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Shi W, Zhao Y, Zhou J, Shi J. Differential neural reward processes in internet addiction: A systematic review of brain imaging research. Addict Behav 2025; 167:108346. [PMID: 40186989 DOI: 10.1016/j.addbeh.2025.108346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Revised: 03/12/2025] [Accepted: 03/24/2025] [Indexed: 04/07/2025]
Abstract
OBJECTIVES This systematic review aims to examine the neural correlates of reward processing in various forms of Internet Addiction (IA) among adults, including generalized IA and specific conditions such as Internet Gaming Disorder (IGD). The study seeks to identify distinct patterns of altered connectivity and activation in reward-related brain regions across different IA subtypes. METHODS We analyzed findings from 44 neuroimaging studies, aligning with the Research Domain Criteria (RDoC) framework. The review focused on three key aspects of reward processing: responsiveness, learning, and valuation. Studies included both structural and functional neuroimaging data from adult populations with various forms of IA. RESULTS Findings suggest distinct patterns of altered connectivity and activation in reward-related brain regions across different IA subtypes. IGD is associated with widespread abnormalities in both structural and functional connectivity within the reward network, whereas excess social media use primarily affects the amygdala-striatal system. However, methodological limitations, including variability in IA definitions, lack of comparative studies between IA subtypes, and predominance of cross-sectional designs, hinder definitive conclusions. CONCLUSION This review underscores the need for a nuanced approach to IA, recognizing potentially distinct neural mechanisms across subtypes. Such insights could inform the development of targeted interventions and enhance the clinical utility of IA research and treatment. Future research should address current methodological limitations to provide more definitive conclusions about the neurobiological underpinnings of various forms of IA.
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Affiliation(s)
- Wendi Shi
- Shanghai Key Laboratory of Mental Health and Psychological Crisis, Affiliated Mental Health Center (ECNU), School of Psychology and Cognitive Science, East China Normal University, Shanghai, China
| | - Ying Zhao
- Shanghai Key Laboratory of Mental Health and Psychological Crisis, Affiliated Mental Health Center (ECNU), School of Psychology and Cognitive Science, East China Normal University, Shanghai, China
| | - Jiaqi Zhou
- Shanghai Key Laboratory of Mental Health and Psychological Crisis, Affiliated Mental Health Center (ECNU), School of Psychology and Cognitive Science, East China Normal University, Shanghai, China.
| | - Jiangboheng Shi
- Shanghai Key Laboratory of Mental Health and Psychological Crisis, Affiliated Mental Health Center (ECNU), School of Psychology and Cognitive Science, East China Normal University, Shanghai, China
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Simkute D, Dores AR, Barbosa F, Griskova-Bulanova I. Problematic Gaming and Gambling: A Systematic Review of Task-Specific EEG Protocols. J Gambl Stud 2024; 40:2153-2187. [PMID: 39002089 DOI: 10.1007/s10899-024-10332-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/15/2024]
Abstract
Even though gaming and gambling bear similar problematic behavioral aspects, there are no recognizable neurophysiological biomarkers or features characterizing and/or distinguishing these conditions. A systematic review of the literature with a focus on methods was performed in PubMed, Scopus, Web of Science (Web of Science Core Collection), EBSCOhost Research Databases (APA PsycINFO; APA PsycArticles; OpenDissertations; ERIC) databases. Following search terms were used to search the databases: ERP, "event related potential*", EP, "evoked potential*", SS, "steady state", EEG, electroencephal*; gam*. Data about the participants (total number, gender, age), main aim of the study and information about the experimental setup (experimental task description, stimuli used, ERPs measured (latency windows and placement of the electrodes), process evaluated) was extracted. A total of 24 studies were revised (problematic gaming - 16, pathological gambling - 8). The experimental protocols could be grouped into 3 main target domains (Cue-reactivity, General Information processing and Reward Processes & Risk Assessment). Sample-related limitations (small sample sizes, gender differences, differences between the groups regarding potential confounding variables) and heterogeneity regarding the experimental tasks, implementation and interpretation reviewed. Gambling-related research is highly focused on the investigation of the reward-related processes, whereas gaming-related research is mostly focused on the altered aspects of more general information processing. A vast heterogeneity regarding the ERP experimental paradigms being used and lack of clear guidelines and standardized procedures prevents identification of measures capable to reliably discriminate or characterize the population susceptible to addictive behavior or being able to diagnose and monitor these disorders.
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Affiliation(s)
- Dovile Simkute
- Life Sciences Center, Institute of Biosciences, Vilnius University, Sauletekio Ave. 7, 10257, Vilnius, Lithuania
| | - Artemisa R Dores
- Escola Superior de Saúde, Politécnico Do Porto, Porto, Portugal
- Laboratory of Neuropsychophysiology, Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal
| | - Fernando Barbosa
- Laboratory of Neuropsychophysiology, Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal
| | - Inga Griskova-Bulanova
- Life Sciences Center, Institute of Biosciences, Vilnius University, Sauletekio Ave. 7, 10257, Vilnius, Lithuania.
