Tech’s appeal: Another look at Internet addiction

Generally speaking, Internet addiction (IA) has been characterized by excessive or poorly controlled preoccupation, urges, and/or behaviours regarding Internet use that lead to impairment or distress in several life domains. However, according to Dr. Kimberly Young, IA is a problematic behaviour akin to pathological gambling that can be operationally defined as an impulse-control disorder not involving the ingestion of psychoactive intoxicants.

Following the conceptual framework developed by Young and her colleagues to understand IA, five specific types of distinct online addictive behaviours were identified: (i) ‘cyber-sexual addiction’, (ii) ‘cyber-relationship addiction’, (iii) ‘net compulsions (i.e., obsessive online gambling, shopping, or trading), (iv) ‘information overload’, and (v) ‘computer addiction’ (i.e., obsessive computer game playing).

However, I have argued in many of my papers over the last 15 years that the Internet may simply be the means or ‘place’ where the most commonly reported addictive behaviours occur. In short, the Internet may be just a medium to fuel other addictions. Interestingly, new evidence pointing towards the need to make this distinction has been provided from the online gaming field where new studies (including some I have carried out with my Hungarian colleagues) have demonstrated that IA is not the same as other more specific addictive behaviours carried out online (i.e., gaming addiction), further magnifying the meaningfulness to differentiate between what may be called ‘generalized’ and ‘specific’ forms of online addictive behaviours, and also between IA and gaming addiction as these behaviours are conceptually different.

Additionally, the lack of formal diagnostic criteria to assess IA holds another methodological problem since researchers are systematically adopting modified criteria from other addictions to investigate IA. Although IA may share some commonalities with other substance-based addictions, it is unclear to what extent such criteria are useful and suitable to evaluate IA. Notwithstanding the existing difficulties in understanding and comparing IA with behaviours such as pathological gambling, recent research provided useful insights on this topic.

A recent study by Dr. Federico Tonioni (published in a 2014 issue of the journal Addictive Behaviors) involving two clinical (i.e., 31 IA patients and 11 pathological gamblers) and a control group (i.e., 38 healthy individuals) investigated whether IA patients presented different psychological symptoms, temperamental traits, coping strategies, and relational patterns in comparison to pathological gamblers, concluded that Internet-addicts presented higher mental and behavioural disengagement associated with significant more interpersonal impairment. Moreover, temperamental patterns, coping strategies, and social impairments appeared to be different across both disorders. Nonetheless, the similarities between IA and pathological gambling were essentially in terms of psychopathological symptoms such as depression, anxiety, and global functioning. Although, individuals with IA and pathological gambling appear to share similar psychological profiles, previous research has found little overlap between these two populations, therefore, both phenomena are separate disorders.

Despite the fact that initial conceptualizations of IA helped advance the current knowledge and understanding of IA in different aspects and contexts, it has become evident that the field has greatly evolved since then in several ways. As a result of these ongoing changes, behavioural addictions (more specifically Gambling Disorder and Internet Gaming Disorder) have now recently received official recognition in the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Moreover, IA can also be characterized as a form of technological addiction, which I have operationally defined as a non-chemical (behavioural) addiction involving excessive human-machine interaction. In this theoretical framework, technological addictions such as IA represent a subset of behavioural addictions featuring six core components: (i) salience, (ii) mood modification, (iii) tolerance, (iv) withdrawal, (v) conflict, and (vi) relapse. The components model of addiction appears to be a more updated framework for understanding IA as a behavioural addiction not only conceptually but also empirically. Moreover, this theoretical framework has recently received empirical support from several studies, further evidencing its suitability and applicability to the understanding of IA.

For many in the IA field, problematic Internet use is considered to be a serious issue – albeit not yet officially recognised as a disorder – and has been described across the literature as being associated with a wide range of co-occurring psychiatric comorbidities alongside an array of dysfunctional behavioural patterns. For instance, IA has been recently associated with low life satisfaction, low academic performance, less motivation to study, poorer physical health, social anxiety, attention deficit/hyperactivity disorder and depression, poorer emotional wellbeing and substance use, higher impulsivity, cognitive distortion, deficient self-regulation, poorer family environment, higher mental distress, loneliness, among other negative psychological, biological, and neuronal aspects.

In a recent systematic literature review conducted by Dr. Wen Li and colleagues (and published in the journal Computers and Human Behavior), the authors reviewed a total of 42 empirical studies that assessed the family correlates of IA in adolescents and young adults. According to the authors, virtually all studies reported greater family dysfunction amongst IA families in comparison to non-IA families. More specifically, individuals with IA exhibited more often (i) greater global dissatisfaction with their families, (ii) less organized, cohesive, and adaptable families, (iii) greater inter-parental and parent-child conflict, and (iv) perceptions of their parents as more punitive, less supportive, warm, and involved. Furthermore, families were significantly more likely to have divorced parents or to be a single parent family.

Another recent systematic literature review conducted by Dr. Lawrence Lam published in the journal Current Psychiatry Reports examined the possible links between IA and sleep problems. After reviewing seven studies (that met strict inclusion criteria), it was concluded that on the whole, IA was associated with sleep problems that encompassed subjective insomnia, short sleep duration, and poor sleep quality. The findings also suggested that participants with insomnia were 1.5 times more likely to be addicted to the Internet in comparison to those without sleep problems. Despite the strong evidence found supporting the links between IA and sleep problems, the author noted that due to the cross-sectional nature of most studies reviewed, the generalizability of the findings was somewhat limited.

IA is a relatively recent phenomenon that clearly warrants further investigation, and empirical studies suggest it needs to be taken seriously by psychologists, psychiatrists, and neuroscientists. Although uncertainties still remain regarding its diagnostic and clinical characterization, it is likely that these extant difficulties will eventually be tackled and the field will evolve to a point where IA may merit full recognition as a behavioural addiction from official medical bodies (ie, American Psychiatric Association) similar to other more established behavioural addictions such as ‘Gambling Disorder’ and ‘Internet Gaming Disorder’. However, in order to achieve official status, researchers will have to adopt a more commonly agreed upon definition as to what IA is, and how it can be conceptualized and operationalized both qualitatively and quantitatively (as well as in clinically diagnostic terms).

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Please note: This article was co-written with Halley Pontes and Daria Kuss.

Further reading

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M.D. (2010). Internet abuse and internet addiction in the workplace. Journal of Workplace Learning, 7, 463-472.

Griffiths, M.D., Kuss, D.J., Billieux J. & Pontes, H.M. (2016). The evolution of internet addiction: A global perspective. Addictive Behaviors, 53, 193–195.

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

Király, O., Griffiths, M.D., Urbán, R., Farkas, J., Kökönyei, G. Elekes, Z., Domokos Tamás, D. & Demetrovics, Z. (2014). Problematic internet use and problematic online gaming are not the same: Findings from a large nationally representative adolescent sample. Cyberpsychology, Behavior and Social Networking, 17, 749-754.

Kuss, D.J. & Griffiths, M.D. (2015). Internet Addiction in Psychotherapy. Basingstoke: Palgrave Macmillan.

Kuss, D.J., Griffiths, M.D. & Binder, J. (2013). Internet addiction in students: Prevalence and risk factors. Computers in Human Behavior, 29, 959-966.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014). Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

Kuss, D.J., Shorter, G.W., van Rooij, A.J., Griffiths, M.D., & Schoenmakers, T.M. (2014). Assessing Internet addiction using the parsimonious Internet addiction components model – A preliminary study. International Journal of Mental Health and Addiction, 12, 351-366.

Kuss, D.J., van Rooij, A.J., Shorter, G.W., Griffiths, M.D. & van de Mheen, D. (2013). Internet addiction in adolescents: Prevalence and risk factors. Computers in Human Behavior, 29, 1987-1996.

Lam, L.T. (2014). Internet Gaming Addiction, Problematic use of the Internet, and sleep problems: A systematic review. Current Psychiatry Reports, 16(4), 1-9.

Li, W., Garland, E.L., & Howard, M.O. (2014). Family factors in Internet addiction among Chinese youth: A review of English-and Chinese-language studies. Computers in Human. Behavior, 31, 393-411.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H.M., Kuss, D.J. & Griffiths, M.D. (2015). The clinical psychology of Internet addiction: A review of its conceptualization, prevalence, neuronal processes, and implications for treatment. Neuroscience and Neuroeconomics, 4, 11-23.

Pontes, H.M., Szabo, A. & Griffiths, M.D. (2015). The impact of Internet-based specific activities on the perceptions of Internet Addiction, Quality of Life, and excessive usage: A cross-sectional study. Addictive Behaviors Reports, 1, 19-25.

Tonioni, F., Mazza, M., Autullo, G., Cappelluti, R., Catalano, V., Marano, G., … & Lai, C. (2014). Is Internet addiction a psychopathological condition distinct from pathological gambling?. Addictive Behaviors, 39(6), 1052-1056.

Widyanto, L. & Griffiths, M.D. (2006). Internet addiction: A critical review. International Journal of Mental Health and Addiction, 4, 31-51.

Young, K. (1998). Caught in the net. New York: John Wiley

Young K. (1999). Internet addiction: Evaluation and treatment. Student British Medical Journal, 7, 351-352.

Money for nothing (and your clicks for free?): Why do gamers buy ‘virtual assets’?

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Video gaming has evolved from a single-player platform to a multi-player realm where interaction with other players is often a necessity. In order to enter the game, players must first create an avatar, a representation of their self in the game that is used to explore and interact with the virtual environment. When creating an avatar, players can also buy virtual assets to augment and/or enhance their online character. Virtual assets are items or customisations for video game avatars, bases, and characters that are purchased with real money.

In a previous blog, I looked at some of the anecdotal evidence that claimed a few individuals had become ‘addicted’ to buying virtual assets. At the time I wrote that article, there was almost nothing published academically on the psychology of virtual assets and why people bought virtual assets. A few months ago, Jack Cleghorn and I published a qualitative paper in the journal Digital Education Review based on our interviews with gamers that regularly bought virtual assets. Today’s blog looks at some of our findings.

For researchers, the buying of virtual assets provides an opportunity to try and understand why people become so immersed in games and what motivates gamers to spend real money on items that some would consider as having no value. In a multi-player environment, it becomes clear that the avatars seen on screen are graphical representations of someone real and may be part of human desires to be noticed, respected, and interacted with. Furthermore the gamer controlling their avatar has motivations, emotions, thoughts, and feelings. Virtual item purchases are therefore likely to impact on a gamer’s psychological wellbeing.

