Agenda
• Mental health effects
• Why VG?
• Diagnosis
• Epidemiology
• Treatment
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
What Happens When its Time to Stop?
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Worldwide Sales (in Billions)
1991 – $12
2001 - $35
2013 - $82
2019 - ~$152
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
How Much Do Youth Play Video Games?
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
How Much Do Kids Play?
• Quadrupled since ‘00 (Common Sense Media Survey
‘15)
• 61 % play VG on a given
day average 2 hrs 13 min
• Boys > girls
• 14% boys & 5% girls
play VG 4 - 10 hrs/day
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Who Plays Video Games?
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Adults Play Too
• 74% gamers are adult (ESA, ‘15)
• Average gamer 33
years old (ESA ‘18)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Why Are Video Games Habit Forming?
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Be All You Can’t Be
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Pretend 2.0
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Escapism
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Flow: state of being fully
immersed in activity, feeling focus &
enjoyment
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
What Does Video Game Flow Look Like?
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
No Stopping Cues
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Psychological Needs
Self determination theory
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Autonomy
Need to control the course of our lives
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Competence
Need to feel effective in dealing with environment
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Relatedness
Need to feel connected with others
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Excessive Play Counterproductive (Wu ’13 & Zhang ‘19)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Persuasive Design• Behavioral Game Design
• Variable & Fixed Ratio
Reinforcement
• Research Labs
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Loot Boxes
• Randomized in-game rewards
• Some sold for $
• Some rewards can sold to other players for $
• 45% meet criteria for gambling (Drummond ‘18)
• Illegal in Belgium and Netherlands
• Legally not gambling in US
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
How Do Video Games Affect Mental Health?
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Online Habits & Mental Health
• TV & Movies
• Video Games
• Computers
• Smartphones
Source: Przyblyski ’17 &
Twenge ‘18
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
https://www.scientificamerican.com/sciam/cache/file/BB46146E-1F49-4F96-84002A3DB36504F4_source.jpg
VG Displace Healthy Habits
• Socializing
IRL
• Exercise
• Academics
• Sleep
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Relationships IRL
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
PS3
Exercise & Diet
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Academics% of 12th graders who read a book for
pleasure almost every day
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Twenge ‘19
VG vs. Sleep
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
PS3
VG vs. Sleep
• Insufficient sleep
strongly predicts
depression, anxiety, &
suicidality (Matamura ‘14)
• IGD triple sleep
deprivation (Rehbein ’10,
Achab ’11, & Lam ‘14)
• Displacement
• Arousal
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Addiction
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Excessive pattern of compulsive behavior
leading to impairment & associated
symptoms
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Online Addictions
Any can become
addictive if
sufficiently
reinforcing:
• Gaming
• Social Media
• Pornography
• Gambling
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Internet Gaming Disorder
• Condition requiring further study (2013)
• Pattern of excessive play
• Impairment or distress
• Additional symptoms
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
1. Increasing Time Playing
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
2. Preoccupation
3. Loss of Interest in Other Hobbies
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
4. Withdrawal
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
5. Can’t Cut Down
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
6. Continue Despite Psychosocial Problem
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
7. Lies
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
8. Threatens Relationship or Education
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
9. Play to Alleviate Negative Mood
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
VG Addiction Testimony
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Additional Symptoms
• Substance use disorder
requires 2 of 9
• Gambling disorder
requires 4 of 9
• IGD requires 5 of 9
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Internet Gaming Disorder Prevalence
• 1 – 5% (Muller ’14, Lemmens ’15, Rehbien ’15,
Pontes ’16, Przybylski ’17 & Wu ’18)
• Greater in SE Asia (Saunders ‘17)
Source: Sussman, Stahl & Weigle ‘18
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Who Gets Addicted to VG?
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Risk Factors
• Boys
• Heavy gaming
• Poor social skills
• Impulsive (Gentile ’11 & Jeong ‘19)
• Poor emotional regulation (Gentile ‘11 & Dang ‘19)
• Poor family relations (Su ‘18)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
What Games are Addictive?
