Internet Gaming Addiction: Identification and Treatment Basics

[00:00:10]- Alrighty.

[00:00:11]Good morning, everyone, and welcome.

[00:00:13]Thank you all for being here today for our webinar on addressing internet gaming addiction brought to you by Strengthening the Heartland.

[00:00:19]I am Anie Wheeler, I'm a member of the Strengthening the Heartland team.

[00:00:23]Before we get started, I wanted to let you all know that if you have any questions throughout the presentation, please feel free to type any of those into the question box.

[00:00:31]I believe we'll go through those questions at the end of the presentation, and I will relay those over to our speaker.

[00:00:36]Finally, we do ask that you fill out a short survey for us at the end.

[00:00:40]You'll see that linked in the chat box.

[00:00:43]This survey helps us with feedback, and we really appreciate your recommendations for future topics in our webinars series.

[00:00:49]We will also be sending out a recording of today's presentation at a later time.

[00:00:53]To see any of their previous webinars and to stay updated about our projects, subscribe to our YouTube channel, Strengthening the Heartland.

[00:01:00]So without further ado, I'd like to introduce our speaker for today, Dr. Amanda Giordano.

[00:01:05]I hope I said that right.

[00:01:06]- You did, yeah.

[00:01:08]- That's good.

[00:01:08](Anie chuckles) She's an Associate Professor at the University of Georgia.

[00:01:12]She specializes in addiction counseling and has clinical instructional and scholarly experience related to both chemical and behavioral addictions.

[00:01:21]Welcome Dr. Giordano.

[00:01:24]We're really excited to have you.

[00:01:25]- Yes.

[00:01:27]Thank you so much for being here today.

[00:01:29]This is a topic that I'm really excited to talk about and something that I think is so relevant for clinicians and counselor educators and supervisors.

[00:01:38]So my goal is we're gonna cover a lot of information today in about 50 minutes, and then we'll have some time for Q&A at the end.

[00:01:47]I also wanted to note that this is a lot of material, so if you have questions at the end on the last slide, I'll have my contact information as well as some resources for further study.

[00:01:58]So you're welcome to contact me if you wanna continue the dialogue.

[00:02:01]This is again, a topic that I'm really passionate about and always enjoy having conversations about behavioral addictions, such as gaming addiction.

[00:02:10]So like Anie mentioned, I'm an Associate Professor of Counseling at the University of Georgia.

[00:02:15]I specialize in addictions counseling, specifically behavioral addictions, so I'm really excited to spend an hour with y'all today.

[00:02:28]Okay, so, just a little bit of an agenda, what you can expect from our time together, we're gonna start with just a quick introduction to, what are behavioral addictions?

[00:02:37]They differ from chemical addictions yet have a lot of similarities as well.

[00:02:42]So we're gonna talk about that.

[00:02:43]I also wanna spend some time just discussing the features and the nature of internet gaming, especially for those of you who aren't gamers.

[00:02:50]It's important to have this knowledge when you work with clients.

[00:02:53]We'll talk about the proposed criteria for internet gaming disorder, I'll cover some assessment instruments that you could find helpful in your work, and then we'll end with talking about treatment considerations.

[00:03:05]So what does clinical work with internet gaming addiction actually look like?

[00:03:09]And then we'll have some time for Q&A at the end with some resources.

[00:03:14]All right.

[00:03:15]So before we begin, just wanted to have a little bit of interaction.

[00:03:18]This is helpful for me to kind of gauge where we're at in terms of our listeners.

[00:03:22]So using the chat feature, if you could just take a minute and share with us, in what capacity have you received training related to behavioral addictions, such as internet gaming addiction?

[00:03:33]So some potential answers might be, I learned about it in graduate school, or I didn't learn about it until I was on the job.

[00:03:39]I've only learned through continuing education workshops and webinars like this one, or just through my own self-study.

[00:03:46]Or of course none is an answer here as well.

[00:03:48]So take just a moment to let us know, where have you learned or received training about behavioral addictions?

[00:03:56]- Okay.

[00:03:58]Well, it looks like so far we have a few people who said that they have had no training on behavioral addictions, like gaming addiction.

[00:04:05]We also have a couple continuing education and self-study.

