Vol. 12

• Lesson 3

Diagnosis and Management of Video Game Addiction Mark D. Griffiths, BSc, PhD, CPsychol, FBPsS, FRSA Dr. Griffiths is Professor of Gambling Studies, International Gaming Research Unit, Psychology Division, Department of Social Sciences, Nottingham Trent University, Burton Street, Nottingham, NG1 4BU, United Kingdom. The author would like to thank Alex Meredith for his contributions to this lesson.

Keywords: Video games • Excessive behavior • Addiction • Video game addiction interventions

Introduction There are many benefits that video game players get from engaging in their chosen activity; these can be educational,1,2 social,3,4 and therapeutic.5,6 However, there is evidence that when done in excess, video game playing can in some cases be addictive,7 especially online video game playing where the game never ends and has the potential to be a 24/7 activity.8 10

Video Game Playing as an Addiction

For many, the concept of video game addiction seems far fetched particularly if their concepts and definitions of addiction involve the use of drugs. Despite the pre

dominance of drug based definitions of addiction, there is now a growing movement that views a number

Learning Objective Clinicians will review the defining parameters of video game excess and addiction; excess versus addiction; the medical consequences of video game excess; the empirical lit erature on excessive video game playing; and management of video game addiction including advice, guidance, and treatment.

of behaviors as potentially addictive including many behaviors that do not involve the ingestion of a psy

choactive drug (e.g., gambling, computer game play

ing, exercise, sex, Internet use).11 Such diversity has led to new all encompassing definitions of what constitutes addictive behavior. The notion of “video game addiction” as being a genuine addiction has started to have some credence in the medical community. For example, in June 2007, the American Medical Association (AMA) recom

mended that the American Psychiatric Association reconsider its position with respect to the Diagnostic and Statistical Manual of Mental Disorders (DSM) revi

sion in 2012;12 however, there are some problems with this that have resulted in the AMA “backtracking” over the issue of medical insurance.12 Some medical experts define addictions—such as alcoholism—as diseases. As a consequence, some sufferers receive insurance com

pensation for treatment. Given there is very little evi

dence that excessive or addictive computer gaming leads to any permanent problems, then it could lead to parents explicitly (or implicitly) encouraging their chil

dren to play to claim insurance money. This evades the question, if it is classified as an addiction, how long will someone have to play excessively to be diagnosed as 27

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persons engaged in video game playing, they gradually build up the amount of the time they spend online engaged in the behavior.

addicted? It seems highly likely that insurance compa

nies would view such claims dubiously.

The Parameters of Video Game Addiction

Research into the area of video game addiction needs to be underpinned by three fundamental questions: (1) What is addiction?, (2) Does video game addiction exist?, and (3) If video game addiction exists, what are people actually addicted to? The first question continues to be a much debated question both amongst psychologists within the field of addiction research as well as those working in other disciplines. For many years, this author has operationally defined addictive behavior as any behavior that features all the core components of addiction.11 It is this author’s contention that any behavior (e.g., video game playing) that fulfills these six criteria is therefore operationally defined as an addic

tion. In the case of video game addiction it would be: •

Salience: This occurs when video game play becomes the most important activity in the person’s life and dominates his or her think ing (preoccupations and cognitive distor tions), feelings (cravings), and behavior (deterioration of socialized behavior). For example, even if the person is not actually playing a video game, he or she will be thinking about the next time he or she can play.

•

Mood modification: This refers to the sub jective experiences that people report as a consequence of engaging in video game play and can be seen as a coping strategy (i.e., they experience an arousing “buzz” or a “high” or paradoxically tranquilizing feel of “escape” or “numbing”).

•

Tolerance: This is the process whereby increasing amounts of video game play are required to achieve the former moodmodi fying effects. This basically means that for

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•

Withdrawal symptoms: These are the unpleasant feeling states or physical effects that occur when video game play is discon tinued or suddenly reduced, for example, the shakes, moodiness, irritability, and so forth.

•

Conflict: This refers to the conflicts between video game players and those around them (interpersonal conflict), conflicts with other activities (job, school work, social life, hob bies, and interests) or from within the indi viduals themselves (intrapsychic conflict and/or subjective feelings of loss of control) that are concerned with spending too much time engaged in video game play.

•

Relapse: This is the tendency for repeated reversions to earlier patterns of video game play to recur and for even the most extreme patterns typical of the height of excessive video game play to be quickly restored after periods of abstinence or control.

Having operationally defined addiction, it is this author’s view that video game addiction does indeed exist but that it affects only a very small minority of players (as we shall see later in this lesson). There appear to be many people who use video games exces

sively but are not addicted as measured by these (or any other) criteria. The third question is perhaps the most interesting and the most important when it comes to researching in this field. What are people actually addicted to? Are they addicted to the interactive medium of playing; the aspects of its specific style (e.g., an anonymous and disinhibiting activity); or the spe

cific types of games (aggressive games, strategy games, etc)? This has led to much debate amongst those work

ing in this field.