The growing market for virtual items indicates that transactions are becoming commonplace in gaming. The virtual market functions similarly to real markets in that there is demand, fluctuating markets, and profits to be made. The importance of virtual items to some people is illustrated by a divorce claim in a story on Hyped Talk in which a wife made a claim for over half of her husband’s virtual assets. In a different case (outlined in a 2005 issue of The Lawyer), Qiu Chengwei, a middle-aged man killed a fellow gamer over a dispute involving a virtual item. Obviously these cases are extreme but they highlight the fact that virtual items can have both financial and psychological value for gamers.

But why do people buy virtual items? Performance and general quality of an item is seen to be an important motivation whether the item is real or virtual. Online, an appeal to social status may be a better predictor for purchase behaviour than function. However, some claim that appealing to social status has no motivational significance in purchase behaviour. Another unique element of buying virtual items is the potential exclusivity. Exclusive or limited items tend to be unattainable through gameplay and instead must be bought with money. Exclusivity online has been shown to be of importance, and segmentation is a technique used by the games producers that limits certain items to certain classes, levels, or races. This has been shown to stimulate purchase behaviour. The amount of time invested in a game is also key to understanding spending patterns, and gamers will often buy virtual items after a dedicated amount of gameplay has been spent building an avatar.

Naturally, the longer the amounts of time that are spent online and in-game, the more the player emotionally and psychologically invests in the game. The concept of ‘flow’ (formulated by Mihaly Csikszentmihalyi in many papers and books) has been applied to gaming and can involve becoming emotionally attached to a character (in fact I published a paper on this with Damien Hull and Glenn Williams in a 2013 issue of the Journal of Behavioral Addictions). Flow is the feeling of complete absorption in an activity and affects consciousness and emotions of the individual experiencing it. A key element of feeling ‘flow’ is the experience and perception of the world of the avatar and has been applied to electronic media. The adaptation of ‘flow’ to the virtual world suggests that just like other leisure activities, an individual investing time in an environment where they feel socially accepted can become emotionally attached to their avatar. Gaming has been shown to affect consciousness and emotions of gamers that are both necessary in experiencing ‘flow’. It could be that purchasing of virtual items is also motivated – at least in part – by the feeling of emotional attachment to an avatar.

Gamers are being drawn in to an environment by the appeal of social interaction, manipulation of objects, exploration, and identification with the avatar. To some gamers, the virtual world can takes on more significance than ‘actual’ life and residency in their preferred games is what they consider their actuality. This suggests that the reward of gaming is great, indicating that those individuals who buy virtual items are doing so because they feel involved in an environment that benefits them personally.

Given the lack of empirical research, the qualitative study I published with Jack Cleghorn was based on in-depth interviews with six gamers who all regularly bought in-game virtual assets. We examined the (i) motivations for purchasing virtual items, (ii) psychological impact of purchasing virtual items on self-esteem and confidence, (iii) social benefits of gaming and virtual asset purchasing, (iv) emotional attachment to an avatar, (v) choice of items and customisation of the avatar as a form of self-expression, (v) impulsivity versus thoughtfulness in purchase intentions of virtual items, and (vii) impact of transaction machinery on the ‘game experience’ from a gamer’s perspective.

Using interpretative phenomenological analysis (IPA), the study was exploratory and aimed to understand the psychology underlying purchase intention of virtual items and assets among online gamers. As a result of interviewing the gamers, seven theses emerged: (i) motivation for purchase, (ii) social aspects of the gaming and purchasing, (iii) emotional attachment to the avatar, (iv) psychological reward and impact, (v) self-expression, (vi) ‘stock market gaming’ and gaming culture, and (vii) research/impulse buying. The use of IPA allowed each gamer to share their unique experience of playing and purchase behaviour.

Despite the negative aspects of online gaming, the gamers in our study emphasised a more positive side to buying virtual items and gaming more generally. Item exclusivity and item function were major motivating factors and contributed to an item’s importance in-game. Another key motivation for purchase behaviour was the appeal to social status. Attainment of items demonstrates to others how powerful the gamer is. Naturally, if an item has benefits for the avatar it is more likely that the gamer will spend money to obtain it. Function linked to progression, purchasing items, and buying in-game currency are all sometimes a necessity to progress. Novelty and collectability were also important motivators for some of our gamers. Despite subjective motivations, purchasing virtual items arose out of gaming as a predominant pastime. All of the gamers in our sample were dedicated gamers who spent relatively large amounts of time online and, as perhaps expected, larger gaming commitment to led to purchase behaviour.

An integral part of multiplayer gaming is the interaction with other gamers. The feeling of ‘social presence’ in an online environment is reliant on an emotional response to social interaction and the gamers in our study felt social satisfaction. The game sometimes enabled social interaction that might not otherwise be present. Previous research has shown how emotional attachment to games affects behaviour. Our study highlighted the role of emotional attachment to an avatar as a predictor for purchase intention. As well as emotional attachment increasing likelihood of spending, the spending of real money on items increases the attachment felt. It could be that purchasing virtual items may be a cyclical behaviour. It is also the case that purchasing affects the cognitions and emotions of gamers – ‘pride’ was a feeling that resonated among our interviewed gamers.

Our study also highlighted how gamers research items before purchasing them. It might be expected that easy-to-use transaction machinery might facilitate spending. However, in reality, the gamers we interviewed were guarded with their spending online and recommendations from friends playing a major role in purchase behaviour. Virtual assets can be then researched and the placing of real monetary value on the virtual items indicates the value they may hold to the gamer. Unlike media coverage focussing on the more negative impact of online gaming, our study highlighted the positive aspects of purchasing virtual assets for the gamer. They are able to feel connected socially, feel confidence in themselves and their success, express their inner and ideal self without constraint or fear, build lasting relationships, impress people, and generally benefit from gaming and buying virtual items.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bowman, N. D., Schultheiss, D., & Schumann, C. (2012). ‘‘I’m attached, and I’m a good guy/gal!’’: How character attachment influences pro- and anti-social motivations to play massively multiplayer online role-playing games. CyberPsychology, Behavior and Social Networking, 15(3), 169-174.

Csikszentmihalyi, M., & Csikszentmihalyi, I. (1992). Optimal experience: Psychological studies of flow in consciousness. Cambridge: Cambridge University Press.

Cole, H. & Griffiths, M. D. (2007). Social interactions in Massively Multiplayer Online Role-Playing gamers. CyberPsychology and Behavior, 10, 575-583.

Griffiths, M. D. (2010). The role of context in online gaming excess and addiction: Some case study evidence. International Journal of Mental Health and Addiction, 8, 119-125.

Griffiths, M.D., Hussain, Z., Grüsser, S., Thalemann, R., Cole, H. Davies, M.N.O. & Chappell, D. (2013). Social interactions in online gaming. In P. Felicia (Ed.), Developments in Current Game-Based Learning Design and Deployment (pp.74-90). Pennsylvania: IGI Global.

Guo, Y., & Barnes, S. (2011). Purchase behavior in virtual worlds: An empirical investigation in Second Life. Information and Management, 48(7), 303-312.

Hamari, J. & Lehdonvirta, V. (2010). Game design as marketing: How game mechanics create demand for virtual goods. International Journal of Business Science and Applied Management, 5(1), 14-29.

Hassouneh, D., & Brengman, M. (2011). Shopping in virtual worlds: Perceptions, motivations and behaviour. Journal of Electronic Commerce Research, 12(4), 320-335.

Huang, E. (2012). Online experiences and virtual goods purchase intention. Internet Research, 22(3), 252-274.

Hull, D., Williams, G. A. & Griffiths, M. D. (2013). Video game characteristics, happiness and flow as predictors of addiction among video game players: A pilot study. Journal of Behavioral Addictions, 2, 145-152.

Hyped Talk (2010). Virtually addicted Chinese woman claims virtual assets in her divorce plea. Available at: http://hypedtalk.blogspot.co.uk/2010/12/virtually-addicted-chinese-women-claims.html [Accessed: 6 March 2013].

Lee, P. (2005). The growth in the computer game market is leading to real legal issues in virtual worlds. The Lawyer, 19 (19), 14.

Lehdonvirta, V. (2009) Virtual item sales as a revenue model: Identifying attributes that drive purchase decisions. Electronic Commerce Research, 9(1-2), 97-113.

Li, Z. (2012). Motivation of virtual goods transactions based on the theory of gaming motivations. Journal of Theoretical and Applied Information Technology, 43(2), 254-260.

Manninen, T. & Kujanpää, T. (2007). The value of virtual assets – the role of game characters in MMOGs. International Journal of Business Science and Applied Management, 2(1), 21-33.

Naming desire: A personal look at my new job title

Back in 2002, I was incredibly proud when I became one of the youngest full Professors in the UK when I was bestowed the title of Professor of Gambling Studies based on my research contribitions to the gambling studies field. Anyone that has followed my career over the last decade (or this blog over the last four years) will no doubt have realised that my research interests and expertise include a lot more than gambling.

Although I still publish a lot of papers on gambling (12 to 17 papers per calendar year; see Appendix 1 below) I have carried out more and more research into non-gambling addictions and over the last six years (2010-2015) my refereed journal outputs on gambling have only constituted one-third of all my refereed journal outputs (32%) (see Appendix 1 and Figure 1).

The overwhelming majority of my published refereed papers since January 2010 (n=246; 88%) concern behavioural addictions (i.e., gambling addiction, videogame addiction, internet addiction, work addiction, sex addiction, exercise addiction, shopping addiction, dancing addiction, etc.). If gambling addiction is removed from these papers, this still leaves 56% of all my papers during the 2010-2015 period concerning other behavioural addictions (n=158). The remainder of my refereed journal papers (34 papers; 12%) mainly concern the topic of mindfulness carried out with my colleagues Edo Shonin and William Van Gordon. Even my three books in the 2010-2105 timeframe have been on three totally separate topics (i.e., problem gambling, internet addiction and mindfulness). Of my 71 book chapters in this 2010-2015 period, 22 have been on gambling addiction, 41 have been on other behavioural addictions, and 8 have concerned other topics (see Figure 2). In the ‘Further reading’ section below is some of the papers that I have published this year and even a quick glance will highlight that gambling papers are in the minority.

It is also worth noting that I am one of the most highly cited academics in the UK (soemthig else that I am very proud of) and a quick look at my Google Scholar citations profile (currently over 24,500 citations as of October 31, 2015) that of my top ten most highly cited papers, only one is on gambling adiction and the other nine concern my papers on videogame addiction and internet addiction.