[00:04:09]- Okay.

[00:04:11]- Some more from university, we have a certified addiction counselor who focuses on substances.

[00:04:19]- Okay.

[00:04:20]- Yeah.

[00:04:21]- Great.

[00:04:22]- So, CEs and some self, more self-study in graduate school.

[00:04:27]- Okay.

[00:04:28]Yeah, thanks, Anie.

[00:04:30]So that's pretty typical for other audiences that I had for this presentation that we don't get a lot of training on behavioral addictions in graduate school.

[00:04:41]And you're gonna see how problematic that is when we talk about the prevalence of internet gaming addiction in just a few slides.

[00:04:48]So for any counselor educators or instructors on this webinar, it'd be great to think about how you can integrate some of this information into your courses.

[00:04:58]Along with integrating behavioral addictions into my addictions class, I also infuse a lot of this into my human development class.

[00:05:05]As we talk about development across the lifespan, a lot of these behavioral addictions begin in adolescents.

[00:05:13]So there's opportunities to weave it into the coursework there.

[00:05:17]But I think we all, it's not surprising to know that we don't get a ton of information about this, and so finding ways to increase awareness like through things like this webinar or conference presentations are so important to kind of bridge that gap.

[00:05:32]So very quickly, I just wanted to introduce the idea of behavioral addictions since internet gaming addiction falls under that particular umbrella.

[00:05:40]So a lot of times I get the question, how can you become addicted to something that doesn't have a drug of abuse or a substance involved?

[00:05:49]Well, drugs of abuse are exogenous chemicals, meaning they originate outside of the body, but they activate a very particular part of the brain called the reward system or a reward circuitry.

[00:06:01]Drugs of abuse are both positively and negatively reinforcing.

[00:06:05]What I mean by that is they are positively reinforcing because they cause euphoria and pleasure, and they're rewarding.

[00:06:12]They're also negatively reinforcing.

[00:06:14]And negative reinforcement means you're taking away something undesirable to increase the probability that you'll engage in a behavior in the future.

[00:06:23]So when you use drugs of abuse, it takes away things like distress and anxiety, depression, dysphoria.

[00:06:30]So drugs of abuse are positively and negatively reinforcing and they activate that very particular part of the brain.

[00:06:38]Some examples, cocaine, cannabis.

[00:06:40]So these are exogenous chemicals.

[00:06:43]Now, certain behaviors, not all behaviors, but certain behaviors stimulate the release of endogenous chemicals, meaning they originate inside the body, specifically neurotransmitters, hormones.

[00:06:56]And certain behaviors stimulate that very same region in the brain.

[00:07:00]Their reward circuitry, the reward system, and they stimulate a release of neurotransmitters like dopamine and GABA, serotonin, endorphins.

[00:07:10]These are things you may have heard of before.

[00:07:12]We know that dopamine in particular is implicated in reward and pleasure, and that experience of wanting and liking rewards as well as our endogenous opioid system and serotonin.

[00:07:24]So there are certain behaviors that can stimulate a release of these pleasurable neurotransmitters and can cause both positive and negative reinforcement as well.

[00:07:36]So very similar to drugs of abuse, we know that rewarding behaviors can stimulate that same portion of the brain.

[00:07:43]So for certain individuals, and I wanna highlight this, it's not every individual who engages in a potentially addictive behavior, but for certain individuals, the rewarding behaviors can become compulsive and can lead to negative consequences, and they may develop a behavioral addiction.

[00:08:00]Now, certain individuals are more at risk of addiction if they have some of these risk factors such as early trauma or a genetic predisposition to addiction, if they were exposed to the addictive behavior early, if they have a certain mental health concerns that we know to be risk factors of behavioral addictions.

[00:08:19]So when we think about behavioral addictions, including gaming, I want us to be thinking about the interaction between a susceptible individual, so an individual that's more vulnerable because of these risk factors, as well as the rewarding nature of the behavior.

[00:08:34]So we think about those two things together.

[00:08:37]Now, today we're gonna focus on internet gaming addiction, but just wanted to highlight other potentially addictive behaviors such as gambling, social media shopping, and non-suicidal self-injury.