Diagnosis and Management of Video Game Addiction

Excess Versus Addiction: Excessive activity and addictive activity are two very different things (although admittedly they do over lap on occasions). The difference between healthy excessive enthusiasms and addictions is that healthy excessive enthusiasms add to life, whereas addic tions take away from it.11 Although all addictive behaviors have idiosyncratic differences, addictions commonly have more similarities. It has been argued that video games and slot machines have more inher

ent similarities than differences (i.e., conceptually, psy

chologically, behaviorally, etc), and that (somewhat paradoxically) video game playing can be described as a nonfinancial form of gambling.13,14 This is one of the reasons why so many researchers investigating “video game addiction” use screening instruments adapted from the gambling literature. As noted later in this les

son, treatment practitioners also treat “video game addiction” using the same treatment techniques as those used in gambling.15,16

Empirical Literature on Excessive Video Game Playing

To date, there has been very little research directly investigating video game addiction, and almost all of it has concentrated on adolescents only.17 26 Furthermore, there are reports of behavioral signs of video game dependency among adolescents. Dependency signs reported include: stealing money to play arcade games or to buy new games cartridges,14,18,19,27 tru anting from school to play,14,18,19 not doing home work or getting bad marks at school,19,22 sacrificing social activities to play,19,28 irritability and annoy ance if unable to play,19,29 and playing longer than intended or experiencing time loss.19,28,30,31 Although it seems that for a minority of people, especially adoles

cents, video games can take up considerable time and that for all intents and purposes they are “addicted” to them, the prevalence of such an addiction is still of great controversy as is the mechanism by which people may become addicted; this is one area which necessi

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tates more research. The need to establish the incidence and prevalence of clinically significant problems associ

ated with video game addiction is of paramount impor

tance. There is no doubt that clearer operational defini

tions are required if this is to be achieved. It has been argued the only way of determining whether nonchemical (behavioral) addictions (such as video game addiction) are addictive in a nonmetaphori

cal sense is to compare them against clinical criteria for other established addictions, such as drug or alcohol addiction. However, most people researching in the field have failed to do this, which has perpetuated the scepticism shown in many quarters of the addiction

research community. The main problems with the addiction criteria suggested by most researchers in the field is that the measures used (1) have no mea sure of severity, (2) have no temporal dimension, (3) have a tendency to overestimate the prevalence of problems, and (4) take no account of the context of video game use. There are also concerns about the sampling methods used. As a consequence, none of the surveys to date conclusively show that video game addiction exists or is problematic to anyone but a small group of people. At best, they indicate that video game addiction may be prevalent in a significant minority of individuals (usually adolescents), but that more research using validated survey instruments and other techniques (e.g., in depth qualitative interviews) are required. Case studies of excessive video game players may provide better evidence of whether video game addic

tion exists by the fact that the data collected are much more detailed. There are case studies in the literature that show that people who play video games excessively, including those that play online,32 37 seem to display many signs of addiction.15 These case studies tend to show that the video games are used to counteract other deficiencies and underlying problems in the person’s life (e.g., relationships, lack of friends, physical appear

ance, disability, coping, etc), but again, further work of a more in depth qualitative nature is needed to defini

tively confirm the existence of video game addiction. 29

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Symptoms of Video Game Addiction The symptoms of computer addiction and video game addiction are quite specific and overlap. These include both psychological and physical symptoms. Psychological symptoms include: 1. Having a sense of wellbeing or euphoria while at the computer or playing a video game 2. Inability to stop the activity 3. Craving more and more time at the computer or playing the video game 4. Neglect of family and friends 5. Feeling empty, depressed, irritable when not at the computer or playing the video game 6. Lying to employers and family about activi ties, and 7. Problems with school or job Physical symptoms include: 1. Carpal tunnel syndrome 2. Dry eyes 3. Migraine headaches 4. Back aches, 5. Eating irregularities, such as skipping meals, 6. Failure to attend to personal hygiene, and 7. Sleep disturbances or change in sleep pattern (http:// www.computeraddiction.com/).

Online Versus Offline Video Games There has been speculation that online gaming may be more problematic and/or addictive than offline 30

Lesson 3

games.33 For example, Grüsser, Thalemann, and Grif

fiths10 investigated the addictive potential of online video gaming. A self selected sample (i.e., those who volunteered to participate in the study) comprising 7,069 gamers, mostly male (94%), with an average age of 21 years, answered two online questionnaires; 1 in 9 fulfilled at least three diagnostic criteria of addiction concerning their gaming behavior. Addictive signs were modelled on key symptoms of dependence syndrome outlined by the World Health Organization and included craving, tolerance, withdrawal symptoms, loss of control, neglect of other activities, and other nega

tive consequences. Those gamers who displayed at least three addictive signs were then compared with the remaining gamers. The “addicted” gamers predictably played for significantly longer daily periods of time. They were also significantly more likely to report with

drawal symptoms and craving. Although these gamers show some signs of addiction normally found in other more traditional addictions, the results did not conclu

sively show that the gamers are genuinely addicted; many gamers played excessively and displayed few neg

ative consequences. However, the 24 hour a day, nev

erending online games may provide a potentially addic

tive medium for those with a predisposition for excessive game playing.

Medical Consequences of Video Game Excess

For more than 25 years, the medical profession has voiced a number of concerns about excessive video game playing. Back in the early 1980s, rheumatologists described cases of “Pac man’s Elbow” and “Space Invaders’ Revenge” in which players suffered skin, joint, and muscle problems from repeated button hitting and joystick pushing on the game machines.38,39 Early research by Loftus and Loftus39 indicated that two

thirds of (arcade) video game players examined com

plained of blisters, calluses, sore tendons, and numbness of fingers, hands, and elbows directly as a result of their playing. There have also been a host of case studies in the medical literature reporting some of the adverse

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Diagnosis and Management of Video Game Addiction

effects of playing video games.40 These have included auditory hallucinations,41 enuresis,42 encopresis,43 wrist pain,44 neck pain,45 elbow pain,46 tenosynovi tis—also called “nintendinitis,”4750 handarm vibra tion syndrome,51 repetitive strain injuries,52 and peripheral neuropathy.53 Admittedly, some of these adverse effects are quite rare, and “treatment” involved nonplaying of the games in question. In the cases involving enuresis and encopresis, the children were so engaged in the games that they did not go to the toilet. In these particular instances, the children were taught how to use the game’s “pause” button. Although this simple intervention appears to somewhat trivialize the condition, it should be remembered that in these cases the video games had such an engrossing effect that the children ignored normal and necessary bodily functions. Finally, it is worth noting that Spielberg54 says there are three factors that have hindered research into gaming addiction by mental health professionals: 1. The speed at which the gaming industry progresses means that both the format of games and the technology they exist on moves forward faster than therapeutic tech niques can be researched and established. 2. Video game addiction costs very little to start and maintain, in comparison to other addictions. 3. Video game playing is seen by most people as harmless entertainment played by all gen erations in a family. The only way that such attitudes will change in relation to the more extreme negative detrimental consequences (i.e., that excessive video gaming can be viewed as an addiction) will be through increased research and education.

