Pressing the right buttons: The positives of playing video games

Whether playing video games has negative effects is something that has been debated for 30 years, in much the same way that rock and roll, television, and even the novel faced much the same criticisms in their time. Purported negative effects such as gaming addiction, increased aggression, and various health consequences such as obesity and repetitive strain injuries tend to get far more media coverage than the positives. I know from my own research examining both sides that my papers on video game addiction receive far more publicity than my research into the social benefits of, for example, playing online role-playing games.

However there is now a wealth of research which shows that video games can be put to educational and therapeutic uses, as well as many studies which reveal how playing video games can improve reaction times and hand-eye co-ordination. For example, research has shown that spatial visualisation ability, such as mentally rotating and manipulating two- and three-dimensional objects, improves with video game playing.

To add to this long line of studies demonstrating the more positive effects of video games is a study in the Proceedings of the National Academy of Sciences by Vikranth Bejjanki and colleagues. Their paper demonstrates that the playing of action video games – the sort of fast-paced, 3D shoot-em-up beloved of doomsayers in the media – confirms what other studies have revealed, that players show improved performance in perception, attention, and cognition.

In a series of experiments on small numbers of gamers (10 to 14 people in each study), the researchers reported that gamers with previous experience of playing such action video games were better at perceptual tasks such as pattern discrimination than gamers with less experience. In another experiment, they trained gamers that had little previous experience of playing action games, giving them 50 hours practice. It was showed that these gamers performed much better on perceptual tasks than they had prior to their training. The paper concludes:

“The enhanced learning of the regularity and structure of environments may act as a core mechanism by which action video game play influences performance in perception, attention, and cognition”.

In my own papers, I have pointed out many features and qualities that make video games potentially useful. For instance, in an educational context, video games can be fun and stimulating, which means it’s easier to maintain a pupil’s undivided attention for longer. Because of the excitement, video games may also be a more appealing way of learning than traditional methods for some.

Video games have an appeal that crosses many demographic boundaries, such as age, gender, ethnicity, or educational attainment. They can be used to help set goals and rehearse working towards them, provide feedback, reinforcement, self-esteem, and maintain a record of behavioural change. Their interactivity can stimulate learning, allowing individuals to experience novelty, curiosity and challenge that stimulates learning. There is the opportunity to develop transferable skills, or practice challenging or extraordinary activities, such as flight simulators, or simulated operations. Because video games can be so engaging, they can also be used therapeutically. For instance, they can be used as a form of physiotherapy as well as in more innovative contexts. A number of studies have shown that when children play video games following chemotherapy they need fewer painkillers than others.

Video games can have great educational potential in addition to their entertainment value. Games specifically designed to address a specific problem or teach a specific skill have been very successful, precisely because they are motivating, engaging, interactive, and provide rewards and reinforcement to improve. But the transferability of skills outside the game-playing context is an important factor. What’s also clear from the scientific literature is that the negative consequences of playing almost always involve people that are excessive video game players. There is little evidence of serious acute adverse effects on health from moderate play.

A version of this article was first published in The Conversation.

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

Further reading

Bejjanki, V. R., Zhang, R., Li, R., Pouget, A., Green, C. S., Lu, Z. L., & Bavelier, D. (2014). Action video game play facilitates the development of better perceptual templates. Proceedings of the National Academy of Sciences, 111(47), 16961-16966.

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

Griffiths, M.D. (1997). Video games and clinical practice: Issues, uses and treatments. British Journal of Clinical Psychology, 36, 639-641.

Griffiths, M.D. (2002). The educational benefits of videogames Education and Health, 20, 47-51.

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

Griffiths, M.D. (2004). Can videogames be good for your health? Journal of Health Psychology, 9, 339-344.

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. (2010). Adolescent video game playing: Issues for the classroom. Education Today: Quarterly Journal of the College of Teachers, 60(4), 31-34.

Griffiths, M.D., Kuss, D.J., & Ortiz de Gortari, A. (2016). Videogames as therapy: An updated selective review of the medical and psychological literature. International Journal of Privacy and Health Information Management, in 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.

Griffiths, M.D. & Sutton, M. (2013). Proposing the Crime Substitution Hypothesis: Exploring the possible causal relationship between excessive adolescent video game playing, social networking and crime reduction. Education and Health, 31, 17-21.

Griffiths, M.D. & Sutton, M. (2015). Screen time and crime: The ‘Crime Substitution Hypothesis’ revisited. Education and Health, 33, 85-87.

You bet! A brief overview of our recent papers on youth gambling

Following my recent blogs where I outlined some of the papers that my colleagues and I have published on mindfulness, Internet addiction, and gaming addiction, here is a round-up of recent papers that my colleagues and I have published on adolescent gambling.

Calado, F., Alexandre, J. & Griffiths, M.D. (2014). Mom, Dad it’s only a game! Perceived gambling and gaming behaviors among adolescents and young adults: An exploratory study. International Journal of Mental Health and Addiction, 12, 772-794.

• Gambling and gaming are increasingly popular activities among adolescents. Although gambling is illegal in Portugal for youth under the age of 18 years, gambling opportunities are growing, mainly due to similarity between gambling and other technology-based games. Given the relationship between gambling and gaming, the paucity of research on gambling and gaming behaviors in Portugal, and the potential negative consequences these activities may have in the lives of young people, the goal of this study was to explore and compare the perceptions of these two behaviors between Portuguese adolescents and young adults. Results from six focus groups (comprising 37 participants aged between 13 and 26 years) indicated different perceptions for the two age groups. For adolescents, gaming was associated with addiction whereas for young adults it was perceived as a tool for increasing personal and social skills. With regard to gambling, adolescents associated it with luck and financial rewards, whereas young adults perceived it as an activity with more risks than benefits. These results suggest developmental differences that have implications for intervention programs and future research.

Delfabbro, P.H., King, D.L. & Griffiths, M.D. (2014). From adolescent to adult gambling: An analysis of longitudinal gambling patterns in South Australia. Journal of Gambling Studies, 30, 547-563.

• Although there are many cross-sectional studies of adolescent gambling, very few longitudinal investigations have been undertaken. As a result, little is known about the individual stability of gambling behaviour and the extent to which behaviour measured during adolescence is related to adult behaviour. In this paper, we report the results of a 4-wave longitudinal investigation of gambling behaviour in a probability sample of 256 young people (50 % male, 50% female) who were interviewed in 2005 at the age of 16–18 years and then followed through to the age of 20–21 years. The results indicated that young people showed little stability in their gambling. Relatively few reported gambling on the same individual activities consistently over time. Gambling participation rates increased rapidly as young people made the transition from adolescence to adulthood and then were generally more stable. Gambling at 15–16 years was generally not associated with gambling at age 20–21 years. These results highlight the importance of individual-level analyses when examining gambling patterns over time.

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.