[00:08:49]So it's really important for us to have a basic awareness of all of these potentially addictive behaviors, but we're gonna spend the next 50 minutes really increasing our understanding of gaming addiction.

[00:09:01]So let's start by just talking about some of the features of gaming.

[00:09:05]So I personally am not a gamer, so I had to learn all of this, and I did a lot of reading and I listened to podcasts from gamers, I watched documentaries about gaming and eSports, so there's a lot to learn if you're not a member of this gaming subculture.

[00:09:22]But some of the important things for us to understand as clinicians is there's lots of different types of games.

[00:09:27]So there's the games that you can play on your smartphone if you remember things like Candy Crush and things that we would do when we're in waiting rooms or we're bored, but then there's games that can be played on consoles, computers, tablets.

[00:09:40]So almost anything connected to the internet can be used for gaming as well as offline consoles as well.

[00:09:47]So lots of places where people can game.

[00:09:50]The fact that they can game on smartphones now really increases I think some of the frequency and prevalence of gaming, because it can happen almost anywhere where there's internet connection.

[00:10:01]Lots of different types of games, there's skill-based games, arcade games, leisure games, there's simulations of sporting events and other activities or social games.

[00:10:12]And then there's Massively Multiplayer Online games or MMOs.

[00:10:15]So with these particular games, gamers from across the globe compete and complete tasks in a shared virtual space.

[00:10:25]So it's a complete immersive experience.

[00:10:28]It is very stimulating of the senses, it's rewarding and it's most linked to gaming addiction.

[00:10:35]So there are different types of MMOs, first person shooter, real-time strategy, role-playing games and multiplayer online battle arena.

[00:10:43]All of these again are played in real time with gamers across the globe in the shared virtual space, and it persists even when an individual gamer logs off.

[00:10:56]So there's this urgency to kind of get back into the game, knowing that it's continuing even when the gamer has logged off.

[00:11:05]In a lot of these Massively Multiplayer Online games, the individual players choose a virtual representation of themselves in the form of an avatar, a champion, a character.

[00:11:16]This is really important for us as clinicians.

[00:11:19]We wanna have a genuine kind of curiosity of our client's relationship with their avatar.

[00:11:25]We have research that shows the stronger the attachment between the individual gamer and their avatar, the increased risk of gaming addiction, and there's also interesting motives for choosing an avatar or a champion, the virtual representation of the self.

[00:11:44]So the individual gamer can choose to be a mythical creature or a creature with desirable features that they may or may not have.

[00:11:54]They can pick different genders, different races.

[00:11:57]So there's a lot that goes into choosing that virtual representation of the self that can be explored in counseling.

[00:12:05]I also wanna note that MMOs in particular really are community games.

[00:12:11]So these gamers will use text or voice communication to talk to other gamers.

[00:12:18]And there have been individuals who say that their best friends are gamers that they've never met in person, but they're actually forming these really strong attachments and relationships with people through communicating only in the virtual world and in the game.

[00:12:35]Also just wanting to note the novelty of gaming.

[00:12:38]So these games are constantly updating with patches.

[00:12:42]They, like I said, persist when the gamer logs off and they're endless.

[00:12:46]So some people engage in the same type of MMO for years at a time 'cause it's always changing, there's always new tasks to be completed or new adventures to pursue.

[00:12:58]I also just wanted to quickly note that we get more dopamine stimulation with novel stimuli.

[00:13:04]So the novelty of gaming really impacts the rewarding nature of the games.

[00:13:12]Okay.

[00:13:13]I also wanna just to mention eSports, if you don't know about eSports, this is just something for us to have a basic understanding of as we are working with internet gaming addiction.

[00:13:22]So eSports are competitive electronic gaming.

[00:13:25]So there are global tournament of eSports, and there's actually fantasy eSport teams now that you can build and bet on.

[00:13:34]In 2018, eSports had a viewership of 395 million people.

[00:13:40]So people go in person to arenas to watch gamers' game, or you can watch online.

[00:13:47]In 2019, there were more than 5,000 eSports tournament and over 28,000 active players.

[00:13:56]So that's really important for us to think about how this is becoming a very important leisure activity and something that people like to play and watch.

[00:14:07]The prize money that was dispersed in 2019 for eSport tournament was over $230 million.