Management of Video Game Addiction To date there have been very few empirically published accounts of treating video game addiction, although there are many overviews providing advice and guid

ance to parents and practitioners;39,55 the next sections review the available evidence from both empirical and nonempirical sources.

Practical Advice and Guidance about Video Game Addiction When dealing with children who are avid gamers, Grif

fiths55 advocates that parents and practitioners should begin by finding out what video games children are actually playing. If they have objections to the content of the games, they should facilitate discussion with chil

dren about this, and if appropriate, have a few rules. Parents and practitioners should aim toward a few goals with children. They should: •

Help them choose suitable games which are still fun

•

Talk with them about the content of the games so that they understand the differ ence between makebelieve and reality

•

Discourage solitary game playing

•

Guard against obsessive playing

•

Follow recommendations on the possible risks outlined by video game manufacturers

•

Ensure that they have plenty of other activi ties to pursue in their free time besides the playing of video games

Griffiths55 reports that parents and practitioners need to remember that in the right context video games can be educational (helping children to think and learn more quickly), can help raise children’s self esteem, and can increase the speed of their reaction times. The ques

tion most asked by parents and practitioners is: “How much video game playing is too much?” To help answer this question, Griffiths55 devised the following check

list. To assess if the child’s video game playing is getting out of hand, one must ask, does the child: •

Play video games almost every day?

•

Often play video games for long periods (over 3 to 4 hours at a time)?

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•

Play video games for excitement or “buzz”?

•

Get restless, irritable, and moody if he or she can’t play video games?

•

Sacrifice social and sporting activities to play video games?

•

Play video games instead of doing his or her homework?

•

Try to cut down video game playing but cannot?

Griffiths asserts that if the answer is “yes” to more than four of these questions, then the child may be playing too much. If a child is playing video games too much, Griffiths55 suggests the following: •

First of all, check the content of the games. Try and give children games that are educa tional rather than the violent.

•

Second, try to encourage video game playing in groups rather than as a solitary activity. This will lead to children talking and work ing together.

•

Third, set time limits on children’s playing time. Tell them that they can play for a cou ple of hours after they have done their homework or their chores—not before.

•

Fourth, follow the recommendations by the video game manufacturers (e.g., sit at least 2 feet from the screen, play in a welllit room, never have the screen at maximum bright ness, and never play video games when feel ing tired).

•

Finally, if all else fails, temporarily take away the games console and then give it back to them on a parttime basis when appropriate.

Online Support Forums Online support services for addictive behaviors are becoming increasingly popular,56 with some specializ

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ing in very specific addictions such as gambling.57,58 In the process of researching this lesson, the author found evidence of a variety of online forums designed by and for the use of those affected by excessive game playing. Some of these are parent run groups, whereas others are run by professional organizations (see Appendix 1 for some popular online help forums). These forums com

monly provide practical advice and experiential case accounts. Much of the advice seems to be based on behavioral reward and punishment systems, such as allowing children to earn “game time” once their chores are completed. It seems that forums such as these have gained quite a following. At the time this lesson was written, the membership of the Everquest Widows Web site stood at 7,300 members, and it had also been the subject of empirical research.8 It has to be noted that most of the Web sites run by nonprofessional groups use “video game addiction” implicitly without ever explaining what it actually entails. One of the better explanations by the National Institute on Media and the Family59 stated: Like other addictions, the video game has replaced friends and family as the source of a person’s emotional life. Increasingly, to feel good, the addicted person spends more time playing video games. Time away from the game causes moodiness or withdrawal. The National Institute on Media and the Family Web site (see Appendix 1) provides a series of articles on gaming presented from an intelligent and balanced perspective. This more balanced approach advocates a collective responsibility for excessive or addicted gam

ing (from children through parents to the games com

panies themselves). Another example is the Mother Nature Web site (see Appendix 1). Their approach is to give pragmatic advice with respect to moderating chil

dren’s playing of computer games using a behavioral paradigm with socialization as a reward mechanism. This includes (1) developing an incentive system, (2) setting limits on playing time, (3) scheduling “reality breaks” to chat to family members about nongame events, (4) making it a social occasion and inviting

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Diagnosis and Management of Video Game Addiction

Table 1 The Twelve Steps (as Applied to Video Game Addiction) Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 Step 11

Step 12

We admitted we were powerless over gaming— that our lives had become unmanageable. Came to believe that a Power greater than ourselves could restore us to a normal way of thinking and living. Made a decision to turn our will and our lives over to the care of this Power of our own understanding. Made a searching and fearless moral and financial inventory of ourselves. Admitted to ourselves and another human being the exact nature of our wrongs. Were entirely ready to have these defects of character removed. Humbly asked God (of our understanding) to remove our shortcomings. Made a list of all the persons we had harmed and became willing to make amends to them all. Made direct amends to such people wherever possible, except when to do so would injure them or others. Continued to take personal inventory, and when we were wrong promptly admitted it. Sought through prayer and meditation to improve our conscious contact with God as we understand him, praying only for knowledge of His will for us and the power to carry that out. Having made an effort to practice these principles in all our affairs, we tried to carry this message to other compulsive gamers.