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Skok K, Waszkiewicz N. Biomarkers of Internet Gaming Disorder-A Narrative Review. J Clin Med 2024; 13:5110. [PMID: 39274323 PMCID: PMC11396063 DOI: 10.3390/jcm13175110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/14/2024] [Accepted: 08/22/2024] [Indexed: 09/16/2024] Open
Abstract
Since game mechanics and their visual aspects have become more and more addictive, there is concern about the growing prevalence of Internet gaming disorder (IGD). In the current narrative review, we searched PubMed and Google Scholar databases for the keywords "igd biomarker gaming" and terms related to biomarker modalities. The biomarkers we found are grouped into several categories based on a measurement method and are discussed in the light of theoretical addiction models (tripartite neurocognitive model, I-PACE). Both theories point to gaming-related problems with salience and inhibition. The first dysfunction makes an individual more susceptible to game stimuli (raised reward seeking), and the second negatively impacts resistance to these stimuli (decreased cognitive control). The IGD patients' hypersensitivity to reward manifests mostly in ventral striatum (VS) measurements. However, there is also empirical support for a ventral-to-dorsal striatal shift and transition from goal-directed to habitual behaviors. The deficits in executive control are demonstrated in parameters related to the prefrontal cortex (PFC), especially the dorsolateral prefrontal cortex (DLPFC). In general, the connection of PFC with reward under cortex nuclei seems to be dysregulated. Other biomarkers include reduced P3 amplitudes, high-frequency heart rate variability (HRV), and the number of eye blinks and saccadic eye movements during the non-resting state. A few studies propose a diagnostic (multimodal) model of IGD. The current review also comments on inconsistencies in findings in the nucleus accumbens (NAcc), anterior cingulate cortex (ACC), and precuneus and makes suggestions for future IGD studies.
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Affiliation(s)
- Katarzyna Skok
- Faculty of Education, University of Bialystok, ul. Świerkowa 20, 15-328 Bialystok, Poland
| | - Napoleon Waszkiewicz
- Department of Psychiatry, Medical University of Bialystok, pl. Wołodyjowskiego 2, 15-272 Bialystok, Poland
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Chang RS, Lee M, Im JJ, Choi KH, Kim J, Chey J, Shin SH, Ahn WY. Biopsychosocial factors of gaming disorder: a systematic review employing screening tools with well-defined psychometric properties. Front Psychiatry 2023; 14:1200230. [PMID: 37533885 PMCID: PMC10390702 DOI: 10.3389/fpsyt.2023.1200230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/21/2023] [Indexed: 08/04/2023] Open
Abstract
Background and aims Considering the growing number of gamers worldwide and increasing public concerns regarding the negative consequences of problematic gaming, the aim of the present systematic review was to provide a comprehensive overview of gaming disorder (GD) by identifying empirical studies that investigate biological, psychological, and social factors of GD using screening tools with well-defined psychometric properties. Materials and methods A systematic literature search was conducted through PsycINFO, PubMed, RISS, and KISS, and papers published up to January 2022 were included. Studies were screened based on the GD diagnostic tool usage, and only five scales with well-established psychometric properties were included. A total of 93 studies were included in the synthesis, and the results were classified into three groups based on biological, psychological, and social factors. Results Biological factors (n = 8) included reward, self-concept, brain structure, and functional connectivity. Psychological factors (n = 67) included psychiatric symptoms, psychological health, emotion regulation, personality traits, and other dimensions. Social factors (n = 29) included family, social interaction, culture, school, and social support. Discussion When the excess amount of assessment tools with varying psychometric properties were controlled for, mixed results were observed with regards to impulsivity, social relations, and family-related factors, and some domains suffered from a lack of study results to confirm any relevant patterns. Conclusion More longitudinal and neurobiological studies, consensus on a diagnostic tool with well-defined psychometric properties, and an in-depth understanding of gaming-related factors should be established to settle the debate regarding psychometric weaknesses of the current diagnostic system and for GD to gain greater legitimacy in the field of behavioral addiction.
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Affiliation(s)
- Rose Seoyoung Chang
- Department of Psychology, Seoul National University, Seoul, Republic of Korea
| | - Minju Lee
- Department of Psychology, Seoul National University, Seoul, Republic of Korea
| | - Jooyeon Jamie Im
- Department of Psychology, Seoul National University, Seoul, Republic of Korea
| | - Kee-Hong Choi
- School of Psychology, Korea University, Seoul, Republic of Korea
| | - Jueun Kim
- Department of Psychology, Chungnam National University, Daejeon, Republic of Korea
| | - Jeanyung Chey
- Department of Psychology, Seoul National University, Seoul, Republic of Korea
| | - Suk-Ho Shin
- Department of Child and Adolescent Psychiatry, Dr. Shin’s Neuropsychiatric Clinic, Seoul, Republic of Korea
| | - Woo-Young Ahn
- Department of Psychology, Seoul National University, Seoul, Republic of Korea
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Razum J, Baumgartner B, Glavak-Tkalić R. Psychometric validity and the appropriateness of tolerance as a criterion for internet gaming disorder: A systematic review. Clin Psychol Rev 2023; 101:102256. [PMID: 36878146 DOI: 10.1016/j.cpr.2023.102256] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 12/16/2022] [Accepted: 02/16/2023] [Indexed: 02/26/2023]
Abstract
Tolerance is a controversial but still an omnipresent criterion in measuring problematic gaming and Internet Gaming Disorder (IGD). Despite criticisms, a systematic review of its suitability has not been conducted until now. The aim of this study was to assess the evidence of psychometric validity and the appropriateness of tolerance as a criterion for IGD. A total of 61 articles were included in the review, 47 quantitative, 7 qualitative studies,plus 7 studies that introduce potential item wordings for operationalizing tolerance. Results showed that the tolerance item tends to have acceptable to high factor loadings on the single IGD factor. While tolerance sometimes did not adequately differentiate the engaged gamers from those with a probable disorder, it was endorsed at medium to high levels of IGD severity and had a good performance in the interviews. It, however, showed weak relations with distress and well-being. In qualitative studies, tolerance as currently defined by DSM-5 and measured by questionnaires (i.e., increasing amounts of time spent on gaming) was almost unequivocally rejected by gamers. The solid performance of tolerance in psychometric studies was probably due to deficiencies of the IGD construct, which also contains other disputed criteria. Tolerance lacks relevance in measuring IGD and care should be taken when using and interpreting IGD measures with this criterion.