• Although the personality trait of urgency has been linked to problem gambling, less is known about psychological mechanisms that mediate the relationship between urgency and problem gambling. One individual variable of potential relevance to impulsivity and addictive disorders is age. The aims of this study were to examine: (i) a theoretical model associating urgency and gambling problems, (ii) the mediating effects of decision-making processes (operationalized as preference for small/immediate rewards and lower levels of deliberative decision-making); and (iii) age differences in these relationships. Participants comprised 986 students (64% male; mean age = 19.51 years; SD = 2.30) divided into three groups: 16–17 years, 18–21 years, and 22–25 years. All participants completed measures of urgency, problem gambling, and a delay-discounting questionnaire involving choices between a smaller amount of money received immediately and a larger amount of money received later. Participants were also asked to reflect on their decision-making process. Compared to those aged 16–17 years and 22–25 years, participants aged 18–21 years had a higher level of gambling problems and decreased scores on lower levels of deliberative decision-making. Higher levels of urgency were associated with higher levels of gambling problems. The association was mediated by a lower level of deliberative decision-making and preference for an immediate/small reward. A distinct pathway was observed for lower levels of deliberative decision-making. Young people who tend to act rashly in response to extreme moods, had lower levels of deliberative decision-making, that in turn were positively related to gambling problems. This study highlights unique decision-making pathways through which urgency trait may operate, suggesting that those developing prevention and/or treatment strategies may want to consider the model’s variables, including urgency, delay discounting, and deliberative decision-making.

Carran, M. & Griffiths, M.D. (2015). Gambling and social gambling: An exploratory study of young people’s perceptions and behavior. Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport, 33(1), 101-113.

• Background and aims: Gambling-type games that do not involve the spending of money (e.g., social and ‘demo’ [demonstration] gambling games, gambling-like activities within video games) have been accused in both the legal and psychological literature of increasing minors’ propensity towards prohibited forms of gambling thus prompting calls for gambling regulation to capture address such games and subject them to age restrictions. However, there is still a shortage of empirical data that considers how young people experience monetary and non-monetary gambling, and whether they are sufficiently aware of the differences. Methods: Data was collected from 23 qualitative focus groups carried out with 200 young people aged between 14 and 19 years old in schools based in London and Kent. As the study was exploratory in nature, thematic analysis was adopted in order to capture how pupils categorise, construct, and react to gambling-like activities in comparison to monetary forms of gambling without the constrains of a predetermined theoretical framework. Results: Despite many similarities, substantial differences between monetary and non-monetary forms of gambling were revealed in terms of pupils’ engagement, motivating factors, strengths, intensity, and associated emotions. Pupils made clear differentiation between non-monetary and monetary forms of gambling and no inherent transition of interest from one to the other was observed among participants. Only limited evidence emerged of ‘demo’ games being used as a practice ground for future gambling. Conclusion: For the present sample, non-monetary forms of gambling presented a different proposition to the real-money gambling with no inherent overlap between the two. For some the ‘softer’ form minimised the temptation to try other forms of gambling that they were not legally allowed to engage in, but ‘demo’ games may attract those who already want to gamble. Policy implications: Regulators must recognise and balance these two conflicting aspects.

Griffiths, M.D. (2015). Adolescent gambling and gambling-type games on social networking sites: Issues, concerns, and recommendations. Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport, 33(2), 31-37.

• Research indicates that compared to the general population, teenagers and students make the most use of social networking sites (SNSs). Although SNSs were originally developed to foster online communication between individuals, they now have the capability for other types of behaviour to be engaged in such as gambling and gaming. The present paper focuses on gambling and the playing of gambling-type games via SNSs and comprises a selective narrative overview of some of the main concerns and issues that have been voiced concerning gambling and gambling-type games played via social network sites. Overall, there is little empirical evidence relating to the psychosocial impact of adolescents engaging in gambling and gambling-type activities on SNSs, and the evidence that does exist does not allow definitive conclusions to be made. However, it is recommended that stricter age verification measures should be adopted for social games via SNSs particularly where children and adolescents are permitted to engage in gambling-related content, even where real money is not involved.

Canale, N., Vieno, A., Griffiths, M.D., Marino, C., Chieco, F., Disperati, F., Andriolo, S., Santinello, M. (2016). The efficacy of a web-based gambling intervention program for high school students: A preliminary randomized study. Computers in Human Behavior, 55, 946-954.

• Early onset in adolescent gambling involvement can be a precipitator of later gambling problems. The aim of the present study was to test the preliminary efficacy of a web-based gambling intervention program for students within a high school-based setting. Students attending a high school in Italy (N= 168) participated in the present study (58% male – age, M = 15.01; SD = 0.60). Twelve classes were randomly assigned to one of two conditions: intervention (N = 6; 95 students) and control group (N = 6; 73 students). Both groups received personalized feedback and then the intervention group received online training (interactive activities) for three weeks. At a two-month follow-up, students in the intervention group reported a reduction in gambling problems relative to those in the control group. However, there were no differences in gambling frequency, gambling expenditure, and attitudes toward the profitability of gambling between the two groups. In addition, frequent gamblers (i.e., those that gambled at least once a week at baseline) showed reductions in gambling problems and gambling frequency post-intervention. Frequent gamblers that only received personalized feedback showed significantly less realistic attitudes toward the profitability of gambling post-intervention. The present study is the first controlled study to test the preliminary efficacy of a web-based gambling intervention program for students within a high school-based setting. The results indicate that a brief web-based intervention delivered in the school setting may be a potentially promising strategy for a low-threshold, low-cost, preventive tool for at-risk gambling high school students.

Canale, N., Griffiths, M.D., Vieno, A., Siciliano, V. & Molinaro, S. (2016). Impact of internet gambling on problem gambling among adolescents in Italy: Findings from a large-scale nationally representative survey. Computers in Human Behavior, 57, 99-106.

• Aims: The primary aim of the present study was to understand the impact of online gambling on gambling problems in a large-scale nationally representative sample of Italian youth, and to identify and then further examine a subgroup of online gamblers who reported higher rates of gambling problems. Design: Data from the ESPAD^®Italia2013 (European School Survey Project on Alcohol and Other Drugs) Study were used for analyses of adolescent Internet gambling. Setting: Self-administered questionnaires were completed by a representative sample of high school students, aged 15–19 years. Participants: A total of 14,778 adolescent students. Measurements: Respondents’ problem gambling severity; gambling behavior (participation in eight different gambling activities, the number of gambling occasions and the number of online gambling occasions, monthly gambling expenditure); Socio-demographics (e.g., family structure and financial status); and control variables were measured individually (i.e., use of the Internet for leisure activities and playing video games). Findings: Rates of problem gambling were five times higher among online gamblers than non-online gamblers. In addition, factors that increased the risk of becoming a problem online gambler included living with non-birth parents, having a higher perception of financial family status, being more involved with gambling, and the medium preferences of remote gamblers (e.g., Internet cafes, digital television, and video game console). Conclusions: The online gambling environment may pose significantly greater risk to vulnerable players. Family characteristics and contextual elements concerning youth Internet gambling (e.g., remote mediums) may play a key role in explaining problem online gambling among adolescents.