Basically, my job title didn’t reflect what I was actually doing on the research front. And this is the very argument I put to my employer (Nottingham Trent University) a number of weeks ago. As far as I am aware, I am the first professor at NTU to ever ask for my title to be changed but last week I was informed by my line manager that the university was convinced by the case I put forward and from now on I will be Professor of Behavioural Addiction.

This new title change has pleased me greatly and of course subsumes the vast majority of the research that I am doing (including my research into gambling addiction). I don’t think I will ever stop carrying out research in the gambling field but my new job title will stop me feeling guilty about working in non-gambling areas. It may also stop some of few abusive emails I get regarding my blogs (saying in very colourful language that I should stop writing about other behavioural addictions and sexual paraphilias and “write about what I get paid to do”). Firstly, I would point out to these individuals that I don’t get paid to write my personal blog and even if I did, I write all my blogs in my spare time.

If you’ve read this far, then thank you. I promise normal service will be resumed in my next blog when it will be about something other than myself.

Appendix 1: Summary statistics of my refereed journal papers (January 1, 2010 to October 20, 2015)

• 2010: Gambling papers (n=17); Behavioural addiction papers (n=19); Other papers (n=1)
• 2011: Gambling papers (n=15); Behavioural addiction papers (n=15); Other papers (n=2)
• 2012: Gambling papers (n=10); Behavioural addiction papers (n=28); Other papers (n=3)
• 2013: Gambling papers (n=12); Behavioural addiction papers (n=23); Other papers (n=4)
• 2014: Gambling papers (n=13); Behavioural addiction papers (n=33); Other papers (n=13)
• 2015: Gambling papers (n=13); Behavioural addiction papers (n=27); Other papers (n=7)
• In press: Gambling papers (n=8); Behavioural addiction papers (n=13); Other papers (n=4)

 

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading (some recent papers)

Andreassen, C.S., Griffiths, M.D., Pallesen, S., Bilder, R.M., Torsheim, T. Aboujaoude, E.N. (2015). The Bergen Shopping Addiction Scale: Reliability and validity of a brief screening test. Frontiers in Psychology, 6:1374. doi: 10.3389/fpsyg.2015.01374.

Atroszko, P.A., Andreassen, C.S., Griffiths, M.D. & Pallesen, S. (2015). Study addiction – A new area of psychological study: Conceptualization, assessment, and preliminary empirical findings. Journal of Behavioral Addictions, 4, 75–84.

Auer, M. & Griffiths, M.D. (2015). Testing normative and self-appraisal feedback in an online slot-machine pop-up message in a real-world setting. Frontiers in Psychology, 6, 339. doi: 10.3389/fpsyg.2015.00339.

Auer, M. & Griffiths, M.D. (2015). The use of personalized behavioral feedback for problematic online gamblers: An empirical study. Frontiers in Psychology, 6, 1406. doi: 10.3389/fpsyg.2015.01406.

Billieux, J., Maurage, P., Lopez-Fernandez, O., Kuss, D.J. & Griffiths, M.D. (2015). Can disordered mobile phone use be considered a behavioral addiction? An update on current evidence and a comprehensive model for future research. Current Addiction Reports, 2, 154-162.

Canale, N. Santinello, M. & Griffiths, M.D. (2015). Validation of the Reasons for Gambling Questionnaire (RGQ) in a British population survey. Addictive Behaviors, 45, 276-280.

Canale, N., Vieno, A., Griffiths, M.D., Rubaltelli, E., Santinello, M. (2015). Trait urgency and gambling problems in young people: the role of decision-making processes. Addictive Behaviors, 46, 39-44.

Canale, N., Vieno, A., Griffiths, M.D., Rubaltelli, E., Santinello, M. (2015). How do impulsivity traits influence problem gambling through gambling motives? The role of perceived gambling risk/benefits. Psychology of Addictive Behaviors, 29, 813–823.

Cleghorn, J. & Griffiths, M.D. (2015). Why do gamers buy ‘virtual assets’? An insight in to the psychology behind purchase behaviour. Digital Education Review, 27, 98-117.

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, 2, 163-174.

Dhuffar, M. & Pontes, H.M. & Griffiths, M.D. (2015). Dysphoric mood states and consequences of sexual behaviours as predictors of hypersexual behaviours in university students: An exploratory study. Journal of Behavioural Addictions, 4, 181–188.

Foster, A.C., Shorter, G.W. & Griffiths, M.D. (2015). Muscle Dysmorphia: Could it be classified as an Addiction to Body Image? Journal of Behavioral Addictions, 4, 1-5.

Greenhill, R. & Griffiths, M.D. (2015). Compassion, dominance/submission, and curled lips: A thematic analysis of dacryphilic experience. International Journal of Sexual Health, 27, 337-350.

Griffiths, M.D. (2015). Problematic technology use during adolescence: Why don’t teenagers seek treatment? Education and Health, 33, 6-9.

Griffiths, M.D., Urbán, R., Demetrovics, Z., Lichtenstein, M.B., de la Vega, R., Kun, B., Ruiz-Barquín, R., Youngman, J. & Szabo, A. (2015). A cross-cultural re-evaluation of the Exercise Addiction Inventory (EAI) in five countries. Sports Medicine Open, 1:5.

Hanss, D., Mentzoni, R.A., Griffiths, M.D., & Pallesen, S. (2015). The impact of gambling advertising: Problem gamblers report stronger impacts on involvement, knowledge, and awareness than recreational gamblers. Psychology of Addictive Behaviors, 29, 483-491.

Hussain, Z., Williams, G. & Griffiths, M.D. (2015). An exploratory study of the association between online gaming addiction and enjoyment motivations for playing massively multiplayer online role-playing games. Computers in Human Behavior, 50, 221–230.

Karanika-Murray, M., Pontes, H.M., Griffiths, M.D. & Biron, C. (2015). Sickness presenteeism determines job satisfaction via affective-motivational states. Social Science and Medicine, 139, 100-106.

Király, O., Griffiths, M.D. & Demetrovics Z. (2015). Internet gaming disorder and the DSM-5: Conceptualization, debates, and controversies, Current Addiction Reports, 2, 254–262.

Király, O., Urbán, R., Griffiths, M.D., Ágoston, C., Nagygyörgy, K., Kökönyei, G. & Demetrovics, Z. (2015). Psychiatric symptoms and problematic online gaming: The mediating effect of gaming motivation. Journal of Medical Internet Research, 17(4) :e88.

Maraz, A., Eisinger, A., Hende, Urbán, R., Paksi, B., Kun, B., Kökönyei, G., Griffiths, M.D. & Demetrovics, Z. (2015). Measuring compulsive buying behaviour: Psychometric validity of three different scales and prevalence in the general population and in shopping centres. Psychiatry Research, 225, 326–334.

Maraz, A., Király, O., Urbán, R., Griffiths, M.D., Demetrovics, Z. (2015). Why do you dance? Development of the Dance Motivation Inventory (DMI). PLoS ONE, 10(3): e0122866. doi:10.1371/ journal.pone.0122866

Maraz, A., Urbán, R., Griffiths, M.D. & Demetrovics Z. (2015). An empirical investigation of dance addiction. PloS ONE, 10(5): e0125988. doi:10.1371/journal.pone.0125988.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2015). Game Transfer Phenomena and its associated factors: An exploratory empirical online survey study. Computers in Human Behavior, 51, 195-202.

Ortiz de Gortari, A.B., Pontes, H.M. & Griffiths, M.D. (2015). The Game Transfer Phenomena Scale: An instrument for investigating the non-volitional effects of video game playing. Cyberpsychology, Behavior and Social Networking, 18, 588-594.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H.M., Kuss, D.J. & Griffiths, M.D. (2015). The clinical psychology of Internet addiction: A review of its conceptualization, prevalence, neuronal processes, and implications for treatment. Neuroscience and Neuroeconomics, 4, 11-23.

Pontes, H.M., Szabo, A. & Griffiths, M.D. (2015). The impact of Internet-based specific activities on the perceptions of Internet Addiction, Quality of Life, and excessive usage: A cross-sectional study. Addictive Behaviors Reports, 1, 19-25.

Quinones, C. & Mark D. Griffiths (2015). Addiction to work: recommendations for assessment. Journal of Psychosocial Nursing and Mental Health Services, 10, 48-59.

Shonin, E., Van Gordon W., Compare, A., Zangeneh, M. & Griffiths M.D. (2015). Buddhist-derived loving-kindness and compassion meditation for the treatment of psychopathology: A systematic review. Mindfulness, 6, 1161–1180.

Szabo, A., Griffiths, M.D., de La Vega Marcos, R., Mervo, B. & Demetrovics, Z. (2015). Methodological and conceptual limitations in exercise addiction research. Yale Journal of Biology and Medicine, 86, 303-308.

Van Gordon W., Shonin, E., Griffiths M.D. & Singh, N. (2015). There is only one mindfulness: Why science and Buddhism need to work together. Mindfulness, 6, 49-56.

Cured meets: Treating addictive behaviours

Addiction is a highly prevalent problem within today’s society and there is a lot of time and many spent in trying to prevent and treat the behaviour. There has also been a move towards getting addicts motivated to want to change their behaviour. The most influential model worldwide is probably the ‘stages of change’ model by Dr. James Prochaska and Dr, Carlo Di Clemente that identifies an individual’s ‘readiness for change’ and tries to get a person to a position where they are highly motivated to change their behaviour. The individual stages of this model are:

• Precontemplation – This is where the person unaware of the consequences of his or her own behaviour and no change in behaviour is foreseeable.
• Contemplation – This is where the person aware problem exists and is contemplating change.
• Preparation – This is where the person has decided to change in the near future (e.g., New Year resolution).
• Action – This is where the person effects change (e.g., gets rid of all association items related to the behaviour).
• Maintenance – This is where the person consolidates behaviour change over time.
• Relapse – This where the person reverts to a former behaviour pattern (e.g., contemplation, preparation).

People can stay in one stage for a long time and it is also possible for unassisted change such “maturing out” or “spontaneous remission”. Various techniques can be used to help people prepare for readiness include motivational techniques, behavioural self-training, skills training, stress management training, anger management training, relaxation training, aerobic exercise, relapse prevention, and lifestyle modification. The goal of treatment can be either abstinence or simply to cut down.

The intervention and treatment options for the treatment of addiction include, but are not limited to counselling/psychotherapies, behavioural therapies, cognitive-behavioural therapies, self-help therapies, pharmacotherapies, residential therapies, minimal interventions and combinations of these (i.e., multi-modal treatment packages). The most important of these are outlined below.