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Affiliation(s)
- Josip Razum
- Ivo Pilar Institute of Social Sciences, Marulićev trg 19/1, 10000 Zagreb, Croatia
| | - Benedict Baumgartner
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität, Ismaningerstr. 22, 81675, München, Germany
| | - Renata Glavak-Tkalić
- Ivo Pilar Institute of Social Sciences, Marulićev trg 19/1, 10000 Zagreb, Croatia.
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Kashif S, Pandey S, Warriach ZI. Neurophysiological Markers of Internet Gaming Disorder: A Literature Review of Electroencephalography Studies. Cureus 2021; 13:e17866. [PMID: 34660067 PMCID: PMC8504875 DOI: 10.7759/cureus.17866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 09/10/2021] [Indexed: 11/17/2022] Open
Abstract
Pathological online gaming is a relatively newer psychiatric disorder. It is the second behavioral addiction (after internet gambling disorder) included in the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM), 5th edition as “Internet Gaming Disorder” (IGD). Recent research is showing high morbidity associated with IGD, thus encouraging researchers to find valid and reliable biomarkers of IGD. So that, early diagnosis and proper treatment could limit the high disability level accompanying excessive online gaming. As electroencephalography (EEG) is a non-invasive and relatively easily available diagnostic technique, we aimed at collecting EEG studies that investigated EEG changes associated with IGD, with a specific focus on finding diagnostic and predictive neurophysiological biomarkers of IGD. We searched PubMed and Google Scholar for EEG studies of IGD. We eliminated those EEG studies that were not focused on finding biomarkers. Scale for the Assessment of Narrative Review Articles (SANRA) is followed in the writing of this review article. Our results showed that increased slow-wave resting-state activity and reduced P300 and N100 can serve as useful IGD diagnostic markers of IGD. Moreover, increased resting-state theta activity can be a predictive biomarker of IGD. Lastly, increased late low potentials (LLPs) can be specific trait markers of cue-induced cravings in IGD.
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Affiliation(s)
- Saima Kashif
- Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Samiksha Pandey
- Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zain I Warriach
- Department of Research, Division of Clinical & Translational Research/Larkin Health System, Miami, USA
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Raiha S, Yang G, Wang L, Dai W, Wu H, Meng G, Zhong B, Liu X. Altered Reward Processing System in Internet Gaming Disorder. Front Psychiatry 2020; 11:599141. [PMID: 33343426 PMCID: PMC7746551 DOI: 10.3389/fpsyt.2020.599141] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/10/2020] [Indexed: 11/17/2022] Open
Abstract
Converging evidence indicates that addiction involves impairment in reward processing systems. However, the patterns of dysfunction in different stages of reward processing in internet gaming addiction remain unclear. In previous studies, individuals with internet gaming disorder were found to be impulsive and risk taking, but there is no general consensus on the relation between impulsivity and risk-taking tendencies in these individuals. The current study explored behavioral and electrophysiological responses associated with different stages of reward processing among individuals with internet gaming disorders (IGDs) with a delayed discounting task and simple gambling tasks. Compared to the healthy control (HC) group, the IGD group discounted delays more steeply and made more risky choices, irrespective of the outcome. As for the event-related potential (ERP) results, during the reward anticipation stage, IGDs had the same stimulus-preceding negativity (SPN) for both large and small choices, whereas HCs exhibited a higher SPN in large vs. small choices. During the outcome evaluation stage, IGDs exhibited a blunted feedback-related negativity for losses vs. gains. The results indicate impairment across different stages of reward processing among IGDs. Moreover, we found negative correlation between impulsivity indexed by BIS-11 and reward sensitivity indexed by SPN amplitude during anticipation stage only, indicating different neural mechanisms at different stages of reward processing. The current study helps to elucidate the behavioral and neural mechanisms of reward processing in internet gaming addiction.
