Thursday, June 1, 2023
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Video game playing is now one of the most popular hobbies across sex and age groups, but a small proportion of gamers develop negative symptoms affecting their mental and physical health and causing functional impairment.
Inclusion of gaming disorder (GD) in the International Classification of Diseases, 11th revision, resulted from a fairly broad expert consensus. To date, there are no authoritative guidelines for what makes an effective GD intervention, nor is the concept of recovery fully applied to GD.
Three studies provide new insight into the growing problem of GD, including the condition’s genesis, its effective treatments, and the need for a greater focus on recovery.
A team of international researchers led by Orsolya Király, PhD, from the Institute of Psychology, Eötvös Loránd University, Budapest, Hungary, reviewed the characteristics and etiology of GD. They concluded that its genesis arises from the interaction of environmental factors, game-specific factors, and individual factors, including personality traits, comorbid psychopathology, and genetic predisposition.
“The development of GD is a complex process, and we identified 3 major factors involved,” study coauthor Mark Griffiths, PhD, distinguished professor of behavioral addiction and director of the International Gaming Research Unit, Psychology Department, Nottingham Trent University, United Kingdom, told Medscape Medical News. Because of this complexity, “prevention and intervention in GD require multiprofessional action.”
The review was published in the April issue of Comprehensive Psychiatry.[1]
In a second paper, Chinese investigators reviewing randomized controlled trials (RCTs) presented “compelling evidence” to support 4 effective interventions for GD: group counseling, an acceptance and cognitive restructuring intervention program (ACRIP), short-term cognitive behavioral therapy (CBT), and craving behavioral intervention (CBI).
The review was published online February 6 in Frontiers in Psychiatry.[2]
A third paper, in which researchers analyzed close to 50 studies of GD, found that the concept of “recovery” is rarely mentioned in GD research. Lead author Belle Gavriel-Fried, PhD, senior professor, Bob Shapell School of Social Work, Tel Aviv University, Israel, told Medscape Medical News that recovery is a “holistic concept that taps into many aspects of life.”
Understanding the “differences in the impact and availability” of negative and positive human resources and their effect on recovery “can help clinicians to customize treatment,” she said.
That review was published online March 14 in the Journal of Behavioral Addictions.[3]
Complex Interplay
GD is garnering increasing attention in the clinical community, especially since 2019, when the World Health Organization included it in the International Classification of Diseases, 11th revision.
“Although for most individuals gaming is a recreational activity or even a passion, a small group of gamers experiences negative symptoms which impact their mental and physical health and cause functional impairment,” write Dr Király and colleagues.
Dr Griffith explained that his team wanted to provide an “up-to-date primer, a ‘one-stop shop,’ on all things etiologic concerning gaming disorder for academics and practitioners” as well as others, such as health policy makers, teachers, and individuals in the gaming industry.
The researchers identified 3 factors that increase the risk of developing GD, the first being gaming-related factors, which make video games “ ‘addictive’ in a way that vulnerable individuals may develop GD,” they write.
For example, GD is more prevalent among online versus offline game players, possibly because online multiplayer games “provide safe environments in which players can fulfil their social needs, while remaining invisible and anonymous.”
Game genre also matters, with massively multiplayer online role-playing games, first-person/third-person shooter games, real-time strategy games, and multiplayer online battle arena games most implicated in problematic gaming. Moreover, the “monetization techniques” of certain games also increase their addictive potential.
The researchers point to individual factors that increase the risk of developing GD, including male sex and younger age, personality traits such as impulsivity and sensation-seeking, and comorbidities including attention-deficit/hyperactivity disorder, anxiety, and depression.
Poor self-esteem and lack of social competencies make gaming “an easy and efficient way to compensate for these deficiencies, which in turn heightens the risk to develop GD,” they add. Neurobiological processes and genetic predisposition also play a role.
Last, the authors mention environmental factors, including family and peer-group issues, problems at work or school, and cultural factors.
“The take-home messages are that problematic gaming has had a long history of empirical research; that the psychiatric community now views GD as a legitimate mental health issue; and that the reasons for GD are complex, with many different factors involved in the acquisition, development, and maintenance of GD,” said Dr Griffiths.
Beneficial Behavioral Therapies
Yuzhou Chen and colleagues, from Southwest University, Chongqing, China, conducted a systematic review of RCTs investigating interventions for treating GD. Despite the “large number of intervention approaches developed over the past decade, as yet there are no authoritative guidelines for what makes an effective GD intervention,” they write.
Few studies have focused specifically on GD, but instead have focused on a combination of internet addiction and GD. But the interventions used to treat internet addiction may not apply to GD. And few studies have used an RCT design. The researchers therefore set out to review studies that specifically used an RCT design to investigate interventions for GD.
They searched 6 databases to identify RCTs that tested GD interventions from the inception of each database until the end of 2021. To be included, participants had to be diagnosed with GD and receive either a “complete and systematic intervention” or be in a comparator control group receiving no intervention or placebo.