[00:14:16]So this is a very, can be a very lucrative profession for professional gamers.

[00:14:21]And some of these eSports stars have reached international stardom.

[00:14:27]So it could be that some adolescents are aspiring to be professional gamers, they're very influenced by the eSport world.

[00:14:35]And it's actually now infiltrating into colleges, that in 2019, more than 170 colleges in the U.S. were associated with the National Association of Collegiate Esports.

[00:14:47]So we have college eSports teams that are forming, and many universities and colleges are offering gaming scholarships to students who are very exceptional at gaming.

[00:14:58]So all of this to say, there is a growing culture around eSports, and time spent gaming is not a sufficient criteria for identifying gaming addiction.

[00:15:10]For those who are professional gamers or who're involved in eSports, they could game for hours a day, and that doesn't necessarily mean they have a gaming addiction.

[00:15:19]Gaming addiction is more than just time spent gaming.

[00:15:25]So I typically get this question from parents, and they ask me, is all gaming bad, because my child games with his friends almost every afternoon, is that bad?

[00:15:35]Should I stop it?

[00:15:36]And so what I like to explain to folks is that just like any other potentially addictive behavior, it ranges on a continuum.

[00:15:44]So we need to be thinking about gaming on this continuum as well.

[00:15:48]So on one end we have just recreational playing, and there's actually been a lot of research showing that gaming in small doses, so maybe an hour a day or a couple hours a week can increase things like socialization skills, connecting with friends, increased response time, 'cause you're actually using those skills to be successful in the game, collaboration skills and communication skills.

[00:16:12]So recreational play that is limited, there's boundaries, it's not causing negative consequences, it can be even beneficial for adolescents.

[00:16:23]But then on the other end of the continuum, we have that pathological play.

[00:16:26]So this is where gaming becomes compulsive.

[00:16:30]This is where the individual seems to lose control over their gaming behaviors, and they're prioritizing gaming over everything else in their life.

[00:16:38]They're experiencing cravings when they're not gaming or they're mentally preoccupied with gaming.

[00:16:43]So even when they're logged off, they're thinking about it, that's really hard to be in the present moment because they're constantly thinking about gaming and they're experiencing negative consequences from their gaming.

[00:16:54]And we'll talk about these in just a minute, but they can be physical, psychological, relational, or financial.

[00:16:59]So we see a lot of negative consequences with gaming addiction just like other addictive behaviors.

[00:17:07]So how do we discern between high involvement in a behavior and a behavioral addiction?

[00:17:12]I think this is really important 'cause one of the criticisms of behavioral addictions is we're just gonna start pathologizing everyone.

[00:17:19]And that's not true, we have very specific hallmarks that we're looking for to make us think as clinicians that an addiction might be present.

[00:17:27]So again, rather than just time-spent gaming, we're gonna be looking for the four Cs of addiction.

[00:17:34]So just like I mentioned on the previous slide, if gaming becomes compulsive, if there's a loss of control over gaming, if the individual continues their gaming behavior despite negative consequences, and if they're craving or they're mentally preoccupied with gaming, this should alert us that we are now on the far side of the continuum of gaming.

[00:17:55]This has moved beyond recreational play and we're actually seeing some pathological and compulsive gaming.

[00:18:03]Another model that I really like was proposed by Griffiths in 2005, and this is the components model.

[00:18:10]So it's another way to distinguish between just enthusiastic engagement in a behavior or a behavioral addiction, so if the behavior has become the most salient thing in the individual's life.

[00:18:23]So I like to think of it as if that particular behavior becomes the thing that the whole life kinda orbits around.

[00:18:31]So family, school, employment, everything else comes second to this behavior.

[00:18:37]The behavior is the most important thing in the individual's life.

[00:18:41]Also, if the behavior is causing conflict.

[00:18:43]So with gaming, it can cause conflict between an individual and their families.

[00:18:48]So it could be an adolescent gamer and their parents, but it also can be conflict internally.

[00:18:54]So it could be that the individual feels conflicted that I'm engaging in a behavior that I feel I've lost control over, it is no longer congruent with my values and my goals for myself, but I keep doing it.

[00:19:08]So it can be relational conflict, but also internal conflict.