• Computer & console games
• Fantasy/RPG games, shooters, &
real-time strategy games (Smythe 07,
Kim ‘10, Elliot ‘12, & Eichenbaum ’15)
• Motivation: achievement & immersion (Lehenbauer-Baum ‘15)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming vs Gambling• Gaming (IGD) high in novelty seeking & risk
aversion
• Gambling (GD) high in sensation seeking,
low in risk aversion
• IGD younger, earlier onset, >ADHD &
aggression, <nicotine (Nuria ‘17)
• IGD more impulsive than GD (Choi ‘14)
• IGD < conscientiousness & extraversion vs
GD, both high in neuroticism (Muller ‘14)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Biological Correlates
• Gambling -
abnormalities in
brain structure &
function
• VG addicts -
similar
abnormalities in
29 studies
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Dopamine & Addiction
• Recreation drug use causes release spike
in striatum & nucleus accumbens
• VG play causes same spike (Koepp ‘98, Hoeft
’08 & Weinstein ‘10)
• Drug addicts decrease sensitivity of
reward systems
• IGD - same abnormality (Weinstein ’10, Kim
’11 & Hou ‘12)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Morphological Changes
• Drug addicts show brain
matter loss including
diminished orbitofrontal
cortex
• IGD show similar pattern (Dong ‘12, Han ’12, Lin ‘12, Hong
’13, Weng ’13, Yuan ’13 & Wang
‘15)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Cognitive Changes
• Impaired response
inhibition
• Cognitive bias
• Executive dysfunction
• Identical in IGD (Van Holst
’12, Zhou ’13, Wang ’15, & Yao
‘15)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Sequelae
• Depression (Gentile ‘11)
• Anxiety
• Insomnia
• School failure (Lam ’10, Achab
’11 & Gentile ’11)
• Worsened family relations(Gentile ‘11 & Su ‘18)
• Decreased supervision
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Family Guidance
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Talking With Families About VG Habits
• Parents as role models
• Make time for sleep, socializing, exercise,
family, schoolwork & chores
• Tech-free times & areas
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Parental Monitoring
• Restrictive – limits
• Active – coplay & discuss
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Parent Monitoring
• Decreasing total screen time improves sleep, school
performance & BMI (Tiberio ’14 & Gentile ’14)
• Decreasing screen violence improves behavior (Gentile ’14)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Activities
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Treatment
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
• Therapy
• Medication
• Comorbidities
Psychotherapy
• Modeled on substance
abuse tx
• CBT (King ‘17)
• Motivational interviewing
• Group & family
• Harm reduction
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Psychotherapy
• Thirty clinical trials showed positive results (King ‘17)
• Evidence limited
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Therapy Techniques
• Denial
• Personal inventory
• Practice the opposite
• Goals
• Abstinence
• Peer group
• Prevent enabling
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Medication
• ADHD
• Antidepressants
• No FDA Approval
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
ADHD Medications
• 62 children w ADHD
methylphenidate X8 weeks -
VG play & addiction
decreased (Han ‘09)
• 86 teens w IGD improved
methylphenidate =
atomoxetine X12 weeks (Park
‘16)
• IGD change correlated w
ADHD
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Bupropion For IGD & MDD
• 50 adults
• 8-week OL showed benefit (Han ‘12)
• 65 teens
• 8-week OL showed benefit
• Bupropion plus group CBT >
bupropion alone (Kim ‘12)
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Escitalopram vs Bupropion For IGD & MDD
• 30 adults DB randomized 12
weeks (Nam ‘17)
• Improvement equal
• 119 w IGD 6 week RCT (Song ‘16)
• Bupropion > escitalopram >
waiting list
• Bupropion improved attention &
impulsivity
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Specialized Treatment Facilities
• Outpatient: The Center For Internet & Technology Addiction, East Hartford
• Inpatient: Internet Addiction Inpatient Program @ Bradford Regional Medical Center, PA
• Residential: reStart, Seattle
• Wilderness: VG & Internet Addiction Treatment Program, UT
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
VG Addiction in China & S. Korea
• #1 public health threat
• Laws limit play
• Hundreds of detox & residential facilities
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Conclusions
• Youth VG engagement increasing
• VG habit-forming by design
• Excessive play often displaces healthy activities
• 1-4% develop Gaming Disorder
• Parental monitoring is preventative
• Pathology & treatment similar to SUD
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
Gaming Disorder: a Virtual Addiction ~ October 30th, 2019
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