Pharmacotherapy: Pharmacological interventions basically consist of addicts being given a drug to help overcome their addiction. These are mainly given to those people with chemical addictions (e.g., nicotine, alcohol, heroin, etc.) but are increasingly being used for those with behavioural addictions (e.g., gambling, sex, work, exercise, etc.). For instance, some drugs produce an unpleasant reaction when used in combination with the drug of dependence, replacing the positive effects of the drug of dependence with a negative reaction. For instance, alcoholics are sometimes prescribed disulfiram (more commonly known as Antabuse), that when combined with alcohol may produce nausea and vomiting. Other common therapies include methadone and the use of opioid antagonists (such as nalaxone or naltrexene) for heroin addiction. The methadone prevents withdrawal symptoms, block the effects of heroin use, and decreases craving. The main criticism of all these treatments is that although the symptoms may be being treated, the underlying reasons for the addictions may be being ignored. On a more pragmatic level, what happens when the drug is taken away? Often, the addicts return to their addiction if this is the only method of treatment used.

Behavioural therapy: Behavioural therapies are based on the view that addiction is a learned maladaptive behaviour and can therefore be ‘unlearned’. These have mainly been based on the classical conditioning paradigm and include aversion therapy, in vivo desensitisation, imaginal desensitisation, systematic desensitisation, relaxation therapy, covert sensitisation, and satiation therapy. All of these therapies focus on cue exposure, and relapse triggers (like the sight and smell of alcohol/drugs, walking through a neighbourhood where casinos are abundant, pay day, arguments, pressure, etc.). The theory is that through repeated exposure to ‘relapse triggers’ in the absence of the addiction, the addict learns to stay addiction free in high-risk situations. It could be argued that if the addiction is caused by some underlying psychological problem, (rather than a learned maladaptive behaviour), then behavioural therapy would at best only eliminate the behaviour but not the problem. This therefore means that the addictive behaviour may well have been curtailed but the problem is still there so the person will perhaps engage in a different addictive behaviour instead.

Cognitive-behavioural therapy: A more recent development in the treatment of addictive behaviours is the use of cognitive-behavioural therapies (CBT). There are many different CBT approaches that have been used in the treatment of addictive behaviours including rational emotive therapy, motivational interviewing, and relapse prevention. The techniques assume that addiction is a means of coping with difficult situations, dysphoric mood, and peer pressure. Treatment aims to help addicts recognise high-risk situations and either avoid or cope with them without use of the addictive behaviour. In relapse prevention, the therapist helps to identify situations that present a risk for relapse (both intrapersonal and interpersonal). Relapse prevention provides the addict with techniques to learn how to cope with temptation (positive self statements, decision review, and distraction activities), coupled with the use of covert modelling (i.e., practicing coping skills in one’s imagination). It also provides skills for coping with lapses (by redefining what is happening), and utilizes graded practice (a desensitization technique where addicts encounter real life situations slowly). Overall, CBT approaches are better researched than the other psychological methods in addiction but are probably no more effective (Luty, 2003).

Psychotherapy: Psychotherapy can include everything from Freudian psychoanalysis and transactional analysis, to more recent innovations like drama therapy, family therapy and minimalist intervention strategies. The therapy can take place as an individual, as a couple, as a family, as a group and is basically viewed as a ‘talking cure’ consisting of regular sessions with a psychotherapist over a period of time. Most psychotherapies view maladaptive behaviour as the symptom of other underlying problems. Psychotherapy often is very eclectic by trying to meet the needs of the individual and helping the addict develop coping strategies. If the problem is resolved, the addiction should disappear. In some ways, this is the therapeutic opposite of pharmacotherapy and behavioural therapy (which treats the symptoms rather than the underlying cause). There has been little evaluation of its effectiveness although most addicts go through at least some form of counselling during the treatment process.

Self-help therapy: The most popular self-help therapy worldwide is the Minnesota Model 12-Step Programme (e.g., Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Overeaters Anonymous, Sexaholics Anonymous, etc.). This treatment programme uses a group therapy technique and uses only ex-addicts as helpers. Addicts attending 12-Step groups involves them accepting personal responsibility and views the behaviour as an addiction that cannot be cured but merely arrested. To some it becomes a way of life both spiritually and socially and compared with almost all other treatments it is especially cost-effective (even if other treatments have greater success rates) as the organization makes no financial demands on members or the community. For the therapy to work, the 12-Step Programme asserts that the addict must come to them voluntarily and must really want to stop engaging in their addictive behaviour. Further to this, they are only allowed to join once they have reached “rock bottom”. To date there has been little systematic study of 12-Step groups but drop out rates are very high (typically 80-90%). There are a number of problems preventing evaluation, particularly anonymity, sample bias, and what the criterion for success is. The empirical evidence suggests that self-help support groups’ complement formal treatment options and can support standardized psychosocial interventions.

When examining all the literature on the treatment of addiction, there are a number of key conclusions that can be drawn. These include that: (i) treatment must be readily available, (ii) no single treatment is appropriate for all individuals., (iii) it is better for an addict to be treated than not to be treated, (iv) it does not seem to matter which treatment an addict engages in as no single treatment has been shown to be demonstrably better than any other, (v) a variety of treatments simultaneously appear to be beneficial to the addict, (vi) individual needs of the addict have to be met (i.e., the treatment should be fitted to the addict including being gender-specific and culture-specific), (vi) clients with co-existing addiction disorders should receive services that are integrated, (vii) remaining in treatment for an adequate period of time is critical for treatment effectiveness, (viii) medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies, (ix) recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment, (x) there is a direct association between the length of time spent in treatment and positive outcomes, and (xi) the duration of treatment interventions is determined by individual needs, and there are no pre-set limits to the duration of treatment.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1996). Pathological gambling and its treatment. British Journal of Clinical Psychology, 35, 477-479.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Griffiths, M.D. & H.F. MacDonald (1999). Counselling in the treatment of pathological gambling: An overview. British Journal of Guidance and Counselling, 27, 179-190.

Hayer, T. & Griffiths, M.D. (2015). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition) (pp. 539-558). New York: Kluwer.

King, D.L., Delfabbro, P.H., Griffiths, M.D. & Gradisar, M. (2012). Cognitive-behavioural approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

Luty, J. (2003). What works in drug addiction? Advances in Psychiatric Treatment, 9, 280–288.

National Institute on Drug Abuse (1999). Principles of drug addiction treatment: A research-based guide. NIDA.

Potenza, M. & Griffiths, M.D. (2004). Prevention efforts and the role of the clinician. In J.E. Grant & M. N. Potenza (Eds.), Pathological Gambling: A Clinical Guide To Treatment (pp. 145-157). Washington DC: American Psychiatric Publishing Inc.

Prochaska, J.O. and DiClemente, C.C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Melbourne, Florida: Krieger Publishing Company

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

United Nations Office on Drugs and Crime/World Health Organization (2008). Principles of Drug Dependence Treatment: Discussion paper. UN/WHO.

Ringing the changes: Can disordered mobile phone use be considered a behavioural addiction?

Over the last decade, I have published various papers on excessive mobile phone use both in general and related to particular aspects of mobile phone use (such as gambling and gaming via mobile phones (see ‘Further reading’ below). Recently, some colleagues and I (and led by Dr. Joël Billieux) published a new review in the journal Current Addiction Reports examining disordered mobile phone use.

I don’t think many people would say that their lives are worse because of mobile phones as the positives appear to greatly outweigh the negatives. However, in the scientific literature, excessive mobile phone use has been linked with self-reported dependence and addiction-like symptoms, sleep interference, financial problems, dangerous use (phoning while driving), prohibited use (phoning in banned areas), and mobile phone-based aggressive behaviours (e.g., cyberbullying).

Despite accumulating evidence that mobile phone use can become problematic and lead to negative consequences, its incidence, prevalence, and symptomatology remain a matter of much debate. For instance, our recent review noted that prevalence studies conducted within the last decade have reported highly variable rates of problematic use ranging from just above 0% to more than 35%. This is mainly due to the fact most studies in the field have been conducted in the absence of a theoretical rationale.

Too often, excessive mobile phone use has simply been conceptualized as a behavioural addiction and subsequently develop screening tools using items adapted from the substance use and pathological gambling literature, without taking into account either the specificities of mobile phone “addiction” (e.g., dysfunctional mobile phone use may often be related to interpersonal processes) or the fact that the most recent generation of mobile phones (i.e., smartphones) are tools that – like the internet – allow the involvement in a wide range of activities going far beyond traditional oral and written (SMS) communication between individuals (e.g., gaming, gambling, social networking, shopping, etc.).

The first scientific studies examining problematic mobile phone use (PMPU) were published a decade ago. Since then, the number of published studies on the topic has grown substantially. At present, several terms are frequently used to describe the phenomenon, the more popular being ‘mobile phone (or smartphone) addiction’, ‘mobile phone (or smartphone) dependence’ or ‘nomophobia’ (that refers to the fear of not being able to use the mobile phone).

PMPU is generally conceptualized as a behavioural addiction including the core components of addictive behaviours, such as cognitive salience, loss of control, mood modification, tolerance, withdrawal, conflict and relapse. Accordingly, the criteria (and screening tools developed using such criteria) that have been proposed to diagnose an addiction to the mobile phone have been directly transposed from those classifying and diagnosing other addictive behaviours, i.e., the criteria for substance use and pathological gambling. For example, in a recent study published in the Journal of Behavioral Addictions, Dr. Peter Smetaniuk reported a prevalence of PMPU around 20% in U.S. undergraduate students using adapted survey items that were initially developed to diagnose disordered gambling.

Although many scholars believe that PMPU is a behavioural addiction, evidence is still lacking that either confirms or rejects such conceptualization. Indeed, the fact that this condition can be considered as an addiction is to date only supported by exploratory studies relying on self-report data collected via convenience samples. More specifically, there is a crucial lack of evidence that similar neurobiological and psychological mechanisms are involved in the aetiology of mobile phone addiction compared to other chemical and behavioural addictions. Such types of evidence played a major role in the recent recognition of Gambling Disorder and Internet Gaming Disorder as addictive disorders in the latest (fifth) addiction of the DSM (i.e., DSM-5) In particular, three key features of addictive behaviours, namely loss of control, tolerance and withdrawal, have – to date – received very limited empirical support in the field of mobile phone addiction research.