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Affiliation(s)
- Syeda Raiha
- Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Guochun Yang
- Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Lingxiao Wang
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
- Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, China
| | - Weine Dai
- Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Sino-Danish College, University of Chinese Academy of Sciences, Beijing, China
- Sino-Danish Center for Education and Research, Beijing, China
- CFIN and Pet Center, Aarhus University, Aarhus, Denmark
| | - Haiyan Wu
- Centre for Cognitive and Brain Sciences and Department of Psychology, University of Macau, Taipa, Macau
| | - Guangteng Meng
- Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Bowei Zhong
- Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Xun Liu
- Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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Huang Q, Huang J, Chen Y, Lin D, Xu S, Wei J, Qi C, Xu X. Overactivation of the Reward System and Deficient Inhibition in Exercise Addiction. Med Sci Sports Exerc 2020; 51:1918-1927. [PMID: 31058764 PMCID: PMC6727945 DOI: 10.1249/mss.0000000000001988] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose Behavior studies have found that exercise addiction is associated with high impulsivity. In other addictions, neural mechanisms of impulsivity reflect abnormalities in the reward and inhibition systems. In this study, we determined whether abnormalities existed in the reward and inhibition systems of exercise addicts. Methods Three groups of male participants (15 exercise addicts, 18 regular exercisers, and 16 exercise avoiders) completed the Mini International Personality Item Pool (Mini-IPIP), the classic go/no-go task, and the exercise-related go/no-go task. Event-related potentials (ERP) were recorded during the go/no-go tasks, and correctly performed trials were analyzed. Results Exercise addicts scored lower for extraversion and higher for neuroticism, reflecting a poor capacity for emotional regulation and impulse control, and had larger N2 and P3d amplitudes during the exercise-related go/no-go task. Exercise addicts and exercise avoiders demonstrated impaired accuracy in the exercise-related go/no-go task and had larger N2 amplitudes compared with regular exercisers during the letter–digit go/no-go task. Exercise addicts and regular exercisers showed larger Go-N1 and Go-P2 amplitudes compared with exercise avoiders during the exercise-related go/no-go task. Exercisers (exercise addicts and regular exercisers) demonstrated higher activation in response to exercise-related stimuli as reflected by larger N1 and P2, and addicts (exercise addicts) demonstrated poorer inhibition as reflected by larger N2 and P3d amplitudes. Go-N1 and Go-P2 were significantly correlated with no-go accuracy in exercise-related task. Conclusions Exercise addicts scored higher for the neuroticism personality trait and exhibited overactivation of the reward system and underactivation of the inhibition system. Overactivation of the reward system may be related to long-term exposure to exercise. Underactivation of the inhibition system may be a crucial factor in exercise addiction.
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Affiliation(s)
- Qin Huang
- Graduate School, Wuhan Sports University, Wuhan, CHINA
| | - Jiaai Huang
- Graduate School, Wuhan Sports University, Wuhan, CHINA
| | - Yanxia Chen
- Graduate School, Wuhan Sports University, Wuhan, CHINA
| | - Deng Lin
- Graduate School, Wuhan Sports University, Wuhan, CHINA
| | - Shun Xu
- Graduate School, Wuhan Sports University, Wuhan, CHINA
| | - Jingping Wei
- Graduate School, Wuhan Sports University, Wuhan, CHINA
| | - Changzhu Qi
- College of Health Science, Wuhan Sports University, Wuhan, CHINA
| | - Xia Xu
- College of Health Science, Wuhan Sports University, Wuhan, CHINA.,Hubei Key Laboratory of Exercise Training and Monitoring, Wuhan Sports University, Wuhan, CHINA
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Leouzon H, Alexandre JM, Fatséas M, Auriacombe M. L’addiction aux jeux vidéo dans le DSM-5, controverses et réponses relatives à son diagnostic et sa définition. ANNALES MÉDICO-PSYCHOLOGIQUES, REVUE PSYCHIATRIQUE 2019. [DOI: 10.1016/j.amp.2019.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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10
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Acuff SF, MacKillop J, Murphy JG. Applying behavioral economic theory to problematic Internet use: An initial investigation. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2019; 32:846-857. [PMID: 30451521 DOI: 10.1037/adb0000404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The widespread availability of the Internet has had profound social, educational, and economic benefits. Yet, for some, Internet use can become compulsive and problematic. The current study seeks to apply a behavioral economic framework to Internet use, testing the hypothesis that, similar to other addictive behaviors, problematic Internet use is a reinforcer pathology, reflecting an overvaluation of an immediately acquirable reward relative to prosocial and delayed rewards. Data were collected through Amazon's Mechanical Turk data collection platform. A total of 256 adults (Mage = 27.87, SD = 4.79; 58.2% White, 23% Asian; 65.2% had an associate degree or greater) completed the survey. Measures of delay discounting, consideration of future consequences, Internet demand, and alternative reinforcement all contributed unique variance in predicting both problematic Internet use and Internet craving. In aggregate models controlling for all significant predictors, alternative reinforcement and future valuation variables contributed unique variance. Individuals with elevated demand and discounting were at greatest risk for problematic Internet use. Consistent with behavioral economic research among substance abusing samples, individuals engaging in heavy Internet use report elevated motivation for the target behavior coupled with diminished motivation for other potentially rewarding activities, especially those associated with delayed reward. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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Affiliation(s)