Pallesen, S., Hanss, D., Molde, H., Griffiths, M.D. & Mentzoni, R.A. (2016). A longitudinal study of factors explaining attitude change towards gambling among adolescents. Journal of Behavioral Addictions, 5, 59–67

• Background and aims: No previous study has investigated changes in attitudes toward gambling from under legal gambling age to legal gambling age. The aim of the present study was therefore to investigate attitudinal changes during this transition and to identify predictors of corresponding attitude change. Methods: In all 1239 adolescents from a national representative sample participated in two survey waves (Wave 1; 17.5 years; Wave 2; 18.5 years). Results: From Wave 1 to Wave 2 the sample became more acceptant toward gambling. A regression analysis showed that when controlling for attitudes toward gambling at Wave 1 males developed more acceptant attitudes than females. Neuroticism was inversely related to development of acceptant attitudes toward gambling from Wave 1 to Wave 2, whereas approval of gambling by close others at Wave 1 was positively associated with development of more acceptant attitudes. Continuous or increased participation in gambling was related to development of more acceptant attitudes from Wave 1 to Wave 2. Conclusions: Attitudes toward gambling became more acceptant when reaching legal gambling age. Male gender, approval of gambling by close others and gambling participation predicted development of positive attitudes toward gambling whereas neuroticism was inversely related to development of positive attitudes toward gambling over time.

Ciccarelli, M., Griffiths, M.D., Nigro, G., & Cosenza, M. (2016). Decision-making, cognitive distortions and alcohol use in adolescent problem and non-problem gamblers: An experimental study. Journal of Gambling Studies, in press.

• In the psychological literature, many studies have investigated the neuropsychological and behavioral changes that occur developmentally during adolescence. These studies have consistently observed a deficit in the decision-making ability of children and adolescents. This deficit has been ascribed to incomplete brain development. The same deficit has also been observed in adult problem and pathological gamblers. However, to date, no study has examined decision-making in adolescents with and without gambling problems. Furthermore, no study has ever examined associations between problem gambling, decision-making, cognitive distortions and alcohol use in youth. To address these issues, 104 male adolescents participated in this study. They were equally divided in two groups, problem gamblers and non-problem gamblers, based on South Oaks Gambling Screen Revised for Adolescents scores. All participants performed the Iowa gambling task and completed the Gambling Related Cognitions Scale and the alcohol use disorders identification test. Adolescent problem gamblers displayed impaired decision-making, reported high cognitive distortions, and had more problematic alcohol use compared to non-problem gamblers. Strong correlations between problem gambling, alcohol use, and cognitive distortions were observed. Decision-making correlated with interpretative bias. This study demonstrated that adolescent problem gamblers appear to have the same psychological profile as adult problem gamblers and that gambling involvement can negatively impact on decision-making ability that, in adolescence, is still developing. The correlations between interpretative bias and decision-making suggested that the beliefs in the ability to influence gambling outcomes may facilitate decision-making impairment.

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

Further reading

Griffiths, M.D. (1995). Adolescent Gambling. London: Routledge.

Griffiths, M.D. (2002). Gambling and Gaming Addictions in Adolescence. Leicester: British Psychological Society/Blackwells.

Griffiths, M.D. (2003). Adolescent gambling: Risk factors and implications for prevention, intervention, and treatment. In D. Romer (Ed.), Reducing Adolescent Risk: Toward An Integrated Approach (pp. 223-238). London: Sage.

Griffiths, M.D. (2010). Asian national adolescent gambling surveys: Methodological issues, protocols, and advice. Asian Journal of Gambling Issues and Public Health, 1, 4-18.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D. (2013). Adolescent gambling via social networking sites: A brief overview. Education and Health, 31, 84-87.

Griffiths, M.D. & Linsey, A. (2006). Adolescent gambling: Still a cause for concern? Education and Health, 24, 9-11.

Griffiths, M.D. & Parke, J. (2010). Adolescent gambling on the Internet: A review. International Journal of Adolescent Medicine and Health, 22, 59-75.

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.

Game over-view: A brief overview of our recent papers on gaming addiction

Following my recent blogs where I outlined some of the papers that my colleagues and I have published on mindfulness and Internet addiction, here is a round-up of recent papers that my colleagues and I have published on gaming addiction.

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.

• Despite the large growth on gaming behaviour research, little has been done to overcome the problem stemming from the heterogeneity of gaming addiction nomenclature and the use of non-standardised measurement tools. Following the recent inclusion of Internet Gaming Disorder [IGD] as a condition worthy of future studies in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5], researchers have now an opportunity to reach consensus and unification in the field. The aim of this study was to develop a new nine-item short-form scale to assess Internet Gaming Disorder (IGDS-SF9) and to further explore its psychometric properties. A sample of 1060 gamers (85.1% males, mean age 27 years) recruited via online gaming forums participated. Exploratory factor analysis [EFA], confirmatory factor analysis [CFA], analyses of the criterion-related and concurrent validity, reliability, standard error of measurement [SEM], population cross-validity, and floor and ceiling effects were performed to assess the instrument’s psychometric properties. The results from the EFA revealed a single-factor structure for IGD that was also confirmed by the CFA. The nine items of the IGDS-SF9 are valid, reliable, and proved to be highly suitable for measuring IGD. It is envisaged that the IGDS-SF9 will help facilitate unified research in the field.

Benrazavi, S.R., Teimouri, M. & Griffiths, M.D. (2015). Utility of parental mediation model on youth’s problematic online gaming. International Journal of Mental Health and Addiction, 13, 712-727.

• The Parental Mediation Model (PMM) was initially designed to regulate children’s attitudes towards the traditional media. In the present era, because of prevalent online media there is a need for similar regulative measures. Spending long hours on social media and playing online games increase the risks of exposure to the negative outcomes of online gaming. This paper initially applied the PMM developed by European Kids Online to (i) test the reliability and validity of this model and (ii) identify the effectiveness of this model in controlling problematic online gaming (POG). The data were collected from 592 participants comprising 296 parents and 296 students of four foreign universities, aged 16 to 22 years in Kuala Lumpur (Malaysia). The study found that the modified model of the five-factor PMM (Technical mediation, Monitoring mediation, Restrictive mediation, Active Mediation of Internet Safety, and Active mediation of Internet Use) functions as a predictor for mitigating POG. The findings suggest the existence of a positive relation between ‘monitoring’ and ‘restrictive’ mediation strategies and exposure to POG while Active Mediation of Internet Safety and Active mediation of Internet use were insignificant predictors. Results showed a higher utility of ‘technical’ strategies by the parents led to less POG. The findings of this study do not support the literature suggesting active mediation is more effective for reducing youth’s risky behaviour. Instead, parents need to apply more technical mediations with their children and adolescents’ Internet use to minimize the negative effects of online gaming.

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.