Given these concerns, it appears that the empirical evidence supporting the conceptualization of PMPU as a genuine addictive behaviour is currently scarce. However, this does not mean that PMPU is not a genuine addictive behaviour (at least for a subgroup of individuals displaying PMPU symptoms), but rather that the nature and amount of the available data at the present time are not sufficient to draw definitive and valid conclusions. Therefore, further studies are required. In particular, longitudinal and experimental research is needed to obtain behavioural and neurobiological correlates of PMPU. In the absence of such types of data, all attempts to consider PMPU within the framework of behavioural addictions will remain tentative. It is worth noting here that it took decades of empirical research before disordered gambling was officially recognized as an addiction (as opposed to a disorder of impulse control) in the DSM-5.

The current conceptual chaos surrounding PMPU research can also be related to the fact that while the number of empirical studies is growing quickly, these studies have (to date) primarily been based on concepts borrowed from other disorders (e.g., problematic Internet use, pathological gambling, substance abuse, etc.). This approach is atheoretical and lacks specificity with regard to the phenomenon under investigation. In fact, by adopting such a ‘confirmatory approach’ relying on deductive quantitative studies, important findings that are unique to the experience of PMPU have been neglected. As an illustration, no qualitative analyses of PMPU exist, and only a few models have been proposed. This implies that most studies have been conducted without a theoretical rationale that goes beyond transposing what is known about addictions in the analysis of PMPU.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Additional input: Joël Billieux, Pierre Maurage, Olatz Lopez-Fernandez and Daria J. Kuss

Further reading

Bianchi, A. & Phillips, J.G. (2005). Psychological predictors of problem mobile phone use. Cyberpsychology and Behavior, 8, 39–51.

Billieux, J. (2012). Problematic use of the mobile phone: A literature review and a pathways model. Current Psychiatry Reviews, 8, 299–307.

Billieux, J., Maurage, P., Lopez-Fernandez, O., Kuss, D.J. & Griffiths, M.D. (2015). Can disordered mobile phone use be considered a behavioral addiction? An update on current evidence and a comprehensive model for future research. Current Addiction Reports, 2, 154-162.

Carbonell, X., Chamarro, A., Beranuy, M., Griffiths, M.D. Obert, U., Cladellas, R. & Talarn, A. (2012). Problematic Internet and cell phone use in Spanish teenagers and young students. Anales de Psicologia, 28, 789-796.

Chóliz M. (2010). Mobile phone addiction: a point of issue. Addiction. 105, 373-374.

Griffiths, M.D. (2007). Mobile phone gambling. In D. Taniar (Ed.), Encyclopedia of Mobile Computing and Commerce (pp.553-556). Pennsylvania: Information Science Reference.

Griffiths, M.D. (2013). Adolescent mobile phone addiction: A cause for concern? Education and Health, 31, 76-78.

Lopez-Fernandez, O., Honrubia-Serrano, L., Freixa-Blanxart, M., & Gibson, W. (2014). Prevalence of problematic mobile phone use in British adolescents. Cyberpsychology, Behavior and Social Networking, 17, 91-98.

Lopez-Fernandez, O., Kuss, D.J., Griffiths, M.D., & Billieux, J. (2015). The conceptualization and assessment of problematic mobile phone use. In Z. Yan (Ed.), Encyclopedia of Mobile Phone Behavior (Volumes 1, 2, & 3) (pp. 591-606). Hershey, PA: IGI Global.

Smetaniuk, P. (2014). A preliminary investigation into the prevalence and prediction of problematic cell phone use. Journal of Behavioral Addictions, 3(1), 41-53.

Net losses: Another look at problematic online gaming

I have examined problematic and/or addictive video gaming in a number of my previous blogs. Despite the increasing amount of empirical research into problematic online gaming, the phenomenon still sadly lacks a consensual definition. Some researchers (including myself, and others such as John Charlton and Ian Danforth) consider video games as the starting point for examining the characteristics of this specific pathology, while other researchers consider the internet as the main platform that unites different addictive internet activities including online games (such as my friends and colleagues Tony Van Rooij and Kimberley Young). There are also recent studies that have made an effort to integrate both approaches (such as some work I carried out with Zsolt Demetrovics and his team of Hungarian researchers in the journal PLoS ONE).

I have noted in a number of my papers on addiction (particularly in a paper I had published in a 2005 issue of the Journal of Substance Use) that although each addiction has several particular and idiosyncratic characteristics, they have more commonalities than differences that may reflect a common etiology of addictive behaviour. Using the ‘components’ model of addiction, within a biopsychosocial framework, I consider online game addiction a specific type of video game addiction that can be categorized as a nonfinancial type of pathological gambling. I developed the components of video game addiction theory by modifying Iain Brown’s earlier addiction criteria. These are:

(1) Salience: This is when video gaming becomes the most important activity in the person’s life and dominates his/her thinking (i.e., preoccupations and cognitive distortions), feelings (i.e., cravings) and behaviour (i.e., deterioration of socialized behaviour);

(2) Mood modification: This is the subjective experience that people report as a consequence of engaging in video game play (i.e. they experience an arousing ‘buzz’ or a ‘high’ or, paradoxically, a tranquillizing and/or distressing feel of ‘escape’ or ‘numbing’).

(3) Tolerance: This is the process whereby increasing amounts of video game play are required to achieve the former effects, meaning that for persons engaged in video game playing, they gradually build up the amount of the time they spend online engaged in the behaviour.

(4) Withdrawal symptoms: These are the unpleasant feeling states or physical effects that occur when video gaming is discontinued or suddenly reduced, for example, the shakes, moodiness, irritability, etc.

(5) Conflict: This refers to the conflicts between the video game player and those around them (i.e., interpersonal conflict), conflicts with other activities (e.g., job, schoolwork, social life, hobbies and interests) or from within the individual themselves (i.e., intrapsychic conflict and/or subjective feelings of loss of control) which are concerned with spending too much time engaged in video game play.

(6) 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 at the height of excessive video game play to be quickly restored after periods of abstinence or control.

John Charlton and Ian Danforth analyzed these six criteria and found that tolerance, mood modification and cognitive salience were indicators of high engagement, while the other components – withdrawal symptoms, conflict, relapse and behavioural salience – played a central role in the development of addiction.

Researchers such as Guy Porter and Vladan Starcevic don’t differentiate between problematic video game use and problematic online game use. They conceptualized problematic video game use as excessive use of one or more video games resulting in a preoccupation with and a loss of control over playing video games, and various negative psychosocial and/or physical consequences. Their criteria for problematic video game use didn’t include other features usually associated with dependence or addiction, such as tolerance and physical symptoms of withdrawal, because in their opinion there is no clear evidence that problem video game use is associated with these phenomena.

Arguably the most well known representative of the internet-based approach is Kimberley Young who developed her theoretical framework for problematic online gaming based on her internet addiction criteria which were based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – (Fourth Edition, DSM-IV) criteria for pathological gambling. Her theory states that online game addicts gradually lose control over their game play, that is, they are unable to decrease the amount of time spent playing while immersing themselves increasingly in this particular recreational activity, and eventually develop problems in their real life. The idea that internet/online video game addiction can be assessed by the combination of an internet addiction score and the amount of time spent gaming are also reflective of the internet-based approach.

Integrative approaches try to take into consideration both aforementioned approaches. For instance, a 2010 paper by M.G. Kim and J. Kim in Computers in Human Behavior claimed that neither the first nor the second approach can adequately capture the unique features of online games such as Massively Multiplayer Online Role-Playing Games (MMORPGs), therefore it’s absolutely necessary to create an integrated approach. They argued that “internet users are no more addicted to the internet than alcoholics are addicted to bottles” which means that the internet is just one channel through which people may access whatever content they want (e.g., gambling, shopping, chatting, sex, etc.) and therefore users of the internet may be addicted to the particular content or services that the Internet provides, rather than the channel itself. On the other hand, online games differ from traditional stand-alone games, such as offline video games, in important aspects such as the social dimension or the role-playing dimension that allow interaction with other real players.

Their multidimensional Problematic Online Game Use (POGU) model reflects this integrated approach fairly well. It was theoretically developed on the basis of several studies and theories (such as those by Iain Brown, John Charlton, Ian Danforth, Kimberley Young and myself), and resulted in five underlying dimensions: euphoria, health problems, conflict, failure of self-control, and preference of virtual relationship. A 2012 study I carried out with Zsolt Demetrovics and his team also support the integrative approach and stresses the need to include all types of online games in addiction models in order to make comparisons between genres and gamer populations possible (such as those who play online Real-Time Strategy (RTS) games and online First Person Shooter (FPS) games in addition to the widely researched MMORPG players). According to this model, six dimensions cover the phenomenon of problematic online gaming – preoccupation, overuse, immersion, social isolation, interpersonal conflicts, and withdrawal. Personally, I believe that online game addiction can be defined as one type of behavioural addiction. In fact ‘internet gaming disorder’ has just been included in the appendices of the new DSM-5 in order to encourage research to determine whether this particular condition should be added to the manual as a disorder in the future.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Additional input: Orsolya Pápay, Katalin Nagygyörgy and Zsolt Demetrovics

Further reading

Charlton, J. P., & Danforth, I.D.W. (2007). Distinguishing addiction and high engagement in the context of online game playing. Computers in Human Behavior, 23(3), 1531-1548.

Demetrovics, Z., Urbán, R., Nagygyörgy, K., Farkas, J., Griffiths, M.D., Pápay, O. & Oláh, A. (2012). The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS ONE, 7(5): e36417. doi:10.1371/journal.pone.0036417.

Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Han, D. H., Hwang, J. W., & Renshaw, P. F. (2010). Bupropion sustained release treatment decreases craving for video games and cue-induced brain activity in patients with Internet video game addiction. Experimental and Clinical Psychopharmacology, 18, 297-304.

Kim, M.G., & Kim, J. (2010). Cross-validation of reliability, convergent and discriminant validity for the problematic online game use scale. Computers in Human Behavior, 26(3), 389-398.

King, D.L., Haagsma, M.C.^, Delfabbro, P.H., Gradisar, M.S.^, Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Peters, C. S., & Malesky, L. A. (2008). Problematic usage among highly-engaged players of massively multiplayer online role playing games. Cyberpsychology & Behavior, 11(4), 480-483.

Pontes, H. & Griffiths, M.D. (2014). The assessment of internet gaming disorder in clinical research. Clinical Research and Regulatory Affairs, 31(2-4), 35-48.