| | - James MacKillop
- Peter Boris Centre for Addictions Research, Department of Psychiatry and Behavioural Neurosciences, McMaster University/St Joseph's Healthcare Hamilton
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ElSalhy M, Miyazaki T, Noda Y, Nakajima S, Nakayama H, Mihara S, Kitayuguchi T, Higuchi S, Muramatsu T, Mimura M. Relationships between Internet addiction and clinicodemographic and behavioral factors. Neuropsychiatr Dis Treat 2019; 15:739-752. [PMID: 30988618 PMCID: PMC6440534 DOI: 10.2147/ndt.s193357] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUNDS AND AIMS While the Internet became an indispensable component of our contemporary life, public and academic attention is also gathered to its negative impact, namely Internet addiction (IA). Although clinicodemographic and behavioral factors are hypothetically implicated in the mechanism of IA, it still remains largely unknown how such factors are linked to IA severity. Thus, this study sought to examine relationships among IA severity and factors potentially associated with IA in Japanese students in different educational stages. METHODS We conducted a questionnaire-based survey, which included questions about types of online activities and clinicodemographic information, the IA test for IA severity, and the K6 scale for psychological distress in 3,224 students at elementary, junior, and senior high schools, and universities. A multiple regression analysis was performed to predict IA severity with clinicodemographic and behavioral factors. RESULTS IA severity was significantly positively related to the following factors: e-messaging, social networking services (SNS), games, holiday Internet usage, and K6 scores, while IA severity had negative correlation with using Internet for educational purposes, age of first exposure to the Internet, and sleep duration. Age was not related to IA severity among participants using both SNS and e-messaging. CONCLUSIONS IA was linked to various online activities and the degree of psychological distress. This indicates the importance of comprehensive assessment of online behavior and psychological factors for further understanding of IA.
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Affiliation(s)
- Muhammad ElSalhy
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan, .,National Hospital Organization Kurihama Medical and Addiction Center, Tokyo, Japan
| | - Takahiro Miyazaki
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan,
| | - Yoshihiro Noda
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan,
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan,
| | - Hideki Nakayama
- National Hospital Organization Kurihama Medical and Addiction Center, Tokyo, Japan
| | - Satoko Mihara
- National Hospital Organization Kurihama Medical and Addiction Center, Tokyo, Japan
| | - Takashi Kitayuguchi
- National Hospital Organization Kurihama Medical and Addiction Center, Tokyo, Japan
| | - Susumu Higuchi
- National Hospital Organization Kurihama Medical and Addiction Center, Tokyo, Japan
| | - Taro Muramatsu
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan, .,National Hospital Organization Kurihama Medical and Addiction Center, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan,
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Paulus FW, Ohmann S, von Gontard A, Popow C. Internet gaming disorder in children and adolescents: a systematic review. Dev Med Child Neurol 2018; 60:645-659. [PMID: 29633243 DOI: 10.1111/dmcn.13754] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 02/02/2023]
Abstract
AIM Internet gaming disorder (IGD) is a serious disorder leading to and maintaining pertinent personal and social impairment. IGD has to be considered in view of heterogeneous and incomplete concepts. We therefore reviewed the scientific literature on IGD to provide an overview focusing on definitions, symptoms, prevalence, and aetiology. METHOD We systematically reviewed the databases ERIC, PsyARTICLES, PsycINFO, PSYNDEX, and PubMed for the period January 1991 to August 2016, and additionally identified secondary references. RESULTS The proposed definition in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition provides a good starting point for diagnosing IGD but entails some disadvantages. Developing IGD requires several interacting internal factors such as deficient self, mood and reward regulation, problems of decision-making, and external factors such as deficient family background and social skills. In addition, specific game-related factors may promote IGD. Summarizing aetiological knowledge, we suggest an integrated model of IGD elucidating the interplay of internal and external factors. INTERPRETATION So far, the concept of IGD and the pathways leading to it are not entirely clear. In particular, long-term follow-up studies are missing. IGD should be understood as an endangering disorder with a complex psychosocial background. WHAT THIS PAPER ADDS In representative samples of children and adolescents, on average, 2% are affected by Internet gaming disorder (IGD). The mean prevalences (overall, clinical samples included) reach 5.5%. Definitions are heterogeneous and the relationship with substance-related addictions is inconsistent. Many aetiological factors are related to the development and maintenance of IGD. This review presents an integrated model of IGD, delineating the interplay of these factors.