• Massively multiplayer online role-playing games (MMORPGs) are a popular form of entertainment used by millions of gamers worldwide. Potential problems relating to MMORPG play have emerged, particularly in relation to being addicted to playing in such virtual environments. In the present study, factors relating to online gaming addiction and motivations for playing in MMORPGs were examined to establish whether they were associated with addiction. A sample comprised 1167 gamers who were surveyed about their gaming motivations. Latent Class Analysis revealed seven classes of motivations for playing MMORPGs, which comprised: (1) novelty; (2) highly social and discovery-orientated; (3) aggressive, anti-social and non-curious; (4) highly social, competitive; (5) low intensity enjoyment; (6) discovery-orientated; and (7) social classes. Five classes of gaming addiction-related experiences were extracted including: (1) high risk of addiction, (2) time-affected, (3) intermediate risk of addiction, (4) emotional control, and (5) low risk of addiction classes. Gender was a significant predictor of intermediate risk of addiction and emotional control class membership. Membership of the high risk of addiction class was significantly predicted by belonging to a highly social and competitive class, a novelty class, or an aggressive, anti-social, and non-curious class. Implications of these findings for assessment and treatment of MMORPG addiction are discussed.

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.

• Scientific interest in behavioral addictions (such as Internet gaming disorder [IGD]) has risen considerably over the last two decades. Moreover, the inclusion of IGD in Section 3 of DSM-5 will most likely stimulate such research even more. Although the inclusion of IGD appears to have been well received by most of the researchers and clinicians in the field, there are several controversies and concerns surrounding its inclusion. The present paper aims to discuss the most important of these issues: (i) the possible effects of accepting IGD as an addiction; (ii) the most important critiques regarding certain IGD criteria (i.e., preoccupation, tolerance, withdrawal, deception, and escape); and (iii) the controversies surrounding the name and content of IGD. In addition to these controversies, the paper also provides a brief overview of the recent findings in the assessment and prevalence of IGD, the etiology of the disorder, and the most important treatment methods.

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.

• Background: The rapid expansion of online video gaming as a leisure time activity has led to the appearance of problematic online gaming (POG). According to the literature, POG is associated with different psychiatric symptoms (eg, depression, anxiety) and with specific gaming motives (ie, escape, achievement). Based on studies of alcohol use that suggest a mediator role of drinking motives between distal influences (e.g., trauma symptoms) and drinking problems, this study examined the assumption that there is an indirect link between psychiatric distress and POG via the mediation of gaming motives. Furthermore, it was also assumed that there was a moderator effect of gender and game type preference based on the important role gender plays in POG and the structural differences between different game types. Objective: This study had two aims. The first aim was to test the mediating role of online gaming motives between psychiatric symptoms and problematic use of online games. The second aim was to test the moderator effect of gender and game type preference in this mediation model. Methods: An online survey was conducted on a sample of online gamers (N=3186; age: mean 21.1, SD 5.9 years; male: 2859/3186, 89.74%). The Brief Symptom Inventory (BSI), the Motives for Online Gaming Questionnaire (MOGQ), and the Problematic Online Gaming Questionnaire (POGQ) were administered to assess general psychiatric distress, online gaming motives, and problematic online game use, respectively. Structural regression analyses within structural equation modeling were used to test the proposed mediation models and multigroup analyses were used to test gender and game type differences to determine possible moderating effects. Results: The mediation models fitted the data adequately. The Global Severity Index (GSI) of the BSI indicated that the level of psychiatric distress had a significant positive direct effect (standardized effect=.35, P<.001) and a significant indirect (mediating) effect on POG (standardized effect=.194, P<.001) via 2 gaming motives: escape (standardized effect=.139, P<.001) and competition (standardized effect=.046, P<.001). The comparison of the 2 main gamer types showed no significant differences in the model. However, when comparing male and female players it was found that women had (1) slightly higher escape scores (on a 5-point Likert scale: mean 2.28, SD 1.14) than men (mean 1.87, SD 0.97) and (2) a stronger association between the escape motive and problematic online gaming (standardized effect size=.64, P<.001) than men (standardized effect size=.20, P=.001). Conclusions: The results suggest that psychiatric distress is both directly and indirectly (via escape and competition motives) negatively associated with POG. Therefore, the exploration of psychiatric symptoms and gaming motives of POG can be helpful in the preparation of prevention and treatment programs.

Fuster, H., Carbonell, X., Pontes, H.M. & Griffiths, M.D. (2016). Spanish validation of the Internet Gaming Disorder-20 (IGD-20) Test. Computers in Human Behavior, 56, 215-224.

• In recent years, problematic and addictive gaming has been a phenomenon of growing concern worldwide. In light of the increasing awareness about this issue, the latest (fifth) edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included Internet Gaming Disorder (IGD) as an area in need of more empirical research. The Internet Gaming Disorder Test (IGD-20 Test) was developed as a valid and reliable tool to assess IGD. The aim of the present study was to validate the Spanish version of the IGD-20 Test, and analyze the different profiles found among a sample of 1074 Spanish-speaking gamers. A confirmatory factor analysis showed the validity of the Spanish version of the IGD-20 Test and its six factor structure (i.e., salience, mood modification, tolerance, withdrawal, conflict and relapse). The latent profile analysis (LPA) showed five different gamer classes. The ‘disordered gamers’ class comprised 2.6% of the participants. Based on this class, sensitivity and specificity analyses showed an adequate empirical cut-off point of 75 (out of 100). It is concluded that the Spanish version of the IGD-20 Test is valid and reliable and can be used in research into IGD among Spanish speaking populations.

Griffiths, M.D., Van Rooij, A., Kardefelt-Winther, D., Starcevic, V., Király, O…Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing Internet Gaming Disorder: A critical commentary on Petry et al (2014). Addiction, 111, 167-175.

• This commentary paper critically discusses the recent debate paper by Petry et al. (2014) that argued there was now an international consensus for assessing Internet Gaming Disorder (IGD). Our collective opinions vary considerably regarding many different aspects of online gaming. However, we contend that the paper by Petry and colleagues does not provide a true and representative international community of researchers in this area. This paper critically discusses and provides commentary on (i) the representativeness of the international group that wrote the ‘consensus’ paper, and (ii) each of the IGD criteria. The paper also includes a brief discussion on initiatives that could be taken to move the field towards consensus. It is hoped that this paper will foster debate in the IGD field and lead to improved theory, better methodologically designed studies, and more robust empirical evidence as regards problematic gaming and its psychosocial consequences and impact.

Kim, N.R., Hwang, S.S-H., Choi, J-S., Kim, D-J., Demetrovics, Z., Király, O., Nagygyörgy, K., Griffiths, M.D., Hyun, S.Y., Youn, H.C. & Sam-Wook Choi, S-W. (2016). Characteristics and psychiatric symptoms of Internet Gaming Disorder among adults using self-reported DSM-5 criteria. Psychiatry Investigation, 13(1), 58-66.

• Objective: The Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) proposed nine diagnostic criteria and five cut-point criteria for Internet Gaming Disorder (IGD). We aimed to examine the efficacy of such criteria. Methods: Adults (n=3041, men: 1824, women: 1217) who engaged in internet gaming within last 6 months completed a self-report online survey using the suggested wordings of the criteria in DSM-5. Major characteristics, gaming behavior, and psychiatric symptoms of IGD were analyzed using ANOVA, chi-square, and correlation analyses. Results: The sociodemographic variables were not statistically significant between the healthy controls and the risk group. Among the participants, 419 (13.8%) were identified and labeled as the IGD risk group. The IGD risk group scored significantly higher on all motivation subscales (p<0.001). The IGD risk group showed significantly higher scores than healthy controls in all nine psychiatric symptom dimensions, i.e., somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism (p<0.001). Conclusion: The IGD risk group showed differential psychopathological manifestations according to DSM-5 IGD diagnostic criteria. Further studies are needed to evaluate the reliability and validity of the specific criteria, especially for developing screening instruments.