Pontes, H., Király, O. Demetrovics, Z. & Griffiths, M.D. (2014). The conceptualisation and measurement of DSM-5 Internet Gaming Disorder: The development of the IGD-20 Test. PLoS ONE, 9(10): e110137. doi:10.1371/journal.pone.0110137.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Porter, G., Starcevic, V., Berle, D., & Fenech, P. (2010). Recognizing problem video game use. The Australian and New Zealand Journal of Psychiatry, 44, 120-128.

Van Rooij, A. J., Schoenmakers, T. M., Vermulst, A. A., Van den Eijnden, R. J., & Van de Mheen, D. (2011). Online video game addiction: identification of addicted adolescent gamers. Addiction, 106(1), 205-212.

Young, K. S. (1998a). Caught in the Net: How to recognize the signs of Internet addiction and a winning strategy for recovery. New York: Wiley.

Young, K. S. (1999). Internet addiction: Symptoms, evaluation, and treatment. In L. Vande Creek & T. Jackson (Eds.), Innovations in clinical practice: A source book (pp. 17, 19–31). Sarasota, FL: Professional Resource Press.

Distraction plans: Excessive smartphone use and pain perception

In a previous blog I outlined many physical syndromes that had been reported in the 1980s medical literature, a number of which related to excessive video game playing. This included ‘Space Invader’s Wrist’ (published in the New England Journal of Medicine), ‘Pseudovideoma’ (Journal of Hand Surgery), ‘Pac-Man Phalanx’ (Arthritis and Rheumatism) and ‘Joystick Digit’ (Journal of the American Medical Association). More recently, other new medical complaints have been reported related to excessive mobile phone use including a report of ‘Blackberry thumb’ in a 2013 issue of the Canadian Medical Association Journal. 

Earlier this month saw the publication of a case report involving a tendon rupture in a man excessively playing a video game on his smartphone. The report appeared in JAMA Internal Medicine by Dr. Andrew Doan and his colleagues (the same Dr. Doan that reported a case study of someone “addicted” to Google Glass that I examined in a previous blog). The authors of the latest report wrote:

“We describe a patient with rupture of the extensor pollicis longus tendon associated with excessive video game play on his smartphone. A 29-year-old, right hand–dominant man presented with chronic left thumb pain and loss of active motion. Before the onset of symptoms, he reported playing a video game on his smartphone all day for 6 to 8 weeks. He played with his left hand while using his right hand for other tasks, stating that ‘playing was a kind of secondary thing, but it was constantly on.’ When playing the video game, the patient reported that he felt no pain. He reported no injuries or prior operations to either hand. He denied a history of inflammatory arthritis, quinolone use, or other predisposing medical condition for ten-don rupture. On physical examination, the left extensor pollicis longus tendon was not palpable, and no tendon motion was noted with wrist tenodesis. The thumb metacarpophalangeal range of motion was 10° to 80°, and thumb interphalangeal range of motion was 30° to 70°. The findings on physical examination of the patient’s right hand were unremarkable. The clinical diagnosis was rupture of the left extensor pollicis longus tendon. A magnetic resonance imaging study of his left hand revealed tendon attenuation and rupture of the tendon. Radiographic studies of the wrist found no bone spurs or prior or current fractures. The patient subsequently underwent an extensor indicis proprius (1 of 2 tendons that extend the index finger) to extensor pollicis longus tendon transfer. During surgery, rupture of the extensor pollicis longus tendon was seen between the metacarpophalangeal and wrist joints”

One of the things that I found interesting was that despite the tendon rupture, when the man was actually playing the game, he felt no pain. This is something I know only too well from personal experience. Unfortunately, I have a chronic and degenerative spinal complaint (herniated discs in my neck) but I feel no pain whatsoever when I am cognitively distracted. I find that work is a much better analgesic than dihydrocodeine (i.e., when I am working I feel no pain whatsoever). However, playing video games come a close second as when I am engaged in video game playing (even on simple casual games), the fact that it takes up all my cognitive resources means that I don’t feel any pain. This is nothing new and many medics are aware of the therapeutic benefits of gaming. There are now many studies showing that children undergoing chemotherapy need much less pain relief if they play video games after their treatment compared to children that don’t play video games. (In fact I’ve written a number of papers and book chapters on ‘video game therapy’ – see ‘Further reading’ below). This case report then went on to say:

“Video games suppress pain perception in pediatric patients and during burn treatments. Visual distraction and neuroendocrine hypothalamic-pituitary-adrenal arousal provide a plausible explanation for why the patient did not feel pain from his injury. Without the expected physiologic negative pain feedback, excessive gaming may have led to tendon attenuation and subsequent attritional rupture of the tendon. Attritional rupture at the midtendon differs from high- energy ruptures that occur where the tendon is thinnest or be- tween tendon and bone. Although this is only a single case report, research might consider whether video games have a role in clinical pain management and as nonpharmacologic alternatives during uncomfortable or painful medical procedures. They may also have a role in reducing stress. It may be interesting to ascertain whether various games differ in their ability to reduce the perception of pain…Research might also consider whether pain reduction is a reason some individuals play video games excessively, manifest addiction, or sustain injuries associated with video gaming”.

This conclusion does appear to suggest that the authors are unaware of the many hundreds of studies that have examined the therapeutic benefits of gaming (in fact there’s even an academic journal dedicated to such studies appropriately called the Games For Health Journal). As I have noted in a number of my writings about video gaming as a medical intervention for children:

• Videogames are likely to engage much of a person’s individual active attention because of the cognitive and motor activity required.
• Videogames allow the possibility to achieve sustained achievement because of the level of difficulty (i.e., challenge) of most games during extended play.
• Videogames appear to appeal most to adolescents.

Consequently, videogames have also been used in a number of studies as ‘distractor tasks’. This latest case report highlights the simultaneous potential positive and negatives of gaming within a single individual but also highlights the fact that video gaming is both mobile and spreading to many more types of hardware. I’m now wondering which medical team will be the first to write about a new medical syndrome relating to the new Apple Watch.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Behr, J.T. (1984). Pseudovideoma. Journal of Hand Surgery, 9(4), 613.

Gibofsky, A. (1983). Pac‐Man phalanx. Arthritis and Rheumatism, 26(1), 120.

Gilman, L., Cage, D.N., Horn, A. Bishop, F., Klam, W.P. & Doan, A.P. (2015). Tendon rupture associated with excessive smartphone gaming. JAMA Internal Medicine, doi:10.1001/jamainternmed.2015.0753

Griffiths, M.D. (2003). The therapeutic use of videogames in childhood and adolescence. Clinical Child Psychology and Psychiatry, 8, 547-554.

Griffiths, M.D. (2005). Video games and health. British Medical Journal, 331, 122-123.

Griffiths, M.D. (2005). The therapeutic value of videogames. In J. Goldstein & J. Raessens (Eds.), Handbook of Computer Game Studies (pp. 161-171). Boston: MIT Press.

Griffiths, M. D., Kuss, D.J., & Ortiz de Gortari, A. (2013). Videogames as therapy: A review of the medical and psychological literature. In I. M. Miranda & M. M. Cruz-Cunha (Eds.), Handbook of research on ICTs for healthcare and social services: Developments and applications (pp.43-68). Pennsylvania: IGI Global.

McCowan, T.C. (1981). Space Invader’s wrist. New England Journal of Medicine, 304,1368.

Osterman, A. L., Weinberg, P., & Miller, G. (1987). Joystick digit. Journal of the American Medical Association, 257(6), 782.

O’Sullivan, B. (2013). Beyond BlackBerry thumb. CMAJ, 185, 185-186.

Soe, G.B., Gersten, L. M., Wilkins, J., Patzakis, M. J., & Harvey, J.P. (1987). Infection associated with joystick mimicking a spider bite. Western Journal of Medicine, 146(6), 748.

Yung, K., Eickhoff, E., Davis, D. L., Klam, W. P., & Doan, A. P. (2014). Internet Addiction Disorder and problematic use of Google Glass™ in patient treated at a residential substance abuse treatment program. Addictive Behaviors, http://dx.doi.org/10.1016/j.addbeh.2014.09.024.

In dependence days: A brief overview of behavioural addictions

Please note: A version of this blog first appeared on addiction.com

Conceptualizing addiction has been a matter of great debate for decades. For many people the concept of addiction involves the taking of drugs. Therefore it is perhaps unsurprising that most official definitions concentrate on drug ingestion. Despite such definitions, there is now a growing movement that views a number of behaviours as potentially addictive including those that do not involve the ingestion of a drug. These include behaviours diverse as gambling, eating, sex, exercise, videogame playing, love, shopping, Internet use, social networking, and work. I have argued in many of my papers that all addictions – irrespective of whether they are chemical or behavioural – comprise six components (i.e., salience, mood modification, tolerance, withdrawal, conflict and relapse). More specifically:

• Salience – This occurs when the activity becomes the single most important activity in the person’s life and dominates their thinking (preoccupations and cognitive distortions), feelings (cravings) and behaviour (deterioration of socialized behaviour). For instance, even if the person is not actually engaged in the activity they will be constantly thinking about the next time that they will be (i.e., a total preoccupation with the activity).
• Mood modification – This refers to the subjective experiences that people report as a consequence of engaging in the activity and can be seen as a coping strategy (i.e., they experience an arousing ‘buzz’ or a ‘high’ or paradoxically a tranquilizing feel of ‘escape’ or ‘numbing’).
• Tolerance – This is the process whereby increasing amounts of the activity are required to achieve the former mood modifying effects. This basically means that for someone engaged in the activity, they gradually build up the amount of the time they spend engaging in the activity every day.
• Withdrawal symptoms – These are the unpleasant feeling states and/or physical effects (e.g., the shakes, moodiness, irritability, etc.) that occur when the person is unable to engage in the activity.
• Conflict – This refers to the conflicts between the person and those around them (interpersonal conflict), conflicts with other activities (e.g., work, social life, hobbies and interests) or from within the individual (e.g., intra-psychic conflict and/or subjective feelings of loss of control) that are concerned with spending too much time engaging in the activity.
• Relapse – This is the tendency for repeated reversions to earlier patterns of excessive engagement in the activity to recur, and for even the most extreme patterns typical of the height of excessive engagement in the activity to be quickly restored after periods of control.

In May 2013, the new criteria for problem gambling (now called ‘Gambling Disorder’) were published in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), and for the very first time, problem gambling was included in the section ‘Substance-related and Addiction Disorders’ (rather than in the section on impulse control disorders as had been the case since 1980 when it was first included in the DSM-III). Although most of us in the field had been conceptualizing extreme problem gambling as an addiction for many years, this was arguably the first time that an established medical body had described it as such.