friends over, and (5) joining in to share time together and so the parent can moderate what games are played. This appears to be a good system for those children in the early stages of excessive playing but might not work so well for outright addicted players. More recently, the On Line Gamers Anonymous organization has been formed. This is a recently formed self help Web site dedicated to stopping people from excessive or addicted gaming levels (see: http://www.olganonboard.org/index.php). The treat

ment philosophy is based heavily on the Minnesota Model system of the “12 Steps” (see Table 1) and is used by such groups as Alcoholics Anonymous and Gamblers Anonymous. As with other 12 step pro

grams, On Line Gamers Anonymous appears to have no formal “therapeutic” techniques but offers support

for people trying to give up gaming themselves. Many offline 12 step programs rely on a system of regular (and sometimes daily) attendance, so research into whether online Web sites such as this actually makes a difference to addicted gamers would prove valuable in determining a treatment strategy. It is clear that online forums and groups have the potential to fulfill an important role in allowing geo

graphically diverse individuals a chance to share experi

ences and opinions, to give and receive advice, and to offer and receive support. Many provide a balanced perspective and should be applauded for this approach, but at the same time there exists a greater proportion whose “scare tactics” serve only to fuel fears and indeed likely drive excessive gamers and those affected by them even further apart.

Gaming Addiction Treatment Clinics

There is growing concern in relation to the need to develop treatment programs for online computer game addiction. The Smith & Jones Clinic (SJC) in the Netherlands claims that it has been taking on an increasing number of young people with gaming addic

tion.60,61 The SJC treatment for gamers follows an abstinence based program that was designed for alco

holics and drug addicts; for treatment to be successful, gaming addicts must never play a video game again. Gamers undergo treatment away from their families in a residential setting, although the final stages of the treatment may involve family therapy; the SJC also helps gamers develop their social skills. Because online video game addicts cannot reason

ably avoid computers in their day to day lives, they have to learn to use them responsibly. This means no gaming whatsoever. The SJC believe that allowing gamers to play for a limited time a day is akin to alco

holics saying they are only going to drink one beer. The SJC approach (as with the 12 step program) aims to show gamers that they are powerless over their addic

tion.62 The SJC teaches gamers “real life excitement” as opposed to the online excitement they get from playing 33

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games—such interventions have included taking the gamers to a club to go dancing, go karting, and para

chute jumping. The SJC philosophy is to get gamers to see that they can achieve the same level of excitement in the real world. The SJC is not the only gaming addiction clinic in existence. There have been an increasing number of stories in the news about the opening of gaming addic

tion treatment clinics in South East Asia, as gaming addictions seem to be on the increase there. According to a report by the Korean government, 2.4% of the population are addicted to games.63 This report also indicates that mental health counseling bears a heavy stigma in Korea; in one case discussed in the report, the father of a child addicted to gaming refused to acknowledge his son had a problem for 3 months, even though he had borrowed substantial amounts of money from family members to support his addiction.63 Simi

lar accounts have also appeared in China.64 Reports such as these indicate cultural concerns and differences. Carjaval65 noted that only males are currently being treated in clinics such as the SJC, and there is some speculation that a masculine desire to control and manipulate events may be behind this gender disparity. Marc Valleur, Director of the Centre Médical Marmot

tan, a public clinic in Paris that is treating an increasing number of patients seeking assistance to quit online gaming, is not sure why they are only attracting men for treatment; he suggests that a rigid hierarchy in the games may satisfy a masculine urge for control.65 Jason Rocca, Executive Director of the International Game Developers Association (based in San Francisco) says that “these so called addictions” are more to do with the person than with the games.65 He claims that gamers who have issues in their personal life will proba

bly withdraw themselves into this world, which is a rich community for interaction. However, preliminary research by Grüsser and col

leagues10 suggests most “hardcore” gamers in World of Warcraft do not play excessively or addictively to attain control. Control is merely a means to an end, and with

out it they would unable to achieve their higher goals of being the best person to person fighter, the best raider, 34

Lesson 3

and so forth. This suggestion also highlights a lack of understanding that currently exists within some research communities about gaming itself. China recently introduced an anti online gaming system and a few clinics as a response to the growing problem of excessive playing of online games there.66 The system allows for 3 hours a day of gaming without penalties, but after 3 hours the values of items won in the game starts to decrease. After 5 hours of gaming per day no experience or benefits can be accrued. This sys

tem was clearly designed by those who know “how to hit players where it hurts,” so to speak. However, with

out further details of how the program operates, it is hard to evaluate whether this would work effectively given that people might be able to create multiple accounts (with characters in each account) to get around the blocking. Such a system will also require monitoring and evaluation and would be much less effective in countries where the government allows a greater level of personal freedom. Press reports indicate that China’s system to curtail excessive game playing only applies to adult gamers. However, the Chinese solution was predictably unpop

ular with gamers and led to a mass exodus from one server to another server when first implemented.66 The Chinese system also includes: (1) banning teenagers from cybercafes, (2) limiting online gaming sessions, (3) boot camps, (4) psychological counselling, and (5) electrocution.67,68 There is little detailed information about the treatment technique used in these therapy centers. The “electrocution” technique is apparently more akin to acupuncture, but it is still hard to see how that might help. It could be that it is a type of aversive therapy where they shock players while they are playing computer games—but this is entirely speculative on the part of the author.