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

Further reading

Beranuy, M., Carbonell, X., & Griffiths, M.D. (2013). A qualitative analysis of online gaming addicts in treatment. International Journal of Mental Health and Addiction, 11, 149-161.

Billieux, J., Deleuze, J., Griffiths, M.D., & Kuss, D.J. (2015). Internet addiction: The case of massively multiplayer online role playing games. In N. El-Guebaly, M. Galanter, & G. Carra (Eds.), The Textbook of Addiction Treatment: International Perspectives (pp.1516-1525). New York: Springer.

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. & 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., Delfabbro, P.H., Griffiths, M.D. (2013). Trajectories of problem video gaming among adult regular gamers: An 18-month longitudinal study. Cyberpsychology, Behavior and Social Networking, 16, 72-76.

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.

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.

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. (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.

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.

Tales of the unexpected: 10 bad habits that sometimes do us good (Part 1)

All of us have bad habits, and all of us from time to time feel guilty about these habits. But there are some bad habits – at least when carried out in moderation – that might actually have benefits for psychological and/or physical wellbeing. Most bad habits help change our mood state and reduce stress (at least in the very short-term) but tend to become less helpful the more they are engaged in. Some of these bad habits turn into addictions where the short-term benefits are outweighed by the long-term costs. However, there are many activities that can sometimes have unexpected benefits and five of these are outlined in this blog. The next five bad habits will be in my next blog.

(1) Fidgeting helps burn calories

While fidgeting might be annoying for individuals and those around them, it is an activity that expends energy and burns calories. Fidgeting is one of a number of activities (along with walking, gardening, typing, tidying up, etc.) that are known as non-exercise activity thermogenesis (NEAT). In basic terms, NEAT is any activity that is not eating, sleeping, or sporting exercise. A number of studies carried out by obesity expert Dr. James Levine at the US Mayo Clinic (Arizona, US) have shown that individuals who fidget burn up about 350kcal a day. This is because fidgeting speeds up an individual’s metabolism by stimulating neurochemicals in the body thus increasing the ability to convert body fat into energy. So, if you are a compulsive foot tapper, an excessive thumb twiddler, or a restless doodler, just remember that all of these activities burn calories.

(2) Chewing gum helps boost thinking and alertness

Watching people chew gum is not a pretty site but if English football managers are anything to go by, chewing gum appears to be a stress relieving activity. In fact, there appear to appear to be many cognitive benefits of chewing gum. Dr. Kin-ya Kubo and colleagues in the book Senescence and Senescence-Related Disorders noted that chewing gum immediately before performing a cognitive task increases blood oxygen levels in the prefrontal cortex and hippocampus (important brain structures involved in learning and memory), thereby improving task performance. Dr. Kubo argues that chewing gum may therefore be a drug-free and simple method of helping those with senile dementia and stress-related disorders that are often associated with cognitive dysfunction. Another study by Dr. Yoshiyuki Hirano and colleagues showed that chewing gum boosts thinking and alertness, and that reaction times among chewers were 10% faster than non-chewers. The research team also reported that up to eight areas of the brain are affected by chewing (most notably the areas concerning attention and movement). As Professor Andy Smith (Cardiff University, UK) neatly summed up: “The effects of chewing on reaction time are profound. Perhaps football managers arrived at the idea of chewing gum by accident, but they seem to be on the right track”. 

(3) Playing video games helps relieve pain

Many individuals that do not play video games view the activity as a complete waste of time and potentially addictive. While excessive video game playing may cause problems in a minority of individuals, there is lots of scientific evidence that playing video games can have many beneficial effects. For instance, a number of studies have shown that children with cancer who play video games after chemotherapy take less pain killing medication. Video games have also been used as pain relieving therapy for other medical conditions such as burns victims and those with back pain. This is because playing video games is an engaging and engrossing activity that means the player cannot think about anything else but playing the game (and is what psychologists refer to as a ‘cognitive distractor task’). Pain has a large psychological component and individuals experience less pain if the person is engaged in an activity that takes up all their cognitive mind space. As well as being a pain reliever, there are also many studies showing that playing video games increase hand-eye co-ordination, increase reaction times, and have educational learning benefits.

(4) Eating snot helps strengthen the immune system (maybe)

How does it make you feel when you see someone picking their nose and then eating what they have found? Disgust? Contempt? Amused? In 2008, Dr Friedrich Bischinger, an Austrian lung specialist, claimed that picking your nose and eating it was good for you. He claimed that people who pick their noses with their fingers were healthy, happier and probably better in tune with their bodies than those who didn’t. Dr. Bischinger believes that eating the dry remains of what you pull out of your nose is a great way of strengthening the body’s immune system. He explained that in terms of the immune system, the nose is a filter in which a great deal of bacteria are collected, and when this mixture arrives in the intestines it works just like a medicine. He said that “people who pick their nose and eat it get a natural boost to their immune system for free. I would recommend a new approach where children are encouraged to pick their nose. It is a completely natural response and medically a good idea as well”. He went on to suggest that if anyone was worried about what other people think, they should pick their noses privately if they want to get the benefits.  This view is also shared by Dr. Scott Napper, a biochemist at the University of Saskatchewan. He theorises that hygiene improvement has led to the increase in allergies and auto-immune disorders and that eating snot may boost the immune system by ingesting small and harmless amounts of germs into the body. The same theory has also been applied to another bad habit – biting fingernails – because again, the act of biting nails introduces germs directly into a person’s orifices.

(5) Daydreaming helps problem solving

Daydreaming is something that can occupy up to one-third of our waking lives and is often viewed as a sign of laziness, inattentiveness and/or procrastination. However, scientific research has shown that the ‘executive network’ in our brain is highly active when we daydream. A study carried out by Professor Kalina Christoff and colleagues and published in the Proceedings of the National Academy of Sciences found activity in numerous brain regions while daydreaming including areas associated with complex problem solving. These brain regions were more active while daydreaming compared to routine tasks. It is believed that when an individual uses conscious thought they can become too rigid and limited in their thinking. The findings suggest that daydreaming is an important cognitive state where individuals turn their attention from immediate tasks to unconsciously think about problems in their lives. Christoff says that “when you daydream, you may not be achieving your immediate goal – say reading a book or paying attention in class – but your mind may be taking that time to address more important questions in your life, such as advancing your career or personal relationships”. In addition to this, Dr. Eric Klinger of the University of Minnesota has argued that daydreaming also serves an evolutionary purpose. When individuals are engaged on one task, daydreaming can trigger reminders of other, concurrent goals so that they do not lose sight of them.

Part 2 of this article will be in the next blog.