There had also been debates about whether or not ‘Internet Addiction Disorder’ should have been included in the DSM-5. As a result of these debates, the Substance Use Disorder Work Group recommended that the DSM-5 include ‘Internet Gaming Disorder’ [IGD] in Section III (“Emerging Measures and Models”) as an area that required further research before possible inclusion in future editions of the DSM. To be included in its own right in the next edition, research will have to establish the defining features of IGD, obtain cross-cultural data on reliability and validity of specific diagnostic criteria, determine prevalence rates in representative epidemiological samples in countries around the world, and examine its associated biological features. Other than gambling and gaming, no other behaviour (e.g., sex, work, exercise, etc.) has yet to be classified as a genuine addiction by established medical and/or psychiatric organizations.

In one of the most comprehensive reviews of chemical and behavioural addictions, Dr. Steve Sussman, Nadra Lisha and myself examined all the prevalence literature relating to 11 different potentially addictive behaviours. We reported overall prevalence rates of addictions to cigarette smoking (15%), drinking alcohol (10%), illicit drug taking (5%), eating (2%), gambling (2%), internet use (2%), love (3%), sex (3%), exercise (3%), work (10%), and shopping (6%). However, most of the prevalence data relating to behavioural addictions (with the exception of gambling) did not have prevalence data from nationally representative samples and therefore relied on small and/or self-selected samples.

Addiction is an incredibly complex behaviour and always result from an interaction and interplay between many factors including the person’s biological and/or genetic predisposition, their psychological constitution (personality factors, unconscious motivations, attitudes, expectations, beliefs, etc.), their social environment (i.e. situational characteristics such as accessibility and availability of the activity, the advertising of the activity) and the nature of the activity itself (i.e. structural characteristics such as the size of the stake or jackpot in gambling). This ‘global’ view of addiction highlights the interconnected processes and integration between individual differences (i.e. personal vulnerability factors), situational characteristics, structural characteristics, and the resulting addictive behaviour.

There are many individual (personal vulnerability) factors that may be involved in the acquisition, development and maintenance of behavioural addictions (e.g. personality traits, biological and genetic predispositions, unconscious motivations, learning and conditioning effects, thoughts, beliefs, and attitudes), although some factors are more personal (e.g. financial motivation and economic pressures in the case of gambling addiction). However, there are also some key risk factors that are highly associated with developing almost any (chemical or behavioural) addiction such as having a family history of addiction, having co-morbid psychological problems, and having a lack of family involvement and supervision. Psychosocial factors such as low self-esteem, loneliness, depression, high anxiety, and stress all appear to be common among those with behavioural addictions.

This article briefly demonstrates that behavioural addictions are a part of a biopsychosocial process and not just restricted to drug-ingested (chemical) behaviours. Evidence is growing that excessive behaviours of all types do seem to have many commonalities and this may reflect a common etiology of addictive behaviour. Such commonalities may have implications not only for treatment of such behaviours but also for how the general public perceive such behaviours.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Berczik, K., Griffiths, M.D., Szabó, A., Kurimay, T., Urban, R. & Demetrovics, Z. (2014). Exercise addiction. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.317-342). New York: Elsevier.

Demetrovics, Z. & Griffiths, M.D. (2012). Behavioral addictions: Past, present and future. Journal of Behavioral Addictions, 1, 1-2.

Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.

Griffiths, M.D. (2009). Gambling addictions. In A. Browne-Miller (Ed.), The Praeger International Collection on Addictions: Behavioral Addictions from Concept to Compulsion (pp. 235-257). Westport, CT: Praeger.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29

Griffiths, M.D. (2011). Behavioural addiction: The case for a biopsychosocial approach. Transgressive Culture, 1(1), 7-28.

Griffiths, M.D. (2011). Workaholism: A 21^st century addiction. The Psychologist: Bulletin of the British Psychological Society, 24, 740-744.

Griffiths, M.D., Kuss, D.J. & Demetrovics, Z. (2014). Social networking addiction: An overview of preliminary findings. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.119-141). New York: Elsevier.

Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Király, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.61-95). New York: Elsevier.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Coining it in: Neologisms and ‘New Syndrome’ Syndrome

One of things I am very proud of in my academic career is the coining of the term ‘technological addiction’ back in 1995 (an umbrella term that I invented to describe a number of different person-machine addictions including slot machine addictions, video game addiction, television addiction, etc.). I’m also proud of coining the term ‘aca-media’ (relating to academics like myself that use the media to disseminate our research). A neologism (i.e., the name for a newly coined term) is often (according to Wikipedia) directly attributable to a specific event, person, publication, or period.

In the 1980s and early 1990s, there seemed to be a real upsurge is the naming of ‘new syndromes’ in the medical literature including many relating to excessive use of technology (such as ‘Space Invader’s Wrist’) and other leisure activities (such as ‘Cuber’s Thumb’ relating to excessive use of the Rubik’s Cube) – both of which made their appearance in 1981 issues of the New England Journal of Medicine. Other videogame medical complaints include ‘Pseudovideoma’ (in a 1984 issue of the Journal of Hand Surgery), ‘Pac-Man Phalanx’ (in a 1983 issue of Arthritis and Rheumatism) and ‘Joystick Digit’ (in a 1987 issue of the Journal of the American Medical Association). Another videogame-related medical complaint (in this case an infection), was reported in a 1987 issue of the Western Journal of Medicine by Dr. G.B. Soe and colleagues:

“We wish to focus WJM readers’ attention on another complication associated with video games-one that originally presented as an “infected spider bite. A 17-year-old right-handed boy noted progressive swelling and redness of his left hand seven days before admission. Two days before admission he was given penicillin intramuscularly and oral cephalexin to take at home. The swelling did not subside and the hand became very painful, so he came to the medical center for treatment. On admission his mother reported that she had seen many spiders around the house with a violin pattern on their backs, and that her son had probably been bitten by a spider…After seven days of parenteral antibiotic therapy, the edema, erythema and fever had disappeared and the patient was discharged home. Further questioning revealed that the young man was spending almost all of his time playing his favorite video game, which involved a fighting kung fu character. The patient used his left hand in manipulating a ball-shaped joystick to move the figure up, down, left and right, and his right in operating buttons to kick and jab. Extensive use of the joystick resulted in blisters on his left palm. He rubbed the blisters off, and an infection resulted that progressed to abscess formation. Neuromuscular complications of video games (‘pseudovideoma’, ‘Pac-Man phalanx’, ‘firing-finger syndrome’ and ‘Space Invaders wrist’) have been reported, as well as video game-induced seizures, but we have not come across any reports of an infectious complication of video games. Perhaps video game players should wear gloves to protect their palms, similar to ones worn by golfers and baseball players, who also need to get a firm grip on their respective sticks”.

Another one that I’d never heard of is ‘Nurd Knuckles’ coined by Dr. J.B. Martin in the Canadian Medical Association Journal in 1982:

“I wish to describe a case of painful knuckles associated with the use and manipulation of a new, allegedly therapeutic product, a Nurd. A Nurd is a head 10 cm across with a smiling face and large ears, reminiscent of the character Yoda of ‘Star Wars’. It is made of malleable material that can be stretched, twisted or deformed in any direction, yet with release of tension quickly resumes its original shape without a trace of distortion. A 32-year-old public school teacher presented with painful knuckles of his right hand. His students, perhaps feeling that their teacher was under increased stress during the marking of exams, had given him a Nurd for Christmas, and during a particularly trying day he had found occasion to use it. He repeatedly stretched its ears and twisted its neck without ill effect; however, on punching it he suffered sharp pain of his fourth and fifth metacarpophalangeal joints. On examination the joints were found to be reddened, with point tenderness over the fifth metacarpal head; there was no evidence of deformity. He was advised to stop beating his Nurd, and the pain subsided. While the Nurd is very plastic, yielding to the linear tension of stretching and twisting, it is very resistant to compression. Punching a Nurd does not cause the surface to give way, and, since the force of the blow is returned to the fist, it is conceivable that a fracture might result. Therefore, although stretching and twisting Nurds does not cause any harm, users should be cautioned against punching their Nurd. The Nurd is advertised as being a ‘punchable, stretchable, pushable and likeable alternative to tension, migraine headaches, drug abuse, alcoholism and manic depression’, but these claims are unsubstantiated. A MEDLINE search of the medical literature shows that no retrospective or prospective case control studies or controlled double blind crossover studies have been undertaken. Before the clinical efficacy of the Nurd can be taken seriously in the treatment of this broad spectrum of disease, full clinical trials must be completed. Subjects entering into trials must, however, be duly informed of the hazards of punching Nurds”.

Another one that caught my attention was a new affliction (‘Breaker’s Neck’) caused by the craze of ‘break dancing’ reported by Dr. Bertha Ramirez and her colleagues in a 1984 issue of the Journal of the American Medical Association. (The reason why I say it caught my eye is that I am currently involved in some research on ‘dancing addiction’ with some of my Hungarian colleagues and we have just had a new paper accepted in the journal PLoS ONE concerning the development of our ‘Dancing Motives Inventory’ – see ‘Further Reading’ below).

“To be added to the rapidly growing list of socially acquired injuries, we report a case of traumatic cervical subluxation caused by a new dance technique. This technique, labeled ‘breaking’ by its devotees, involves a modified head stand, in which the dancer, using his arms and hands for balance, spins rapidly on his head, neck, or shoulders to the rhythm of disco music. He then lowers his body to the floor and performs a series of rotational motions using his arms as a fulcrum…A 15-year-old boy was seen in our pediatric emergency room complaining that, on awakening two days previously, he felt a ‘snap’ in his neck, followed by persistent neck stiffness. He reported having ‘danced on his head’ the night prior to this incident. On physical examination, his head was tilted to the left with an inability to flex”.

Engaging in excessive sporting activity has given rise to a number of medical syndromes. One such consequence is ‘Rower’s Rump’ reported by Drs. K Tomecki and J. Mikesell in a 1987 issue of the Journal of the American Academy of Dermatology. In a previous blog I examined addiction to cycling. In the 1980s there were many medical complaints reported as a result of excessive cycling. One such complaint (given the name of ‘Bicycling nipples’) was highlighted by Dr. B. Powell in a 1983 issue of the Journal of the American Medical Association:

“Bicyclists are likely to suffer from a number of maladies, including dysuria, numb penises, and more. During cool or cold weather, another problem, bicyclist’s nipples, may occur. This condition is similar to jogger’s nipples, but it is primarily a thermal injury instead of an irritation secondary to friction, as with the jogger’s complaint. Often the rider is out in the cold weather for some time, and his or her undershirt, jersey, and jacket can become moist from perspiration. Evaporation and the chill of the wind lower the temperature of the nipples. They get downright cold, and they hurt. The pain continues after the ride is over. Indeed, it can continue for several days. The nipples are sore, sensitive to both temperature change and touch”.