Behavior Therapy and Cognitive Behavior Therapy

Some treatment specialists such as Orzack69 believe that the most effective method to deal with video game addiction is cognitive behavior therapy (CBT), which teaches individuals to identify and eventually solve

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Diagnosis and Management of Video Game Addiction

their underlying problem(s), and then to learn coping skills to prevent relapse; the treatment may also be accompanied by medication. In addition, Orzack rec

ommends support groups for other people affected (e.g., family members). CBT can identify problematic cognitions that may underlie the reason why a person uses video games as a psychological crutch, but is unlikely to cure addictive playing on its own as the behavior is likely to have biopsychosocial antecedents that require more multimodal treatment interventions. Orzack claims that for most players, recovery involves looking at the issues underlying the game habit. Using a CBT approach, gamers examine the emotional motives that prompt them to play a game excessively and look for alternate ways to satisfy those needs. Orzack says the goal of therapy is to get people to realize there is a psychological underpinning to their behavior and that gamers need to take control of changing it. Additional techniques include motiva

tional interviewing to set positive goals, making con

tracts to specify video game use, and the development of other recreational pursuits. Orzack advocates that by looking at the motivating psychological factors and get

ting clients to acknowledge and change these, long

term improvements can be made. Young70 uses CBT as a primary focus but also as an adjunct to other treatment interventions (such as inter

personal psychotherapy techniques) to moderate online usage and to address underlying psychosocial issues often coexistent with this addiction (e.g., social phobia, mood disorders, marital dissatisfaction, job burnout, childhood sexual abuse). Young says that therapy should use (1) time management techniques that help the client structure and regulate online gaming sessions and (2) strategies that help gamers to develop alterna

tive activities that take them away from the computer (e.g., more time with family, engage in hobbies, or exer

cise programs). According to Young,70 Internet addicts (including online gamers) typically suffer interpersonal difficulties such as introversion or have limited social support sys

tems in place, which is in part, why they turn to virtual relationships as a substitute for the lack of real life social

connection. In other cases, because of their addiction, they have lost significant real life relationships such as a spouse, a parent, or a close friend. Interpersonal ther

apy is a brief form of treatment that focuses on educa

tion use to improve interpersonal functioning. Specific interventions include encouragement of affect, com

munication analysis, modelling, and role playing to establish new ways of interacting that address role tran

sitions and interpersonal deficits. Young also advocates use of a 12 step group to assist addicts in finding ade

quate support and sponsorship that enable recovery. Finally, Young says that couples counselling may be an essential part of recovery among online addicts whose marital and familial relationships have been disrupted and negatively influenced by Internet addiction. The therapeutic techniques appear to be based on CBT, skills training, and humanistic techniques. The reasons for using these are: •

Cognitive behavior therapy: Used for under lying psychological conditions such as social phobia, and so forth

•

Skills training: Used for various life training activities such as time management, finding other rewarding activities, and developing core life skills

•

Interpersonal therapy: Used for developing personal skills and social functioning

•

Couple therapy or family therapy: Used for addressing problems caused between part ners and family

Therapeutic interventions such as these appear to provide a coherent and wide ranging therapeutic pro

gram, which given its breadth, would be likely to work well. It is also assumed that the treatment program would be individually tailored for each client. However, the use of a 12 step program appears to sit uncomfort

ably (at least at a philosophical level) with various psy

chotherapies with primary perspectives that each indi

vidual is responsible for his or her own mental state. One of the problems with accepting that people are 35

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“powerless” over their addiction means that it removes free will and responsibility for their actions and could potentially allow them to adopt a “victim” mentality. However, because there is little information available as to the precise procedures adopted by such clinics, it is hard to establish the extent to which these procedures are followed. Woog71 advocates the use of behavioral techniques using gaming as a reward mechanism (i.e., video game play being contingent on completing other daily activi

ties), along with punishments for transgressions (e.g., cancellation of gaming magazine subscriptions). His treatment protocol for gaming addicts is to get players to: •

Acknowledge their level of play and accept responsibility for their actions

•

Reduce the amount of time that they play video games

•

Increase the number of prosocial realworld activities

•

Use the game as reward for engaging in the treatment protocol

•

Get treatment for underlying mood disor ders (e.g., depression, anxiety, etc.)

Motivational Interviewing One therapeutic approach that has been used by some clinical psychologists known to the authors is motiva tional interviewing (MI). MI borrows strategies from cognitive therapy, client centered counseling, systems theory, and the social psychology of persuasion and contains elements of both directive and nondirective therapeutic approaches. Because gamers are often coerced into therapy by a third party (concerned parent or partner), the first task of a therapist is to motivate clients to change something about themselves. Miller and Rollnick72 are the main proponents of such an approach and advocate that MI is primarily about the motivational aspects of changing people’s behavior in the therapeutic setting, an area that is most salient to 36

Lesson 3

those people who engage in addictive behaviors. The underlying theme of such a therapeutic approach is the issue of ambivalence, and how the therapist can use MI to resolve it and allow the client to build commitment and reach a decision to change. Miller and Rollnick argue that motivation is not a personality problem and that there is little evidence for an addictive personality. Such assertions are integral to MI’s theoretical basis. The focus for MI highlights Pro

chaska and DiClemente’s73 well known six stage “wheel of change,” which seeks to explain how people change either with or without a therapist. These stages consist of precontemplation, contemplation, determination, action, maintenance, and relapse. The method employed in MI consists of using a mnemonically structured (A–H) list of eight effective motivational strategies (giving Advice, removing Barriers, providing Choice, decreasing Desirability, practicing Empathy, providing Feedback, clarifying Goals, and active Help

ing). This is intertwined with the five general principles of MI (expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self efficacy). Such a cognitive client cen

tered approach does seem to hold clear possibilities in the rehabilitation of addicted gamers, but as yet there are no reported studies of use in this field.