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

Further reading

Christoff, K., Gordon, A.M., Smallwood, J., Smith, R., & Schooler, J.W. (2009). Experience sampling during fMRI reveals default network and executive system contributions to mind wandering. Proceedings of the National Academy of Sciences, 106, 8719-872

Fox, K.C., Nijeboer, S., Solomonova, E., Domhoff, G.W., & Christoff, K. (2013). Dreaming as mind wandering: evidence from functional neuroimaging and first-person content reports. Frontiers in Human Neuroscience, 7, 42. doi: 10.3389/fnhum.2013.00412.

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.

Hirano, Y., Obata, T., Takahashi, H., Tachibana, A., Kuroiwa, D., Takahashi, T., … & Onozuka, M. (2013). Effects of chewing on cognitive processing speed. Brain and Cognition, 81, 376-381.

Kato, P. M., Cole, S. W., Bradlyn, A. S., & Pollock, B. H. (2008). A video game improves behavioral outcomes in adolescents and young adults with cancer: A randomized trial. Pediatrics, 122, E305-E317.

Klinger, E. (2009). Daydreaming and fantasizing: Thought flow and motivation. In Markman, K. D., Klein, W.P., & Suhr, J.A. (Eds.), Handbook of Imagination and Mental Simulation (pp. 225-239). New York: Psychology Press.

Klinger, E., Henning, V. R., & Janssen, J. M. (2009). Fantasy-proneness dimensionalized: Dissociative component is related to psychopathology, daydreaming as such is not. Journal of Research in Personality, 43, 506-510.

Kubo, K. Y., Chen, H., & Onozuka, M. (2013). The relationship between mastication and cognition. In Wang, Z. & Inuzuka (Eds.), Senescence and Senescence-Related Disorders. InTech. Located at: http://www.intechopen.com/books/senescence-and-senescence-related-disorders

Levine, J.A. (2004). Nonexercise activity thermogenesis (NEAT): environment and biology. American Journal of Physiology-Endocrinology And Metabolism, 286, E675-E685.

Levine, J.A., Melanson, E. L., Westerterp, K. R., & Hill, J.O. (2001). Measurement of the components of nonexercise activity thermogenesis. American Journal of Physiology-Endocrinology and Metabolism, 281, E670-E675.

Levine, J.A., Schleusner, S. J., & Jensen, M.D. (2000). Energy expenditure of nonexercise activity. American Journal of Clinical Nutrition, 72, 1451-1454.

Redd, W.H., Jacobsen, P.B., DieTrill, M., Dermatis, H., McEvoy, M., & Holland, J.C. (1987). Cognitive-attentional distraction in the control of conditioned nausea in pediatric cancer patients receiving chemotherapy. Journal of Consulting and Clinical Psychology, 55, 391-395.

Reichlin, L., Mani, N., McArthur, K., Harris, A.M., Rajan, N., & Dacso, C.C. (2011). Assessing the acceptability and usability of an interactive serious game in aiding treatment decisions for patients with localized prostate cancer. Journal of Medical Internet Research, 13, 188-201.

Vasterling, J., Jenkins, R.A., Tope, D.M., & Burish, T.G. (1993). Cognitive distraction and relaxation training for the control of side effects due to cancer chemotherapy. Journal of Behavioral Medicine, 16, 65-80.

Wighton, K. (2013). From biting your nails to burping and even eating in bed: The bad habits that can be GOOD for you! Daily Mail, April 8. Located at: http://www.dailymail.co.uk/health/article-2305953/Bad-habits-From-biting-nails-burping-eating-bed-The-bad-habits-GOOD-you.html

Playing the field: Another look at Internet Gaming Disorder

Research into online addictions has grown considerably over the last two decades and much of it has concentrated on problematic gaming, particularly MMORPGs (Massively Multiplayer Online Role-Playing Games). In the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), Internet Gaming Disorder (IGD) (also commonly referred in the literature as problematic gaming and gaming addiction) was included in Section 3 (‘Emerging Measures and Models’) as a promising area that needed future research before being included in the main section of future editions of the DSM.

The DSM-5 proposed nine criteria for IGD (of which five or more need to be endorsed over the period of 12 months and result in clinically significant impairment to be diagnosed as experiencing IGD). More specifically the criteria include (1) preoccupation with games; (2) withdrawal symptoms when gaming is taken away; (3) the need to spend increasing amounts of time engaged in gaming, (4) unsuccessful attempts to control participation in gaming; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, gaming; (6) continued excessive use of games despite knowledge of psychosocial problems; (7) deception of family members, therapists, or others regarding the amount of gaming; (8) use of 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 games.

There is no agreement on the prevalence of IGD as the vast majority of studies have surveyed non-representative self-selected samples using over 20 different screening instruments. A review of problematic gaming prevalence studies that I published with Orsi Király, Halley Pontes, and Zsolt Demetrovics (in the 2015 book Mental Health in the Digital Age: Grave Dangers, Great Promise) reported a large variation in the prevalence rates (from 0.2% up to 34%). However, we noted that there were many factors that could have accounted for the wide variation in prevalence rates including the type of gaming examined (i.e., some studies just examined online gaming, whereas others examined console gaming or a mixture of both), sample size, participants’ age range, participant type (i.e., some surveyed the general population while others assessed gamers only), and instruments used to assess gaming.

There have been a handful of studies that have reported the prevalence of IGD using nationally representative samples. The prevalence rates reported were 8.5% of American youth aged 8–18 years, 1.2% of German adolescents aged 13-18 years, 5.5% among Dutch adolescents aged 13-20, and 5.4% among Dutch adults, 4.3% of Hungarian adolescents aged 15-16 years, 1.4% of Norwegian gamers, and 1.6% of European youth from seven countries aged 14-17 years.

There are now over 20 different screening instruments including a number of new ones specifically incorporating the IGD criteria (including a number that I have co-developed with Halley Pontes). The multiplicity of problematic gaming screens remains a key challenge in the field and partially reflects the lack of consensus in terms of the assessment of the phenomenon. A comprehensive 2013 review that I published with Daniel King and others in Clinical Psychology Review examined the criteria of 18 problematic gaming screens. The 18 screens had been utilized in 63 quantitative studies (N=58,415 participants). The main weaknesses identified were (i) inconsistency of core addiction indicators across studies, (ii) a general lack of any temporal dimension, (iii) inconsistent cutoff scores relating to clinical status, (iv) poor and/or inadequate inter-rater reliability and predictive validity, and (v) inconsistent and/or untested dimensionality. We also questioned the appropriateness of certain screens for certain settings, because those used in clinical practice may require a different emphasis than those used in epidemiological, experimental, or neurobiological research settings.