After reading this I found out that Dr. Fred Levit had reported a case of ‘Jogger’s Nipples’ in a 1977 issue of the New England Journal of Medicine. All of these related nipple conditions are all examples of fissure of the nipple as they are all caused by friction resulting in soreness, dryness or irritation to, or bleeding of, one or both nipples. The Wikipedia entry also notes that “the condition is also experienced by women who breastfeed, and by surfers who do not wear rash guards”. The article also noted that:

“Jogger’s nipple is caused by friction from the repeated rubbing of a t-shirt or other upper body clothing against the nipples during a prolonged period of exercise. The condition is suffered mainly by runners. Long-distance runners are especially prone, because they are exposed to the friction on the nipple for the greatest period of time. However, it is not only suffered by athletes; the inside of a badge, a logo on normal items of clothing, or breastfeeding can also cause the friction which results in this condition”.

Outside of the leisure sphere, there were two case study reports of ‘Diaper Doer’s Hand’ in a 1987 issue of the journal Clinical Rehabilitation by Dr. J.L. Cosgrove and colleagues:

“Three cases of stenosing tenosynovitis occurred three to six months postpartum. Childcare activities aggravated the symptoms of pain and swelling in both patients. In two cases, a specific method of carrying the child was implicated as the mechanism of injury. Although there was no evidence of generalized inflammatory arthritis, all patients had very low positive titres of anti-nuclear antibodies. While it is likely that tenosynovitis was caused by mechanical factors, the possibility of increased susceptibility to inflammatory disease in the postpartum period cannot be discounted. The patients were successfully treated with a low temperature plastic splint, superficial heat and gentle mobilization”.

All of these new syndromes lead to why I put this article together in the first place. I found this letter in the British Medical Journal by Dr. E.P. Hoare entitled ‘New Syndrome Syndrome’ that I found both funny and poignant:

“Your readers will be familiar with tennis elbow, brazier’s ague, and soap packer’s jig not to mention Achilles’ heel. More recently we have heard of Space Invader’s wrist, jogger’s nipples, and the ultimate futility of Cuber’s thumb. May I point out another occupational disease which I have noticed among patrons of the reading room medical journal correspondence column reader’s neck or, more succinctly, the new syndrome syndrome. Symptoms usually begin with muscular contraction of the eyebrows, hyperventilation, and involuntary utterances, which in severe cases can lead to coprolalia. These may be followed by drowsiness, disorientation, hysterical amblyopia, and double vision (of the deja vu variety). If untreated the condition can result in a chronic pain in the neck. Treatment is 200 ml of gin and tonic stat by mouth and complete rest; music can also be helpful. The long-term prognosis is poor, however, unless journal editors can be persuaded to ban further reports of occupational afflictions or at least print a health warning at the head of their correspondence columns”.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Behr, J.T. (1984). Pseudovideoma. Journal of Hand Surgery, 9(4), 613.

Cosgrove, J. L., Welch, D. A., Richardson, G. S., & Nicholas, J. J. (1987). Diaper doer’s hand: stenosing tenosynovitis in the postpartum period. Clinical Rehabilitation, 1(3), 219-223.

Gibofsky, A. (1983). Pac‐Man phalanx. Arthritis and Rheumatism, 26(1), 120.

Griffiths, M.D. (1995). Technological addictions. Clinical Psychology Forum, 76, 14-19.

Griffiths, M.D. (1995). Pop psychology and “aca-media”: A reply to Mitchell. The Psychologist: Bulletin of the British Psychological Society, 8, 537-538.

Griffiths, M.D. (2001). A moral obligation in aca-media? The Psychologist: Bulletin of the British Psychological Society, 14, 460.

Hite, P. R., Greene, K. A., Levy, D. I., & Jackimczyk, K. (1993). Injuries resulting from bungee-cord jumping. Annals of emergency medicine, 22(6), 1060-1063.

Hoare, E.P. (1982). Points: New syndrome syndrome. British Medical Journal, 285(6352), 1429.

Levit, F. (1977). Jogger’s nipples. New England Journal of Medicine, 297(20), 1127.

Maraz, A., Király, O., Urbán, R., Griffiths, M.D., Demetrovics, Z. (2015). Why do you dance? Development of the Dance Motivation Inventory (DMI). PLoS ONE, in press.

Martyn, J. B. (1983). Nurd knuckles. Canadian Medical Association Journal, 129(3), 228.

McCowan, T.C. (1981). Space Invader’s wrist. New England Journal of Medicine, 304,1368.

Osterman, A. L., Weinberg, P., & Miller, G. (1987). Joystick digit. Journal of the American Medical Association, 257(6), 782.

Powell, B. (1983). Bicyclist’s nipples. Journal of the American Medical Association, 249(18), 2457-2457.

Ramirez, B., Masella, P. A., Fiscina, B., Lala, V. R., & Edwards, M. D. (1984). Breaker’s neck. Journal of the American Medical Association, 252(24), 3366-3367.

Soe, G.B., Gersten, L. M., Wilkins, J., Patzakis, M. J., & Harvey, J.P. (1987). Infection associated with joystick mimicking a spider bite. Western Journal of Medicine, 146(6), 748.

Tomecki, K. J., & Mikesell, J. F. (1987). Rower’s rump. Journal of the American Academy of Dermatology, 16(4), 890-891.

Torre, P. R., Williams, G. G., Blackwell, T., & Davis, C. P. (1993). Bungee jumper’s foot drop peroneal nerve palsy caused by bungee cord jumping. Annals of emergency medicine, 22(11), 1766-1767.

Waugh, D. (1981). Cuber’s thumb. New England Journal of Medicine, 305, 768.

Played to death: What turns online gaming into a health risk?

Please note that the following article is a slightly extended version of an article that was first published by CNN International

Last month, a 32-year old male gamer was found dead at a Taiwanese Internet café following a non-stop three-day gaming session. This followed the death of another male gamer who died in Taipei at the start of the year following a five-day gaming binge.

While these cases are extremely rare, it does beg the question of why gaming can lead to such excessive behaviour. I have spent nearly three decades studying videogame addiction and there are many studies published in both the medical and psychological literature showing that very excessive gaming can lead to a variety of health problems that range from repetitive strain injuries and obesity, through to auditory and visual hallucinations and addiction. I have to stress that there is lots of scientific research showing the many educational and therapeutic benefits of playing but there is definitely a small minority of gamers that develop problems as a result of gaming overuse.

But what is it that makes gaming so compulsive and addictive for the small minority? For me, addiction boils down to constant reinforcement, or put more simply, being constantly rewarded while playing the game. Gaming rewards can be physiological (such as feeling ‘high’ or getting a ‘buzz’ while playing or beating your personal high score), psychological (such as feeling you have complete control in a specific situation or knowing that your strategic play helped you win), social (such as being congratulated by fellow gamers when doing something well in the game) and, in some cases, financial (such as winning a gaming tournament). Most of these rewards are – at least to some extent – unpredictable. Not knowing when the next reward will come keeps some players in the game. In short, they carry on gaming even though they may not have received an immediate reward. They simply hope that another reward is ‘just around the corner’ and keep on playing.

Added to this is the shift over the last decade from standalone console gaming to massively multiplayer online games where games never end and gamers have to compete and/or collaborate with other gamers in real time (instead of being able to pause the game and come back and play from the point at which the player left it). Many excessive gamers report that they hate logging off and leaving such games. They don’t like it as they don’t know what is going on in the game when they are not online.

The last five years has seen large increase in the number of scientific studies on problematic gaming. In May 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). For the first time, the DSM-5 included ‘internet gaming disorder’ (IGD) as a psychological condition that warrants future research. Throughout my research career I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences such as total preoccupation, mood modification, cravings, tolerance, withdrawal symptoms, conflict with work, education and other people, and loss of control. These similarities likely reflect a common etiology of addictive behaviour.

So when does a healthy enthusiasm turn into an addiction? At the simplest level, healthy enthusiams add to life and addictions take away from it. But how much is too much? This is difficult to answer as I know many gamers who play many hours every day without any detrimental effects. The DSM-5 lists nine criteria for IGD. If any gamer endorses five or more of the following criteria they would likely be diagnosed as having IGD: (1) preoccupation with internet games; (2) withdrawal symptoms when internet gaming is taken away; (3) the need to spend increasing amounts of time engaged in internet gaming, (4) unsuccessful attempts to control participation in internet gaming; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming; (6) continued excessive use of internet games despite knowledge of psychosocial problems; (7) deception of family members, therapists, or others regarding the amount of internet gaming; (8) use of the internet gaming to escape or relieve a negative mood;  and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games.

The good news is that only a small minority of gamers suffer form IGD. Most online games are fun and exciting to play. But like any activity that is taken to excess, in a minority of cases the activity can become addictive. Any activity if done for days on end could lead to severe health problems and even death – and gaming is no exception. Instead of demonizing games, we need to educate gamers about the potential dangers of very excessive use.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2014). Gaming addiction in adolescence (revisited). Education and Health, 32, 125-129.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, 4(1), 1-4.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

King, D.L., Haagsma, M.C., Delfabbro, P.H., Gradisar, M.S.^, Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction: A systematic review. International Journal of Mental Health and Addiction, 10, 278-296.

Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction in adolescence: A literature review of empirical research. Journal of Behavioral Addictions, 1, 3-22.

Lopez-Fernandez, O., Honrubia-Serrano, M.L., Baguley, T. & Griffiths, M.D. (2014). Pathological video game playing in Spanish and British adolescents: Towards the Internet Gaming Disorder symptomatology. Computers in Human Behavior, 41, 304–312.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H., Király, O. Demetrovics, Z. & Griffiths, M.D. (2014). The conceptualisation and measurement of DSM-5 Internet Gaming Disorder: The development of the IGD-20 Test. PLoS ONE, 9(10): e110137. doi:10.1371/journal.pone.0110137.

Spekman, M.L.C., Konijn, E.A, Roelofsma, P.H.M.P. & Griffiths, M.D. (2013). Gaming addiction, definition, and measurement: A large-scale empirical study, Computers in Human Behavior, 29, 2150-2155.