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Affiliation(s)
- Frank W Paulus
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
| | - Susanne Ohmann
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
| | - Christian Popow
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
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Kuss DJ, Pontes HM, Griffiths MD. Neurobiological Correlates in Internet Gaming Disorder: A Systematic Literature Review. Front Psychiatry 2018; 9:166. [PMID: 29867599 PMCID: PMC5952034 DOI: 10.3389/fpsyt.2018.00166] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 04/11/2018] [Indexed: 12/25/2022] Open
Abstract
Internet Gaming Disorder (IGD) is a potential mental disorder currently included in the third section of the latest (fifth) edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) as a condition that requires additional research to be included in the main manual. Although research efforts in the area have increased, there is a continuing debate about the respective criteria to use as well as the status of the condition as mental health concern. Rather than using diagnostic criteria which are based on subjective symptom experience, the National Institute of Mental Health advocates the use of Research Domain Criteria (RDoC) which may support classifying mental disorders based on dimensions of observable behavior and neurobiological measures because mental disorders are viewed as biological disorders that involve brain circuits that implicate specific domains of cognition, emotion, and behavior. Consequently, IGD should be classified on its underlying neurobiology, as well as its subjective symptom experience. Therefore, the aim of this paper is to review the neurobiological correlates involved in IGD based on the current literature base. Altogether, 853 studies on the neurobiological correlates were identified on ProQuest (in the following scholarly databases: ProQuest Psychology Journals, PsycARTICLES, PsycINFO, Applied Social Sciences Index and Abstracts, and ERIC) and on MEDLINE, with the application of the exclusion criteria resulting in reviewing a total of 27 studies, using fMRI, rsfMRI, VBM, PET, and EEG methods. The results indicate there are significant neurobiological differences between healthy controls and individuals with IGD. The included studies suggest that compared to healthy controls, gaming addicts have poorer response-inhibition and emotion regulation, impaired prefrontal cortex (PFC) functioning and cognitive control, poorer working memory and decision-making capabilities, decreased visual and auditory functioning, and a deficiency in their neuronal reward system, similar to those found in individuals with substance-related addictions. This suggests both substance-related addictions and behavioral addictions share common predisposing factors and may be part of an addiction syndrome. Future research should focus on replicating the reported findings in different cultural contexts, in support of a neurobiological basis of classifying IGD and related disorders.
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Affiliation(s)
- Daria J Kuss
- International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, United Kingdom
| | - Halley M Pontes
- International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, United Kingdom
| | - Mark D Griffiths
- International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, United Kingdom
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Gender comparison of online and land-based gamblers from a nationally representative sample: Does gambling online pose elevated risk? COMPUTERS IN HUMAN BEHAVIOR 2017. [DOI: 10.1016/j.chb.2017.02.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Kuss DJ, Griffiths MD, Pontes HM. Chaos and confusion in DSM-5 diagnosis of Internet Gaming Disorder: Issues, concerns, and recommendations for clarity in the field. J Behav Addict 2017; 6:103-109. [PMID: 27599673 PMCID: PMC5520132 DOI: 10.1556/2006.5.2016.062] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background The umbrella term "Internet addiction" has been criticized for its lack of specificity given the heterogeneity of potentially problematic behaviors that can be engaged in online as well as different underlying etiological mechanisms. This has led to the naming of specific online addictions, the most notable being Internet Gaming Disorder (IGD). Methods Using the contemporary literature concerning IGD and cognate topics, issues and concerns relating to the concept of IGD are examined. Results Internet addiction and IGD are not the same, and distinguishing between the two is conceptually meaningful. Similarly, the diagnosis of IGD as proposed in the appendix of the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) remains vague regarding whether or not games need to be engaged in online, stating that IGD typically involves specific Internet games, but can also include offline games, adding to the lack of clarity. A number of authors have voiced concerns regarding the viability of including the word "Internet" in IGD, and instead proposed to use the term "video gaming disorder" or simply "gaming disorder," suggesting addiction to video gaming can also occur offline. Conclusion The DSM-5 has caused more confusion than clarity regarding the disorder, reflected by researchers in the field contesting a supposedly reached consensus for IGD diagnosis.
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Affiliation(s)
- Daria J. Kuss
- The International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, UK
| | - Mark D. Griffiths
- The International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, UK,Corresponding author: Mark D. Griffiths; The International Gaming Research Unit, Psychology Department, Nottingham Trent University, Burton Street, Nottingham NG1 4BU, UK; Phone: +44 115 848 2401; E-mail:
| | - Halley M. Pontes
- The International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, UK
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Psychometric Assessment of Internet Gaming Disorder in Neuroimaging Studies: A Systematic Review. INTERNET ADDICTION 2017. [DOI: 10.1007/978-3-319-46276-9_11] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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D'Hondt F, Maurage P. Electrophysiological studies in Internet addiction: A review within the dual-process framework. Addict Behav 2017; 64:321-327. [PMID: 26476664 DOI: 10.1016/j.addbeh.2015.10.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 10/05/2015] [Accepted: 10/07/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Fabien D'Hondt
- Laboratory for Experimental Psychopathology, Psychological Sciences Research Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Pierre Maurage
- Laboratory for Experimental Psychopathology, Psychological Sciences Research Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium.