Research into IGD is needed from clinical, epidemiological, and neurobiological aspects of IGD. There has been an increasing number of neurobiological studies on IGD and a 2014 meta-analysis by Dr. Y. Meng and colleagues in Addiction Biology of 10 neuroimaging studies investigating the functional brain response to cognitive tasks from IGD using quantitative effect size signed differential mapping meta-analytic methods. found reliable clusters of abnormal activation in IGD within the regions comprising the bilateral medial frontal gyrus/cingulate gyrus, the left middle temporal gyrus and fusiform gyrus when compared to healthy controls. The same review also found that greater amounts of time spent per week playing was associated with hyper-activity in the left medial frontal gyrus and the right cingulate gyrus. Despite the useful findings reported, one of the major limitations of this meta-analysis was that 90% of the studies reviewed were conducted in Asian countries or regions, which might be problematic since prevalence rates of IGD in these populations are usually inflated compared to prevalence rates reported in Western countries. Furthermore, a systematic review of neuroimaging studies examining Internet addiction (IA) and IGD by Daria Kuss and myself in the journal Brain Sciences concluded that:

“These studies provide compelling evidence for the similarities between different types of addictions, notably substance-related addictions and Internet and gaming addiction, on a variety of levels. On the molecular level, Internet addiction is characterized by an overall reward deficiency that entails decreased dopaminergic activity. On the level of neural circuitry, Internet and gaming addiction lead to neuroadaptation and structural changes that occur as a consequence of prolonged increased activity in brain areas associated with addiction. On a behavioral level, Internet and gaming addicts appear to be constricted with regards to their cognitive functioning in various domains”

Over the last decade, a number of studies have investigated the association between IGD (and its derivatives) and various personality and comorbidity factors. Our recent review in the book Mental Health in the Digital Age: Grave Dangers, Great Promise summarized the research examining the relationship between personality traits and IGD. Empirical studies have shown IGD to be associated with (i) neuroticism, (ii) aggression and hostility, (iii) avoidant and schizoid tendencies, loneliness and introversion, (iv) social inhibition, (v) boredom inclination, (vi) sensation-seeking, (vii) diminished agreeableness, (viii) diminished self-control and narcissistic personality traits, (ix) low self-esteem, (x) state and trait anxiety, and (xi) low emotional intelligence. However, we noted that it was difficult to assess the aetiological significance of such associations because these personality factors are not unique to problematic gaming. Our review also reported that IGD had been associated with various comorbid disorders, including (i) attention deficit hyperactivity disorder, (ii) symptoms of generalized anxiety disorder, panic disorder, depression, and social phobia, and (iii) various psychosomatic symptoms.

According to a 2013 editorial in the journal Addiction, Nancy Petry and Charles O’Brien (2013), IGD will not be included as a separate mental disorder in future editions of the DSM until the (i) defining features of IGD have been identified, (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally, (iii) prevalence rates have been determined in representative epidemiological samples across the world, and (iv) aetiology and associated biological features have been evaluated.

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

Please note: Additional input from Daria Kuss and Halley Pontes

Further reading

Gentile, D. (2009). Pathological video-game use among youth ages 8–18: A national study. Psychological Science, 20(5), 594-602. doi: 10.1111/j.1467-9280.2009.02340.x

Griffiths, M.D., Van Rooij, A., Kardefelt-Winther, D., Starcevic, V., Király, O…Demetrovics, Z. (2016). Working towards an international consensus on criteria for assessing Internet Gaming Disorder: A critical commentary on Petry et al (2014). Addiction, 111, 167-175.

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. doi: 10.2217/npy.13.82

Griffiths, M. D., Király, O., Pontes, H. M., & Demetrovics, Z. (2015). An overview of problematic gaming. In E. Aboujaoude & V. Starcevic (Eds.), Mental Health in the Digital Age: Grave Dangers, Great Promise (pp. 27-45). Oxford: Oxford University Press. doi: 10.1093/med/9780199380183.003.0002

Griffiths, M. D., & Pontes, H. M. (2014). Internet Addiction Disorder and Internet Gaming Disorder are not the same. Journal of Addiction Research & Therapy, 5(4), e124. doi: 10.4172/2155-6105.1000e124

Griffiths, M. D., & Szabo, A. (2014). Is excessive online usage a function of medium or activity? An empirical pilot study. Journal of Behavioral Addictions, 3(1), 74-77. doi: 10.1556/JBA.2.2013.016

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(3), 331-342. doi: 10.1016/j.cpr.2013.01.002

Király, O., Griffiths, M. D., & Demetrovics, Z. (2015). Internet Gaming Disorder and the DSM-5: Conceptualization, debates, and controversies. Current Addiction Reports, 2(3), 254-262. doi: 10.1007/s40429-015-0066-7

Király, O., Griffiths, M. D., Urbán, R., Farkas, J., Kökönyei, G., Elekes, Z., 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(12), 749-754. doi: 10.1089/cyber.2014.0475

Király, O., Sleczka, P., Pontes, H. M., Urbán, R., Griffiths, M. D., & Demetrovics, Z. (2016). Validation of the ten-item Internet Gaming Disorder Test (IGDT-10) and evaluation of the nine DSM-5 Internet Gaming Disorder criteria. Addictive Behaviors. doi: 10.1016/j.addbeh.2015.11.005

Kuss, D. J., & Griffiths, M. D. (2015). Internet addiction in psychotherapy. London: Palgrave.

Kuss, D. J., & Griffiths, M. D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2(3), 347-374. doi: 10.3390/brainsci2030347

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(25), 4026-4052. doi: 10.2174/13816128113199990617

Lemmens, J. S., Valkenburg, P. M., & Gentile, D.A. (2015). The Internet Gaming Disorder Scale. Psychological Assessment, 27(2), 567-582. doi: 10.1037/pas0000062

Meng, Y., Deng, W., Wang, H., Guo, W., & Li, T. (2014). The prefrontal dysfunction in individuals with Internet Gaming Disorder: A meta-analysis of functional magnetic resonance imaging studies. Addiction Biology, 20(4), 799-808. doi: 10.1111/adb.12154

Müller, K. W., Janikian, M., Dreier, M., Wölfling, K., Beutel, M. E., Tzavara, C., Richardson, C., & Tsitsika, A. (2015). Regular gaming behavior and internet gaming disorder in European adolescents: results from a cross-national representative survey of prevalence, predictors, and psychopathological correlates. European Child and Adolescent Psychiatry, 24(5), 565-574. doi: 10.1007/s00787-014-0611-2

Petry, N. M., & O’Brien, C. P. (2013). Internet gaming disorder and the DSM-5. Addiction 108(7), 1186–1187. doi: 10.1111/add.12162

Pontes, H. M., & Griffiths, M. D. (2015). New concepts, old known issues: The DSM-5 and Internet Gaming Disorder and its assessment. In J. Bishop (Ed.), Psychological and Social Implications Surrounding Internet and Gaming Addiction (pp. 16-30). Hershey, PA: Information Science Reference. doi: 10.4018/978-1-4666-8595-6.ch002

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. doi: 10.1016/j.chb.2014.12.006

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. doi: 10.1016/j.abrep.2015.03.002

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. M., Kuss, D. J., & Griffiths, M. D. (2015). Clinical psychology of Internet addiction: a review of its conceptualization, prevalence, neuronal processes, and implications for treatment. Neuroscience and Neuroeconomics, 4, 11-23. doi: 10.2147/NAN.S60982

