Gaming Disorder: a Virtual Addiction · VG vs. Sleep • Insufficient sleep strongly predicts...

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 is an official

diagnosis in ICD-11


Agenda

• Mental health effects

• Why VG?

• Diagnosis

• Epidemiology

• Treatment


What Happens When its Time to Stop?


Worldwide Sales (in Billions)

1991 – $12

2001 - $35

2013 - $82

2019 - ~$152


How Much Do Youth Play Video Games?


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


Who Plays Video Games?


Adults Play Too

• 74% gamers are adult (ESA, ‘15)

• Average gamer 33

years old (ESA ‘18)


Why Are Video Games Habit Forming?


Be All You Can’t Be


Pretend 2.0


Escapism


Flow: state of being fully

immersed in activity, feeling focus &

enjoyment


What Does Video Game Flow Look Like?


No Stopping Cues


Psychological Needs

Self determination theory


Autonomy

Need to control the course of our lives


Competence

Need to feel effective in dealing with environment


Relatedness

Need to feel connected with others


Excessive Play Counterproductive (Wu ’13 & Zhang ‘19)


Persuasive Design• Behavioral Game Design

• Variable & Fixed Ratio

Reinforcement

• Research Labs


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


How Do Video Games Affect Mental Health?


Online Habits & Mental Health

• TV & Movies

• Video Games

• Computers

• Smartphones

Source: Przyblyski ’17 &

Twenge ‘18


https://www.scientificamerican.com/sciam/cache/file/BB46146E-1F49-4F96-84002A3DB36504F4_source.jpg

VG Displace Healthy Habits

• Socializing

IRL

• Exercise

• Academics

• Sleep


Relationships IRL


PS3

Exercise & Diet


Academics% of 12th graders who read a book for

pleasure almost every day


Twenge ‘19

VG vs. Sleep


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


Addiction


Excessive pattern of compulsive behavior

leading to impairment & associated

symptoms


Online Addictions

Any can become

addictive if

sufficiently

reinforcing:

• Gaming

• Social Media

• Pornography

• Gambling


Internet Gaming Disorder

• Condition requiring further study (2013)

• Pattern of excessive play

• Impairment or distress

• Additional symptoms


1. Increasing Time Playing



2. Preoccupation

3. Loss of Interest in Other Hobbies


4. Withdrawal


5. Can’t Cut Down


6. Continue Despite Psychosocial Problem


7. Lies


8. Threatens Relationship or Education


9. Play to Alleviate Negative Mood


VG Addiction Testimony


Additional Symptoms

• Substance use disorder

requires 2 of 9

• Gambling disorder

requires 4 of 9

• IGD requires 5 of 9


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


Who Gets Addicted to VG?


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)


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 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)


Biological Correlates

• Gambling -

abnormalities in

brain structure &

function

• VG addicts -

similar

abnormalities in

29 studies


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)


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)


Cognitive Changes

• Impaired response

inhibition

• Cognitive bias

• Executive dysfunction

• Identical in IGD (Van Holst

’12, Zhou ’13, Wang ’15, & Yao

‘15)


Sequelae

• Depression (Gentile ‘11)

• Anxiety

• Insomnia

• School failure (Lam ’10, Achab

’11 & Gentile ’11)

• Worsened family relations(Gentile ‘11 & Su ‘18)

• Decreased supervision


Family Guidance


Talking With Families About VG Habits

• Parents as role models

• Make time for sleep, socializing, exercise,

family, schoolwork & chores

• Tech-free times & areas


Parental Monitoring

• Restrictive – limits

• Active – coplay & discuss


Parent Monitoring

• Decreasing total screen time improves sleep, school

performance & BMI (Tiberio ’14 & Gentile ’14)

• Decreasing screen violence improves behavior (Gentile ’14)


Activities


Treatment


• Therapy

• Medication

• Comorbidities

Psychotherapy

• Modeled on substance

abuse tx

• CBT (King ‘17)

• Motivational interviewing

• Group & family

• Harm reduction


Psychotherapy

• Thirty clinical trials showed positive results (King ‘17)

• Evidence limited


Therapy Techniques

• Denial

• Personal inventory

• Practice the opposite

• Goals

• Abstinence

• Peer group

• Prevent enabling


Medication

• ADHD

• Antidepressants

• No FDA Approval


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


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)


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


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


VG Addiction in China & S. Korea

• #1 public health threat

• Laws limit play

• Hundreds of detox & residential facilities


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 · VG vs. Sleep • Insufficient sleep strongly predicts...

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