[00:19:12]If gaming becomes the primary means of mood modification, that's another aspect of addiction.

[00:19:18]So rather than regulating emotions in other ways, the individual relies on gaming as their sole means of mood modification.

[00:19:28]So that means they game when they wanna feel good or they game if they don't wanna feel bad.

[00:19:33]It becomes the primary means of emotion regulation.

[00:19:37]Also tolerance and withdrawal.

[00:19:39]So we see tolerance with behavioral addictions just like we do with chemical addiction.

[00:19:43]So tolerance with gaming might look like increased gaming frequency.

[00:19:49]So I'm gaming every day instead of every other day, or gaming for longer durations of time.

[00:19:55]So I'm gaming for four hours a night when I used to game for one hour a night.

[00:20:00]We also see withdrawal.

[00:20:01]So there is a research documenting withdrawal symptoms for gaming such as anxiety, irritability, range, restlessness, and sleep problems.

[00:20:11]So we're seeing withdrawal symptoms when gaming stops and we also see relapse.

[00:20:16]So for individuals with a behavioral addiction, we might see them try to limit their own engagement in a behavior and say, okay, this weekend I'm just gonna catch up on homework, I'm just gonna do chores, I'm not gonna game.

[00:20:29]And they're not able to uphold even the own limits they set for themselves.

[00:20:33]They have those relapses in their own experience, and then of course in more formal treatment, when they have entered abstinence from gaming, they may find themselves relapsing again.

[00:20:44]So if all six of these components are present, then that should indicate to us as clinicians that we are looking at a potential behavioral addiction.

[00:20:54]So these are two different models, both are really helpful, the four Cs and the components model, to help us differentiate between just high involvement in a behavior and a behavioral addiction.

[00:21:06]So let's talk a little bit about the prevalence of gaming addiction.

[00:21:10]It's a global phenomenon.

[00:21:11]So China was in the news a couple of weeks ago because they have implemented new restrictions and curfews for gaming in their countries.

[00:21:20]So now in China, minors can only game on Friday, Saturday, and Sunday.

[00:21:26]So they're unable to game Monday through Thursday, and on Friday, Saturday and Sunday, they can only game for one hour at a time.

[00:21:33]So those are some of the restrictions being put in place to curb the prevalence of gaming addiction.

[00:21:38]Korea, Thailand, they also have curfews and restrictions.

[00:21:42]In South Korea they have the option for families to determine when their adolescents can game and set those curfews for them.

[00:21:51]So this is a global issue.

[00:21:54]We're also seeing a spike in internet gaming addiction and gaming in general during the COVID pandemic.

[00:22:00]And this isn't surprising to us.

[00:22:02]We have seen spikes in addiction across the board during COVID.

[00:22:06]And a lot of that has to do with more time at home, more unstructured time, less responsibilities and structure outside of the home, at work or at school.

[00:22:19]Actually just got some data back, so this is kind of hot off the press, but just got some data back from school counselors.

[00:22:26]So we had over 270 school counselors, and we asked them if they saw an increase in gaming-related issues due to the COVID pandemic or during the COVID pandemic, and 90% of our samples said, yes, we are seeing more issues related to gaming addiction among our students since COVID started.

[00:22:47]So I just wanted to also show some prevalence rates.

[00:22:50]I won't read all of these.

[00:22:50]You can see them on the slide.

[00:22:52]But in terms of adolescents, when we look at community and clinical samples, we can get prevalence rates up to 5.5% globally.

[00:23:01]Among gamers, you're gonna see higher prevalence rates.

[00:23:04]So 17.8% of an international sample of adult gamers endorse the criteria for gaming addiction.

[00:23:13]And we know that across the board when we look at internet gaming disorder or gaming addiction, more males are affected than those who identify as female.

[00:23:22]And there's a couple of hypotheses about why.

[00:23:25]One is that games are typically designed with males in mind.

[00:23:32]The designers of games are typically male and they prioritize masculine ideals like competition, defeating opponents, success and achievement.

[00:23:41]Also the sexualization of women is present in a lot of games, and this idea of competition may link to more of those masculine traits.

[00:23:51]But I think it's important for us to note, whenever I talk about gender differences, I always am wary of it because we also see women or females addicted to gaming.