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Nuyens F, Deleuze J, Maurage P, Griffiths MD, Kuss DJ, Billieux J. Impulsivity in Multiplayer Online Battle Arena Gamers: Preliminary Results on Experimental and Self-Report Measures. J Behav Addict 2016; 5:351-6. [PMID: 27156376 PMCID: PMC5387787 DOI: 10.1556/2006.5.2016.028] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background and aims Multiplayer Online Battle Arena (MOBA) games have become the most popular type of video games played worldwide, superseding the playing of Massively Multiplayer Online Role-Playing Games and First-Person Shooter games. However, empirical studies focusing on the use and abuse of MOBA games are still very limited, particularly regarding impulsivity, which is an indicator of addictive states but has not yet been explored in MOBA games. In this context, the objective of the present study is to explore the associations between impulsivity and symptoms of addictive use of MOBA games in a sample of highly involved League of Legends (LoL, currently the most popular MOBA game) gamers. Methods Thirty-six LoL gamers were recruited and completed both experimental (Single Key Impulsivity Paradigm) and self-reported impulsivity assessments (s-UPPS-P Impulsive Behavior Scale, Barratt Impulsiveness Scale), in addition to an assessment of problematic video game use (Problematic Online Gaming Questionnaire). Results Results showed links between impulsivity-related constructs and signs of excessive MOBA game involvement. Findings indicated that impaired ability to postpone rewards in an experimental laboratory task was strongly related to problematic patterns of MOBA game involvement. Although less consistent, several associations were also found between self-reported impulsivity traits and signs of excessive MOBA game involvement. Conclusions Despite these results are preliminary and based upon a small (self-selected) sample, the present study highlights potential psychological factors related to the addictive use of MOBA games.
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Affiliation(s)
- Filip Nuyens
- Laboratory for Experimental Psychopathology, Psychological Science Research Institute, Université catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Jory Deleuze
- Laboratory for Experimental Psychopathology, Psychological Science Research Institute, Université catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Pierre Maurage
- Laboratory for Experimental Psychopathology, Psychological Science Research Institute, Université catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Mark D. Griffiths
- International Gaming Research Unit, Psychology Division, Nottingham Trent University, Burton Street, Nottingham, NG1 4BY, United Kingdom
| | - Daria J. Kuss
- International Gaming Research Unit, Psychology Division, Nottingham Trent University, Burton Street, Nottingham, NG1 4BY, United Kingdom
| | - Joël Billieux
- Laboratory for Experimental Psychopathology, Psychological Science Research Institute, Université catholique de Louvain, Louvain-La-Neuve, Belgium,Corresponding author: Joël Billieux; Psychological Sciences Research Institute, Université catholique de Louvain, 10, Place du Cardinal Mercier, 1348 Louvain-La-Neuve, Belgium; Phone: +32 10 47 46 38; Fax: +32 10 47 48 34; E-mail:
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Cui F, Zhu X, Gu R, Luo YJ. When your pain signifies my gain: neural activity while evaluating outcomes based on another person's pain. Sci Rep 2016; 6:26426. [PMID: 27193060 PMCID: PMC4872235 DOI: 10.1038/srep26426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 04/29/2016] [Indexed: 11/15/2022] Open
Abstract
The overlap between pain and reward processing pathways leds researchers to hypothesize that there are interactions between them in the human brain. Two hypotheses have been proposed. The "competition hypothesis" posits that reward can reduce pain-related neural activity and vice versa. The "salience hypothesis" suggests that the motivational salience of pain and reward can be mutually reinforced. However, no study has tested these two hypotheses from temporal perspective as we know. In the present study, pictures depicted other people in painful or non-painful situations were used to indicate the valence of outcomes in a gambling task. The event-related potential results revealed an interaction between another person's pain and outcome valence in multiple time stages. Specifically, the amplitudes of the N1 and P3 were enhanced in the win condition compared with the loss condition when the outcome was indicated by painful picture. This interactions between pain and reward support the salience hypothesis but not the competition hypothesis. The present results provide evidence from human subjects that support the salience hypothesis, which claims that observing other people's pain can enhance the salience of reward.
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Affiliation(s)
- Fang Cui
- Institute of Affective and Social Neuroscience, Shenzhen University, Shenzhen, China
| | - Xiangru Zhu
- Institute of Cognition and Behavior, Henan University, Kaifeng, China
| | - Ruolei Gu
- Institute of psychology, Chinese Academy of Sciences, Beijing, China
| | - Yue-jia Luo
- Institute of Affective and Social Neuroscience, Shenzhen University, Shenzhen, China
- Research Center of Sport Psychology, Wuhan Sports University, Wuhan, China
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Kuss DJ, Lopez-Fernandez O. Internet addiction and problematic Internet use: A systematic review of clinical research. World J Psychiatry 2016; 6:143-76. [PMID: 27014605 PMCID: PMC4804263 DOI: 10.5498/wjp.v6.i1.143] [Citation(s) in RCA: 266] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 11/19/2015] [Accepted: 01/05/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To provide a comprehensive overview of clinical studies on the clinical picture of Internet-use related addictions from a holistic perspective. A literature search was conducted using the database Web of Science. METHODS Over the last 15 years, the number of Internet users has increased by 1000%, and at the same time, research on addictive Internet use has proliferated. Internet addiction has not yet been understood very well, and research on its etiology and natural history is still in its infancy. In 2013, the American Psychiatric Association included Internet Gaming Disorder in the appendix of the updated version of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) as condition that requires further research prior to official inclusion in the main manual, with important repercussions for research and treatment. To date, reviews have focused on clinical and treatment studies of Internet addiction and Internet Gaming Disorder. This arguably limits the analysis to a specific diagnosis of a potential disorder that has not yet been officially recognised in the Western world, rather than a comprehensive and inclusive investigation of Internet-use related addictions (including problematic Internet use) more generally. RESULTS The systematic literature review identified a total of 46 relevant studies. The included studies used clinical samples, and focused on characteristics of treatment seekers and online addiction treatment. Four main types of clinical research studies were identified, namely research involving (1) treatment seeker characteristics; (2) psychopharmacotherapy; (3) psychological therapy; and (4) combined treatment. CONCLUSION A consensus regarding diagnostic criteria and measures is needed to improve reliability across studies and to develop effective and efficient treatment approaches for treatment seekers.