Treatment of Video Game Addiction: Empirical Case Studies

To date, there have been very few published accounts of treating video game addiction. Kuczmierczyk, Walley, and Calhoun16 reported the case of an 18 year old col

lege student who had been playing video games 3 to 4 hours a day at an average cost of $5 a day over a 5

month period. Kuczmierczyk et al assumed that compulsive video game playing was conceptually similar to pathological gambling and used a cogni tivebehavioral modification approach in their treat ment. Using a combination of self monitoring, Galvanic Skin Response (GSR) biofeedback assisted relaxation train

ing, in vivo exposure, and response prevention, a 90%

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Diagnosis and Management of Video Game Addiction

reduction of playing was observed and continued to be observed at 6 and 12 month follow up examinations. In addition, the patient reported a more satisfying interper

sonal life, had developed an interest in the martial arts, and was significantly less anxious and withdrawn. The only other reported case of treating a video game addict was that of Keepers.15 A 12 year old boy was brought by his mother for psychiatric help because her son was playing videogames for 4 to 5 hours a day at an average cost of $30 to $50 a day over a 6 month period. The amount of money spent significantly exceeded the boy’s disposable income, and he had been stealing and truanting from school to play. Keepers reported that the boy was physically abused by his father (as was the mother). He was placed in a residen

tial treatment center and given family therapy. During therapy the boy remained reluctant to discuss his home situation or his parents. In an effort to uncover some of his feelings, the boy was asked to design his own video game. Using video games as a vehicle for communica

tion, the boy was gradually able to talk about the fear of his father and his feelings of helplessness. Family ther

apy was again undertaken with the eventual outcome of parental separation and return of the boy to his mother. At 6 month follow up, no recurrence of the boy’s diffi

culty was noted. Keepers also considered his patient’s behavior to be reminiscent of pathological gambling.

Multimodal and “Alternative” Treatments

Davis74 outlines a range of diverse treatment tech

niques, from many different behavioral techniques, including both operant conditioning (i.e., negative reinforcement through denial of privileges, and removal of the ability to play), and aversive classical condition

ing (i.e., electric shock treatment), self help groups (modelled on the 12 step programs), and psychophar

macological intervention (e.g., use of antidepressants, antipsychotics, and tranquilizers). There was no evalua

tion of whether any of these treatments worked, and there are ethical dilemmas about whether some of these treatments should be given in the first place (e.g., aver

sive conditioning). There is also the argument that

many of these interventions treat the symptoms (e.g., behavioral and pharmacological treatments) and not the underlying problem of why these individuals are playing to excess in the first place. There are also other unevaluated and somewhat alternative “treatments” for video game addiction such as subliminal therapy (see http://www.subliminaltherapy.com/conditions/gamead diction.html) that offers hypnotherapy through CDs for antianxiety, antidepression, and confidence, and the “Sedona Method” (see http://www.sedona.com/lp

video games.aspx). From the promotional information on the Sedona Method Web site, it would appear that the technique uses some form of cognitive behavioral intervention, although the details are limited: •

By simply stopping and recognizing what is going on you are already interrupting the problem. Next decide to let go of the feeling that is motivating you to do something you know you will later regret. With the Sedona Method, whenever you feel you are losing control you’ll repeat a series of simple ques tions that will allow you to release. When you let go of negative thoughts or feelings, you will instead be filled with a sense of empowerment, confidence and freedom— everything.

It is also worth mentioning that there are a number of commercial products that restrict or block access to gaming sites such as Time Boss, a control system that allows parents to limit the amount of time that their children spend playing a game (see http://www.nicekit. com/parental control/addictions/video game addic

tion treatment.html). Although these various methods may or may not work, it appears that the increased concern over video games has resulted in a booming commercial industry for their treatment. With respect to treatment there appears to be increasing awareness of the problem, as indicated both by sites referring to treatments and those simply identifying the problem. The Chinese techniques appear to use some behavioral techniques, but other mechanisms seem to have no therapeutic 37

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models to sustain them, for example, boot camps. Without further information it is difficult to assess either their techniques or chances of success. Within some Web sites, however, there is an implicit assump

tion that gaming addiction is akin to other addictions and as such, they advise the adoption of the 12 step programs. However, the lack of scientific consensus has not stopped commercial companies trying to make money, and it would be fair to say that the sensational

ist media accounts have created perfect conditions for any pseudo scientific treatment to sell itself as the cure for “game addiction.”

Conclusions

In reviewing the literature on video game addiction at the outset of this lesson, it is clear from the case studies and medical reports displaying the more negative conse

quences of video game playing that they all involved peo

ple who were excessive users of video games. From sur

veys in this area, there is little evidence of serious acute adverse effects on health from moderate play. Adverse effects are likely to be relatively minor and temporary, resolving spontaneously with decreased frequency of play, or to affect only a small subgroup of players. Exces

sive players are the most at risk from developing health problems, although more research appears to be much needed. The need to establish the incidence and preva

lence of clinically significant problems associated with video game play is of paramount importance. There is also no doubt that clearer operational definitions are required if this is to be achieved. Taking all factors and variables into account and by considering the prevalence of play, the evidence of serious adverse effects on health is rare. An overview of the available literature appears to indicate that adverse effects are likely to affect only a very small subgroup of players and that frequent players are the most at risk for developing health problems. Those that it does affect will experience subtle, relatively minor, and temporary effects that resolve spontaneously with decreased frequency of play. Worldwide, there are currently very few practitioners that specialize in the treatment of video game addiction, and this may be because there are so few players who are 38

Lesson 3

genuinely addicted to playing video games. However, as highlighted in the first half of this lesson, the Internet may be facilitating excessive online game playing. Since the mid 1990s, almost all of the writings on treatment of video game addiction have focused on online video game addiction, and it is this variant that appears to cause the most problems for users. There are some specialist addiction treatment clinics (e.g., in Holland, China, Korea, United States), but details of the therapeutic programs have not been pub

lished in the academic literature. It would appear that most of the treatment clinics use a diverse range of inter

ventions, as do those individual practitioners that have written on the issue (in academic journals and Internet

published articles). The programs appear to be split into two camps—the first being a total abstinence model (e.g., Smith & Jones Clinic) and those who believe the problematic gaming behavior can be relearned (Woog).71 In addition, there are individuals such as Young70 (Cen

ter for On Line Addiction) and Orzack (Computer Addiction Services), who use multimodal elements but do not necessarily advocate total abstinence or modera

tion. All the treatment programs aim to increase prosocial skills through social activities and replacement of time spent on the computer with real life activities. In addi

tion, they all provide some form of personal “talking” therapy to address individual issues such as depression and anxiety. They also integrate management skills such as goal setting and time keeping so that players can estab

lish control over their behavior. Woog outlines some strong behavioral components such as the use of the computer as a reward for good behavior and punishment when excessive gaming is indulged in. In the right treatment schedule, this system could be very powerful and allow the player to relearn appropriate gaming behaviors. The Smith & Jones Clinic and Young use the use of an adapted 12 step pro

gram that advocates abstinence, although the extent to which this is applied to all their gamers is unclear. It could be argued that those who participate in 12 step programs are not getting therapy at all—they are simply avoiding the addictive stimulus through the testimonials