[00:24:02]So I don't want to present it as only a male issue, but right now we see higher prevalence rates of gaming addiction among males.

[00:24:10]46% of all gamers identify as female.

[00:24:15]So it is important to know that internet gaming addiction can affect anyone across genders, but we tend to see higher rates among males.

[00:24:28]Okay, so what makes gaming so rewarding?

[00:24:32]There's a couple of things that really lead to the positive and negative reinforcing properties of gaming.

[00:24:39]One is just the visual stimulation.

[00:24:42]So these games have very impressive graphics, and the landscape and the visuals can be very appealing.

[00:24:52]There are sounds, there's music, there's a lot of sensory stimulation in games.

[00:24:58]Also it offers the opportunity for team play, so there's a lot of social reinforcement that comes in the gaming world as well.

[00:25:06]So there are individuals who feel very successful in gaming, and they get a lot of social reinforcement from clan members or guild members and others that they are gaming with.

[00:25:17]There's also unlimited opportunities to excel.

[00:25:20]So like I mentioned, games are always updating, they're always changing, there's new challenges.

[00:25:26]So it's always novel, it's always new.

[00:25:29]And I wanna introduce this idea of supernormal stimuli.

[00:25:32]This is something that I think really helps us understand behavioral addictions.

[00:25:36]So supernormal stimuli refer to artificial exaggerations of a natural instinct.

[00:25:44]So it is an artificial concoction of something that represents a natural reward, but the artificial exaggeration offers more reward than even the natural counterpart.

[00:26:00]So an example of this is, consider the sweetness of a strawberry, the natural reward that comes from eating a sweet fruit.

[00:26:11]Now compare that to hard candy or donuts or processed foods with refined sugar.

[00:26:17]So that artificial exaggeration of the sweetness of a strawberry, it really outweighs the sweetness of the strawberries.

[00:26:25]So people tend to now choose that artificial exaggerated stimulus, because it's more rewarding than the natural stimulus.

[00:26:34]So this has been applied to gaming as well, that the virtual world with all of the excitement and the social reinforcement and the tasks and the challenges can actually be a supernormal stimulus compared to the offline world, which at times may be dull, and there may be lulls in the day, and it may be boring at times, but this internet game, this virtual world offers constant simulation.

[00:27:04]So it's been categorized as a supernormal stimulus that is more rewarding and may be preferred over the natural stimulus which would be the offline world.

[00:27:15]So we have some individuals saying that they prefer to be online than offline because they find it so much more rewarding and so much more stimulating.

[00:27:25]We know that dopamine is released when individuals are gaming.

[00:27:29]And so again, think back to what we talked about at the beginning, when we think about behavioral addictions, we're looking at that interaction between the rewarding activity like gaming and the susceptible individual.

[00:27:41]So if an individual has genetic predispositions that make them more vulnerable to addiction, perhaps they have a deficiency in the reward center, and this increase of dopamine release through gaming is extremely euphoric to them due to their genetics.

[00:27:58]Others may game and saying that was fun, but I can kinda take it or leave it while these susceptible individuals experience that dopamine release when gaming and think this is something I can't resist.

[00:28:11]Another aspect that makes gaming so rewarding is the use of variable ratio reinforcement schedules.

[00:28:17]So if you think back to when you learned about behaviorism in Skinner, this is where this comes from.

[00:28:24]Variable ratio reinforcement schedules is actually the most reinforcing and the most difficult to extinguish.

[00:28:31]So this is when you know a reward is coming, but you don't know when that reward is coming.

[00:28:36]So it's unpredictable and you have to engage in the behavior for an uncertain number of times to get the reward.

[00:28:43]So think about gambling, you know a payout's coming, you don't know when, that's variable ratio reinforcement schedules.

[00:28:50]It keeps people engaged longer 'cause they think maybe this time I'll get the reward.

[00:28:54]Maybe this time, maybe this time.

[00:28:56]So it keeps people engaged for longer durations of time.

[00:28:59]This is used in gaming.

[00:29:01]So there are things called loot boxes or individuals can purchase these boxes that may or may not contain things that help them play better in the game that there are in-game rewards, you could open a loot box and find something very valuable for the game or open it and find something not valuable.