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GRIFFITHS MARKD, VAN ROOIJ ANTONIUSJ, KARDEFELT-WINTHER DANIEL, STARCEVIC VLADAN, KIRÁLY ORSOLYA, PALLESEN STÅLE, MÜLLER KAI, DREIER MICHAEL, CARRAS MICHELLE, PRAUSE NICOLE, KING DANIELL, ABOUJAOUDE ELLIAS, KUSS DARIAJ, PONTES HALLEYM, FERNANDEZ OLATZLOPEZ, NAGYGYORGY KATALIN, ACHAB SOPHIA, BILLIEUX JOËL, QUANDT THORSTEN, CARBONELL XAVIER, FERGUSON CHRISTOPHERJ, HOFF RANIA, DEREVENSKY JEFFREY, HAAGSMA MARIAC, DELFABBRO PAUL, COULSON MARK, HUSSAIN ZAHEER, DEMETROVICS ZSOLT. Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addiction 2016; 111:167-75. [PMID: 26669530 PMCID: PMC5699464 DOI: 10.1111/add.13057] [Citation(s) in RCA: 242] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/27/2015] [Accepted: 07/12/2015] [Indexed: 12/21/2022]
Abstract
This commentary paper critically discusses the recent debate paper by Petry et al. (2014) that argued there was now an international consensus for assessing Internet Gaming Disorder (IGD). Our collective opinions vary considerably regarding many different aspects of online gaming. However, we contend that the paper by Petry and colleagues does not provide a true and representative international community of researchers in this area. This paper critically discusses and provides commentary on (i) the representativeness of the international group that wrote the ‘consensus’ paper, and (ii) each of the IGD criteria. The paper also includes a brief discussion on initiatives that could be taken to move the field towards consensus. It is hoped that this paper will foster debate in the IGD field and lead to improved theory, better methodologically designed studies, and more robust empirical evidence as regards problematic gaming and its psychosocial consequences and impact.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - SOPHIA ACHAB
- University Hospitals of Geneva, Geneva, Switzerland
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Electrophysiological correlates of problematic Internet use: Critical review and perspectives for future research. Neurosci Biobehav Rev 2015; 59:64-82. [DOI: 10.1016/j.neubiorev.2015.10.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 10/09/2015] [Accepted: 10/12/2015] [Indexed: 12/19/2022]
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Love T, Laier C, Brand M, Hatch L, Hajela R. Neuroscience of Internet Pornography Addiction: A Review and Update. Behav Sci (Basel) 2015; 5:388-433. [PMID: 26393658 PMCID: PMC4600144 DOI: 10.3390/bs5030388] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/29/2015] [Accepted: 09/08/2015] [Indexed: 02/07/2023] Open
Abstract
Many recognize that several behaviors potentially affecting the reward circuitry in human brains lead to a loss of control and other symptoms of addiction in at least some individuals. Regarding Internet addiction, neuroscientific research supports the assumption that underlying neural processes are similar to substance addiction. The American Psychiatric Association (APA) has recognized one such Internet related behavior, Internet gaming, as a potential addictive disorder warranting further study, in the 2013 revision of their Diagnostic and Statistical Manual. Other Internet related behaviors, e.g., Internet pornography use, were not covered. Within this review, we give a summary of the concepts proposed underlying addiction and give an overview about neuroscientific studies on Internet addiction and Internet gaming disorder. Moreover, we reviewed available neuroscientific literature on Internet pornography addiction and connect the results to the addiction model. The review leads to the conclusion that Internet pornography addiction fits into the addiction framework and shares similar basic mechanisms with substance addiction. Together with studies on Internet addiction and Internet Gaming Disorder we see strong evidence for considering addictive Internet behaviors as behavioral addiction. Future research needs to address whether or not there are specific differences between substance and behavioral addiction.
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Affiliation(s)
- Todd Love
- Society for the Advancement of Sexual Health, Ardmore, PA 19003, USA.
| | - Christian Laier
- Department of General Psychology: Cognition, University of Duisburg-Essen, Duisburg 47057, Germany.
| | - Matthias Brand
- Department of General Psychology: Cognition, University of Duisburg-Essen, Duisburg 47057, Germany.
- Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen 45141, Germany.
| | - Linda Hatch
- Private Practice, Santa Barbara, CA 93103, USA.
| | - Raju Hajela
- Health Upwardly Mobile Inc., Calgary, AB T2S 0J2, Canada.
- Diagnostic and Descriptive Terminology Action Group (DDTAG), American Society of Addiction Medicine (ASAM), Chevy Chase, MD 93101, USA.
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