Seven studies met the inclusion criteria (N = 332 participants). The studies tested 5 interventions:
The mean duration of the interventions ranged from 3 to 15 weeks.
The primary outcome was GD severity, with secondary outcomes including depression, anxiety, cognition, game time, self-esteem, self-compassion, shyness, impulsivity, and psychological well-being.
Group counseling, CBI, ACRIP, and short-term CBT interventions had “a significant effect on decreasing the severity of GD,” whereas tDCS had “no significant effect.”
Results for secondary outcomes are listed in Table 1.
Behavioral therapy “exerts its effect on the behavioral mechanism of GD; for example, by reducing the association between game-related stimuli and the game player’s response to them,” the authors suggest.
Table 1. Results for Secondary Outcomes in Systematic Review of RCTs
| Intervention | Reduction | Increase |
|---|---|---|
| Group counseling | Depression Maladaptive cognition Number of hours spent gaming Anxiety |
|
| Short-term CBT | Depression | |
| ACT | Maladaptive cognition | Self-compassion |
| CBI | Number of hours spent gaming | |
| CBT | Shyness | |
| ACRIP | Psychological well-being |
Behavioral therapy “exerts its effect on the behavioral mechanism of GD; for example, by reducing the association between game-related stimuli and the game-players responses to them,” Dr Chen and colleagues suggest.
Recovery vs Pathology
Recovery “traditionally represents the transition from trauma and illness to health,” Dr Gavriel-Fried and colleagues note.
Two paradigms of recovery are “deficit-based” and “strength-based.” The first assesses recovery in terms of abstinence, sobriety, and symptom reduction, and the second focuses on “growth, rather than a reduction in pathology.”
But although recovery is “embedded within mental [health] addiction policies and practice,” the concept has received “scant attention” in GD research.
Most studies (n = 32) consisted of exclusively male subjects. Only 10 included both sexes, and female participants were in the minority.
Most studies (n = 42) did not address the concept of recovery, although all studies did report significant improvements in gaming-related pathology. Typical terminology used to describe changes in participants’ GD were “reduction” and/or “decrease” in symptom severity.
Although 18 studies mentioned the word “recovery,” only 5 actually discussed issues related to the notion of recovery, and only 5 used the term “abstinence.”
In addition, only 13 studies examined positive components of life in patients with GD, such as increased psychological well-being, life satisfaction, and quality of life; improved emotional state, relational skills, and executive control; and improved self-care, hygiene, sleep, and interest in school studies.
“As a person and researcher who believes that words shape the way we perceive things, I think we should use the word ‘recovery’ rather than ‘pathology’ much more in research, therapy, and policy,” said Dr Gavriel-Fried.
She noted that because GD is a “relatively new behavioral addictive disorder, theories are still being developed and definitions of the symptoms are still being fine-tuned.”
“The field as a whole will benefit from future theoretical work that will lead to practical solutions for treating GD and ways to identify the risk factors,” Dr Gavriel-Fried said.
Filling a Research Gap
Commenting for Medscape Medical News, David Greenfield, MD, founder and medical director of the Connecticut-based Center for Internet and Technology Addiction, noted that 3 decades ago, there was almost no research into this area.
“The fact that we have these reviews and studies is good because all of the research adds to the science providing more data about an area we still don’t know that much about, where research is still in its infancy,” said Dr Greenfield, who was not involved with the present study.
“Although we have definitions, there’s no complete agreement about the definitions of GD, and we do not yet have a unified approach,” continued Dr Greenfield.
He suggested that “recovery” is rarely used as a concept in GD research perhaps because there is a “bifurcation in the field of addiction medicine in which behavioral addictions are not seen as equivalent to substance addictions,” and particularly with GD, the principles of “recovery” have not yet matured.
“Recovery means meaningful life away from the screen, not just abstinence from the screen,” said Dr Greenfield.
The study by Dr Chen and colleagues was supported by grants from the National Social Science Foundation of China, the Chongqing Research Program of Basic Research and Frontier Technology, and the Fundamental Research Funds for the Central Universities. The authors have reported no relevant financial relationships. Dr Griffiths has reported receiving research funding from Norsk Tipping (the gambling operator owned by the Norwegian government). The study by Dr Király and colleagues received support from the Hungarian National Research Development and Innovation Office and the Janos Bolyai Research Scholarship Academy of Sciences to individual investigators. A coauthor has received funding for a number of research projects in the area of gambling from Gamble Aware. The study by Dr Gavriel-Fried and colleagues received support from the Hungarian National Research Development and Innovation Office and the Janos Bolyai Research Scholarship Academy of Sciences to individual investigators. Dr Gavriel-Fried has reported receiving grants from the Israel National Insurance Institute and the Committee for Independent Studies of the Israel Lottery. Disclosures for the other authors are listed with the article. Dr Greenfield has reported no relevant financial relationships.
