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
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.
Downwardly mobile? A brief look at cell phone addiction
“One in ten people say they are addicted to their smartphone, a poll has revealed. And more owners than ever are seeking expert help. The US study of 2,000 college students found ten per cent claimed to have a full-blown addiction to the gadgets. Eighty-five per cent constantly checked theirs for the time, while three-quarters slept beside it. Meanwhile counsellor Peter Smith reported a ten per cent increase in Brits seeking help for smartphone addiction at his clinic in Weston-Super-Mare, Somerset. He said: ‘Smartphone users feel they’ve got more control to communicate with whoever they want, whenever they want. But ironically, it’s that sense of control that creates the anxiety. It’s made younger people more reliant on maintaining those contacts – which can create issues from bullying, to being marginalised and excluded. People lose track of time, becoming socially isolated and before they know it, can’t stop. Not having your phone raises your heart rate and signs of panic. These symptoms are almost identical to alcoholism or addiction to gambling, food or drugs” (The Sun, March 21, 2013)
The news report above appeared in The Sun newspaper last week, and as part of that article I was asked to devise a 10-item ‘smartphone addiction test’ for Sun readers which I did (and can be found at the end of today’s blog). As regular readers of my blog will be aware, I have been studying ‘technological addictions’ for over two decades and I coined the term ‘technological addictions’ in a paper I wrote back in 1995. Although I have published a lot of papers on various technological addictions (e.g., slot machine addiction, video game addiction, internet addiction, etc.), I have only ever published one study on mobile phone addiction (with some of my research colleagues in Ramon Llull University, Barcelona, Spain).
Our study was published last year in the Anales de Psicologia, and comprised 1,879 students from Catalonian educational institutions (322 students of Ramon Llull University, and 1,557 secondary school students). We surveyed the students using the 10-item ‘Questionnaire on Cell Phone Related Experiences’ (Cuestionario de Experiencias Relacionadas con el Movil [CERM]), a psychometric instrument developed by Dr. Marta Beranuy and her colleagues in 2009. The CERM examines two areas of cell phone use conflicts and communicative/emotional use.
Our study reported that frequent problems with cell phone use were reported by 2.8 % of the participants. Problematic use was greatest in the youngest age groups. Perhaps unsurprisingly, the most used applications were text-messaging and making calls. We carried out a regression analysis and found that the types of cell phone use that contributed the most to problematic use were text-messaging and playing games, whereas making calls contributed the least. Our results suggest that very few young people have problems with cell phones, in contrast with the findings of previous studies in Spain that reported pathological cell phone rates of 7.9%-10.4%. Our results suggested that females have some difficulties with phone use. Other researchers have also reported that females use cell phones more than males, and perceive their use as more problematic than. We also noted in our paper that cell phones are becoming more varied in their use and new applications such as the playing of games appears to be more attractive to males.
Traditionally, the use of cell phones has been for communication and as such, the risk of problematic use was minimal. However, this risk of problematic use and/or addiction could be potentially higher for smartphones that include applications that promote the altering of user identity (e.g., gaming, social networking, etc.).
We also argued that some people may confuse habitual use of such technology as an addictive behaviour (when in reality it may not be). For instance, some people may consider themselves cell phone addicts because they never go out of the house without their cell phone, do not turn their cell phone off at night, are always expecting calls from family members or friends, and/or over-utilise cell phones in their work and/or social life. There is also the importance of economic and/or life costs. The crucial difference between some forms of cell phone use and pathological cell phone use is that some applications involve a financial cost. If a person is using the application more and is spending more money, there may be negative consequences as a result of not being able to afford the activity (e.g., negative economic, job-related, and/or family consequences). High expenditure may also be indicative of cell phone addiction but the phone bills of adolescents are often paid for by parents, therefore the financial problems may not impact on the users themselves.
It is very difficult to determine at what point cell phone use becomes an addiction. The cautiousness of researchers suggests that we are not yet in a position to confirm the existence of a serious and persistent psychopathological addictive disorder related to cell phone addiction on the basis of population survey data alone. This cautiousness is aided and supported by other factors including: (a) the absence of any clinical demand in accordance with the percentages of problematic users identified by these investigations, (b) the fact that the psychometric instruments used could be measuring ‘concern’ or ‘preoccupation’ rather than ‘addiction, (c) the normalisation of behaviour and/or absence of any concern as users grow older; and (d) the importance of distinguishing between excessive use and addictive use.
All researchers agree in the necessity of longitudinal studies in order to check if perception of the problematic use of cell phones still exists over time. Many university students on the basis of self-report claim to have been ‘addicted’ to texting/instant messaging during some period of their adolescence. Our research suggests they are simply describing a period of their development with strong needs of social ties rather than a true addiction. If any of you reading this really want to know if you may have a problem with your smartphone, then you can take this test I devised. If you answer ‘yes’ to six or more of these statements, it may be indicative of a problematic and/or addictive use of your smartphone.
(1) “My smartphone is the most important thing in my life”
(2) “Conflicts have arisen between me and my family and/or my partner about the amount of time I spend on my smartphone”
(3) “My smartphone use often gets in the way of other important things I should be doing (working, education, etc.)”
(4) “I spend more time on my smartphone than almost any other activity”
(5) “I use my smartphone as a way of changing my mood”
(6) “Over time I have increased the amount of time I spend on my smartphone during the day”
(7) “If I am unable to use my smartphone I feel moody and irritable”
(8) “I often have strong urges to use my smartphone”
(9) “If I cut down the amount of time I spend on my smartphone, and then start using it again, I always end up spending as much time on my smartphone as I did before”.
(10) “I have lied to other people about how much I use my smartphone”
Just remember that excessive use does not necessarily mean addiction, and the difference between a healthy enthusiasm and addiction is that healthy enthusiasms add to life, and addictions take away from them.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Beranuy, M., Oberst, U., Carbonell, X., & Chamarro, A. (2009). Problematic Internet and mobile phone use and clinical symptoms in college students: The role of emotional intelligence. Computers in Human Behavior, 25, 1182–1187.
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.
Carbonell, X., Guardiola, E., Beranuy, M., & Belles, A. (2009). A bibliometric analysis of the scientific literature on Internet, video games, and cell phone addiction. Journal of Medical Library Association, 97(2), 102-107.
Beranuy, M., Chamarro, A., Graner, C., & Carbonell, X. (2009). Validacion de dos escalas breves para evaluar la adiccion a Internet y el abuso de movil. Psicothema, 21, 480-485.
Griffiths, M.D. (1995). Technological addictions. Clinical Psychology Forum, 76, 14-19.
Griffiths, M.D. (1996). Behavioural addictions: An issue for everybody? Journal of Workplace Learning, 8(3), 19-25.
Griffiths, M.D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.
Larkin, M., Wood, R.T.A. & Griffiths, M.D. (2006). Towards addiction as relationship. Addiction Research and Theory, 14, 207-215.