Griffiths

Diagnosis and Management of Video Game Addiction

of other ex addicts. Because there is very little empirical research into the long term effectiveness of these pro

grams it is hard to establish the credibility of these clinics or their techniques. The cognitive behavioral model is both better researched (although with reference to differ

ent disorders), has tried and tested therapeutic tech

niques, and is underpinned by a verified psychological theory. Overall, further research is required to establish the therapeutic efficacy of any and all treatment pro

grams directed at excessive gaming.

Appendix 1 List of Online Support Forums for Excessive Video Game Playing • http://parents.berkeley.edu/advice/teens/gameaddiction.html

• http://www.mediafamily.org/facts/facts_gameaddiction.shtml

• http://games.groups.yahoo.com/group/spousesagainsteverquest/ • http://health.groups.yahoo.com/group/EverQuest-Widows/

• http://www.childrenfirst.nhs.uk/families/experts/c/computergame_addiction.html • http://www.wowdetox.com/index.php

• http://www.mothernature.com/Library/bookshelf/Books/ 50/116.cfm

References 1. Griffiths MD. The educational benefits of videogames. Educ Health (Abingdon). 2002;20:47–51. 2. de Freitas S, Griffiths MD. Online gaming as an educational tool in learning and training. British Journal of Educational Technology. 2007;38:536–538. 3. Cole H, Griffiths MD. Social interactions in massively mul

tiplayer online role playing gamers. Cyberpsychol Behav. 207; 10:575–583. 4. Hussain Z, Griffiths MD. Gender swapping and socialising in cyberspace: an exploratory study. Cyberpsychol Behav. 2008;11:47–53. 5. Griffiths MD. Video games and health. BMJ. 2005;331: 122–123. 6. Griffiths MD. The therapeutic value of videogames. In: Gold stein J, Raessens J, eds. Handbook of Computer Game Stud

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8. Chappell D, Eatough VE, Davies, MNO, Griffiths MD. EverQuest—It’s just a computer game right? An interpreta

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32. Griffiths MD. Does internet and computer “addiction” exist? Some case study evidence. Cyberpsychol Behav. 2000;3:211–218. 33. Griffiths MD, Davies MNO, Chappell D. Breaking the stereotype: the case of online gaming. Cyberpsychol Behav. 2003;6:81–91. 34. Griffiths MD, Davies MNO, Chappell D. Online computer gaming: a comparison of adolescent and adult gamers. J Ado lesc. 2004;27:87–96.

17. Shotton M. Computer Addiction? A Study of Computer Depen dency. London: Taylor and Francis; 1989.

35. Griffiths MD, Davies MNO, Chappell D. Demographic fac

tors and playing variables in online computer gaming. Cyberpsychol Behav. 2004;7:479–487.

18. Griffiths MD, Hunt N. Computer game playing in adoles

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36. Wan C, Chiou W. Psychological motives and online games addiction: a test of flow theory and humanistic needs theory for Taiwanese adolescents. Cyberpsychol Behav. 2006;9:317–324.

19. Griffiths MD, Hunt N. Dependence on computer games by adolescents. Psychol Rep. 1998;82:475–480.

37. Wan C, Chiou W. Why are adolescents addicted to online gaming? An interview study in Taiwan. Cyberpsychol Behav. 2006;9:762–766.

20. Fisher SE. Identifying video game addiction in children and adolescents. Addictive Behaviors. 1994;19:545–553. 21. Parsons K. Educational places or terminal cases: young people and the attraction of computer games. Paper presented at: British Sociological Association Annual Conference; 1995; University of Leicester. 22. Phillips CA, Rolls S, Rouse A, Griffiths M. Home video game playing in schoolchildren: a study of incidence and patterns of play. J Adolesc. 1995;18:687–691. 23. Griffiths MD. Computer game playing in early adolescence. Youth and Society. 1997;29: 223–237. 24. Tejeiro Dalguero RAT, Moran RMB. Measuring problem video game playing in adolescents. Addiction. 2002;97: 1601–1606. 25. Hauge MR, Gentile DA. Video game addiction among adoles cents: associations with academic performance and aggression. Paper presented at: Society for Research in Child Develop

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38. Rushton DN. “Space invader” epilepsy. Lancet. 1981;1:501. 39. Loftus GA, Loftus EF. Mind at Play: The Psychology of Video Games. New York: Basic Books; 1983. 40. Griffiths MD. Gambling and Gaming Addictions in Adolescence. Leicester: British Psychological Society/Blackwells; 2002. 41. Spence SA. Nintendo hallucinations: a new phenomenologi

cal entity. Psychology and Psychotherapy: Theory, Research and Practice. 1993;10: 98–99. 42. Schink JC. (1991). Nintendo enuresis. Am J Dis Child. 145, 1094. 43. Corkery JC. Nintendo power. Am J Dis Child. 1990;144:959. 44. McCowan TC. Space invaders wrist. N Engl J Med. 1981; 304:1368. 45. Miller DLG. Nintendo neck. CMAJ. 1991;145;1202. 46. Bright DA, Bringhurst DC. Nintendo elbow. West J Med. 1992;156:667–668. 47. Reinstein L. de Quervain’s stenosing tenosynovitis in a video games player. Arch Phys Med Rehabil. 1983;64:434–435.