Rehbein, F., Kliem, S., Baier, D., Mößle, T., & Petry, N. M. (2015). Prevalence of Internet Gaming Disorder in German adolescents: Diagnostic contribution of the nine DSM-5 criteria in a state-wide representative sample. Addiction, 110(5), 842–851. doi: 10.1111/add.12849

Thomas, N., & Martin, F. (2010). Video-arcade game, computer game and Internet activities of Australian students: Participation habits and prevalence of addiction. Australian Journal of Psychology. 62(2), 59-66. doi: 10.1080/00049530902748283

van Rooij, A. J., Schoenmakers, T. M., & van de Mheen, D. (2015). Clinical validation of the C-VAT 2.0 assessment tool for gaming disorder: A sensitivity analysis of the proposed DSM-5 criteria and the clinical characteristics of young patients with ‘video game addiction’. Addictive Behaviors. doi: 10.1016/j.addbeh.2015.10.018

Wittek, C. T., Finserås, T. R., Pallesen, S., Mentzoni, R. A., Hanss, D., Griffiths, M. D., & Molde, H. (2015). Prevalence and predictors of video game addiction: A study based on a national representative sample of gamers. International Journal of Mental Health and Addiction, 1-15. doi: 10.1007/s11469-015-9592-8

Young, K.S. (1999). Internet addiction: Symptoms, evaluation and treatment. Innovations in clinical practice: A source book, (Vol. 17; pp. 19-31). Sarasota, FL: Professional Resource Press.

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.

Term warfare: Internet Gaming Disorder and Internet Addiction Disorder are not the same

Over the last 15 years, research into various online addictions has greatly increased. Alongside this, there have been scholarly debates about whether internet addiction really exists. Some may argue that because internet use does not involve the ingestion of a psychoactive substance, then it should not be considered a genuine addictive behaviour. However, the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) re-classified ‘Gambling Disorder’ as a behavioural addiction rather than as a disorder of impulse control. The implications of this reclassification are potentially far-reaching. The most significant implication is that if an activity that does not involve the consumption of drugs (i.e., gambling) can be a genuine addiction accepted by the psychiatric and medical community, there is no theoretical reason why other problematic and habitual behaviours (e.g., shopping, work, exercise, sex, video gaming, etc.) cannot be classed as a bone fide addiction.

There have also been debates among scholars that consider excessive problematic internet use to be a genuine addiction as to whether the those in the field should study generalized internet addiction (the totality of all online activities) and/or specific addictions on the internet such as internet gambling, internet gaming and internet sex. Since the late 1990s, I have constantly argued that there is a fundamental difference between addictions on the internet, and addictions to the internet. I argued that the overwhelming majority of individuals that were allegedly addicted to the internet were not internet addicts but were individuals that used the medium of the internet as a vehicle for other addictions. More specifically, I argued that internet gambling addicts and internet gaming addicts were not internet addicts but were gambling and gaming addicts using the convenience and ubiquity of the internet to gamble or play video games.

Prior to the publication of the latest DSM-5, there had also been debates as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. However, far from clarifying the debates surrounding generalized versus specific internet use disorders, the section of the DSM-5 discussing IGD noted that:

“There are no well-researched subtypes for Internet gaming disorder to date. Internet gaming disorder most often involves specific Internet games, but it could involve non-Internet computerized games as well, although these have been less researched. It is likely that preferred games will vary over time as new games are developed and popularized, and it is unclear if behaviors and consequence associated with Internet gaming disorder vary by game type…Internet gaming disorder has significant public health importance, and additional research may eventually lead to evidence that Internet gaming disorder (also commonly referred to as Internet use disorder, Internet addiction, or gaming addiction) has merit as an independent disorder” (p.796).

In light of what has been already highlighted in previous research, two immediate problematic issues arise from these assertions. Firstly, IGD is clearly seen as synonymous with internet addiction as the text claims that internet addiction and internet use disorder are simply other names for IGD. Secondly – and somewhat confusingly – it is asserted that IGD (which is by definition internet-based) can also include offline gaming disorders.

With regards to the first assertion, internet addiction and online gaming addiction are not the same. A number of recent studies (including ones I’ve co-authored) clearly shows that to be the case. The second assertion that IGD can include offline video gaming is both baffling and confusing. Some researchers consider video games as the starting point for examining the characteristics of gaming disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. For instance, I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflects a common etiology of addictive behaviour. For me, IGD is clearly a sub-type of video game addiction. For people like Dr. Kimberley Young, ‘cyber-relationship addictions’, ‘cyber-sexual addictions’, ‘net compulsions’ (gambling, day trading) and ‘information overload’ are all internet addictions. However, many would argue that these – if they are addictions – are addictions on the internet, not to it. The internet is a medium and it is a situational characteristic. The fact that the medium might enhance addictiveness or problematic behaviour does not necessarily make it a sub-type of internet addiction.

However, recent studies have made an effort to integrate both approaches. For instance, some researchers claim that neither the first nor the second approach adequately captures the unique features of Massively Multiplayer Online Role-Playing Games (MMORPGs), and argue an integrated approach is a necessity. A common observation is that “Internet users are no more addicted to the Internet than alcoholics are addicted to bottles”. The internet is just a channel through which individuals may access whatever content they want (e.g., gambling, shopping, chatting, sex). On the other hand, online games differ from traditional standalone 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. Consequently, it could be argued that IGD can either be viewed as a specific type of video game addiction, or as a variant of internet addiction, or as an independent diagnosis. However, the idea that IGD can include offline gaming disorders does little for clarity or conceptualization.

Finally, it is also worth mentioning that there are some problematic online behaviours that could be called internet addictions as they can only take place online. The most obvious activity that fulfills this criterion is social networking as it is a ‘pure’ online activity and does not and cannot take place offline. Other activities such as gambling, gaming, and shopping can still be engaged in offline (as gamblers can go to a gambling venue, gamers can play a standalone console game, shoppers can go to a retail outlet). However, those engaged in social networking would not (if unable to access the internet) walk into a big room of people and start chatting to them all. However, even if social networking addiction is a genuine internet addiction, social networking itself is still a specific online application and could still be considered an addiction on the internet, rather than to it.

Based on recent empirical evidence, IGD (or any of the alternate names used to describe problematic gaming) is not the same as Internet Addiction Disorder. The gaming studies field needs conceptual clarity but as demonstrated, the DSM-5 itself is both misleading and misguided when it comes to the issue of IGD.

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

Further reading

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.

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

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10(4), 191-197.

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

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.

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., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

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

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.

Koronczai, B., Urban, R., Kokonyei, G., Paksi, B., Papp, K., Kun, B., . . . Demetrovics, Z. (2011). Confirmation of the three-factor model of problematic internet use on off-line adolescent and adult samples. Cyberpsychology, Behavior and Social Networking, 14, 657–664.

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

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

Petry, N.M., & O’Brien, C.P. (2013). Internet gaming disorder and the DSM-5. Addiction, 108, 1186–1187.

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. & 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.

Pontes, H., Kuss, D. & 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.

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.

Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. Cyberpsychology and Behavior, 1, 237-244.

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.

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.