26. Gentile DA. Video game addiction: is it real? http:// www.harrisinteractive.com/news/allnewsbydate.asp?NewsID =1196. Accessed May 17, 2008.

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50. Siegal IM. Nintendonitis. Orthopedics. 1991;14:745.

29. Rutkowska JC, Carlton T. Computer games in 12–13 year olds’ activities and social networks. Paper presented at: British Psychological Society Annual Conference; April 1994; Uni

versity of Sussex. 30. Wood RTA, Griffiths MD. Time loss whilst playing video games: is there a relationship to addictive behaviours? Inter national Journal of Mental Health and Addiction. 2007;5: 141–149. 31. Wood RTA, Griffiths MD, Parke A. Experiences of time loss among videogame players: an empirical study. Cyberpsychol Behav. 2007;10:45–56.

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51. Cleary AG, Mckendrick H, Sills JA. Hand arm vibration syndrome may be associated with prolonged use of vibrating computer games. BMJ. 2002;324:301. 52. Mirman M, Bonian VG. “Mouse elbow”: a new repetitive stress injury. J Am Osteopath Assoc. 1992;92:701. 53. Friedland RP, St. John JN. Video game palsy: distal ulnar neuropathy in a video game enthusiast. N Engl J Med. 1984; 311:58–59. 54. Spielberg I. The challenges of stopping gaming addiction. http://www.treatmentonline.com/treatments.php?id=204. Accessed May 17, 2008.

Diagnosis and Management of Video Game Addiction

Griffiths

References 55. Griffiths MD. Videogames: advice for teachers and parents. Education and Health. 2003;21:48–49.

http://www.iht.com/articles/2006/06/11/business/addict12. php?page=1. Accessed June 30, 2008.

56. Griffiths MD. Online therapy for addictive behaviors. Cyberpsychol Behav. 2005;8:555–561.

66. Dickie M. China moves to zap online game addiction. Finan

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57. Griffiths MD, Cooper G. Online therapy: implications for problem gamblers and clinicians. British Journal of Guidance and Counselling. 2003;13:113–135. 58. Wood RTA, Griffiths MD. Online guidance, advice, and support for problem gamblers and concerned relatives and friends: an evaluation of the Gam Aid pilot service. British Journal of Guidance and Counselling. 2007;35:373–389. 59. National Institute on Media and the Family. Computer and video game addiction. http://www.mediafamily.org/facts/ facts_gameaddiction.shtml. Accessed May 17, 2008. 60. Courtenay Smith N. The frightening new addiction: com

puter gaming. Daily Mail, November 29, 2006. http://www.dailymail.co.uk/pages/live/femail/article.html?in _article_id=419514&in_page_id=1879. Accessed May 17, 2008. 62. Rauh S. Detox for video game addiction? CBC News, July 3, 2006.http://www.cbsnews.com/stories/2006/07/03/health/ webmd/main1773956.shtml. Accessed May 17, 2008. 63. Faiola A. When escape seems just a mouse click away: stress

driven addiction to online games spikes in S. Korea. Washing ton Post, May 27, 2006. http://www.washingtonpost.c om/wp dyn/content/article/2006/05/26/AR2006052601960 .html. Accessed May 17, 2008. 64. Sebag Montefiore, P. China’s young escape into the web. The Guardian, November 20, 2005. http://www.guardian.co.uk/ technology/2005/nov/20/news.china. Accessed May 17, 2008. 65. Carjaval D. Virtual gamers with addictions cause plenty of real concerns. International Herald Tribune, June 12, 2006.

67. Chapman, M. China “electrocutes” teen web addicts. Vunet.com, February 26, 2007. http://www.vnunet. com/vnunet/news/2184143/china electrocutes internet. Accessed May 17, 2008. 68. Williams I. Chinese gamer dies after 15 day session. Vunet.com, March 1, 2007. http://www.vnunet.com/ vnunet/news/2184523/online addict games himself. Accessed May 17, 2008. 69. Orzack MH, Vouse AC, Wolf D, Hennen J. An ongoing study of group treatment for men involved in problematic Internet enabled sexual behavior. CyberPsychology and Behav ior. 2006;9:348–360. 70. Young K. Addiction to MMORPGs: symptoms and treat

ment. http://www.netaddiction.com/articles/articles.htm. Accessed May 17, 2008. 71. Woog, K.M. Gaming addiction. http://www.wooglabs. com/gaming addiction.pdf. Accessed May 17, 2008. 72. Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guildford Press; 1991. 73. Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice. 1982;19:276–288. 74. Davis D. Video game addiction scale. http://domdavis.com/ 2008/02/04/video game addiction scale with abridged fore

word/. Accessed May 17, 2008.

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Lesson 3

Questions B a s e d O n T h i s L e s s o n

To earn CE credits, answer the following questions on your quiz response form.

9. Which of the following medical conditions has not been reported as a consequence of excessive video game playing? A. Visual hallucinations

A. Alcoholism

B. Repetitive strain injury

B. Heroin addiction

C. Enuresis

C. Pathological gambling

D. Hand arm vibration syndrome

D. Exercise addiction

10. All of the following represent central problems with the criteria for video game addiction measures, except: A. Have no measure of severity B. Have no temporal dimension C. Have a tendency to under estimate the preva

lence of problems D. Take no account of the context of video game use

42

11. To date, most treatments of video game addiction tend to be based on the treatment philosophies of:

12. All of the following were mentioned as methods for treating video game addiction, except: A. Online support groups B. Cognitive behavior therapy C. Motivational interviewing D. Sensory depravation