[00:29:20]So some have called this gambling in the game, 'cause you use actual currency to pay for these loot boxes, which may or may not have in-game rewards.

[00:29:32]So that is one example of variable ratio reinforcement schedules in the game.

[00:29:37]Also leveling up in a game can come after a long time or short duration of time.

[00:29:44]Typically you level up faster at the beginning of the game, and then it's longer later so you don't actually know when you have completed that level.

[00:29:53]And then this act of grinding, which is engaging in the same behavior over and over until it accomplishes what you're trying to accomplish in the game.

[00:30:00]That's also unpredictable.

[00:30:02]So lots of ways in which a variable ratio reinforcement is infused into the games.

[00:30:08]And remember that's a very powerful form of reinforcement and really hard to extinguish.

[00:30:13]It keeps people gaming for longer durations of time.

[00:30:17]Finally, I just wanted to mention neuroadaptation.

[00:30:21]So, for anyone who engages in a behavioral addiction, so a addictive behavior for long periods of time, they can experience neuroadaptations, which means the brain changes in response to experience.

[00:30:40]So with increased surges of dopamine that come from gaming or other potentially addictive behaviors like pornography use or gambling, there may be a downregulation of the dopamine system.

[00:30:52]And what that means is the brain recognizes, wow, there's a lot of dopamine release in the reward circuitry.

[00:30:58]We're seeing a lot of these neurotransmitters.

[00:31:00]So the brain could respond by adapting through decreasing the natural production of dopamine, decreasing dopamine receptors or transporters.

[00:31:10]There's a lot of ways that the brain can adapt to what it perceives as too much dopamine.

[00:31:14]So that can really cause changes in an individual's mood.

[00:31:19]If your baseline dopamine levels have been reduced, then that means you can go throughout your day feeling differently than you did when you had a higher level of natural dopamine production.

[00:31:31]So we see mood changes among those who have behavioral addictions, particularly over time as we see these neuroadaptations take place.

[00:31:42]Okay, so why do people game?

[00:31:43]This is an important thing for us as counselors to think about when we're working with clients who game.

[00:31:48]There are lots of different motives.

[00:31:49]And so we have to understand what gaming does for the client.

[00:31:54]So asking questions like, when do you feel the strongest desire to game?

[00:31:58]Or what does gaming do for you?

[00:32:00]That's really important for us to assess the motives for gaming.

[00:32:03]So it could just be recreation.

[00:32:05]So when I'm bored, I like gaming, it's what everyone else does, it's kind of available to me, it's just a leisure activity.

[00:32:12]Others may say I game to achieve.

[00:32:15]I like to feel successful.

[00:32:17]Maybe I'm not that successful at school or at sports, but I'm really successful in the game.

[00:32:23]Some people say their motive for gaming is just to build relationships.

[00:32:27]They like the social connection, it's how they stay connected to their peers, and then other global friends are made.

[00:32:34]So there's a social component that can be an important motivator.

[00:32:39]Others say they game to escape, or they game to immerse in the virtual world and create a new identity.

[00:32:48]So as you can imagine, those immersion-type motives are more linked to gaming addiction.

[00:32:55]We see that people who are trying to escape in games often are looking to avoid reality or find ways to cope with adversity or their negative emotions by just getting lost in the game, becoming someone new.

[00:33:09]And so that can relieve the distress and the dysphoria and really serve as a way to avoid negative events in life or negative situations.

[00:33:20]So immersion and achievement have been linked to gaming addiction, which is why it's so important for us to figure out what gaming does for our clients.

[00:33:29]One of the treatment considerations is once we determine the function of gaming in the client's life, we help them meet that need in another way.

[00:33:37]So, are there more adaptive ways for our clients to feel successful or to build a social network, or to find ways to cope with life's adversities instead of only relying on the game?

[00:33:52]Okay, so it's important for clinicians to know that there have been proposed criteria for internet gaming disorder.

[00:33:59]So these are listed in the "DSM" in Section III, so not the "DSM" proper, but that section for Conditions for Further Study, but it's a great tool for us to use to help understand whether or not our client may have internet gaming addiction or disorder with gaming.

[00:34:18]And we can look at these proposed criteria.

[00:34:20]So just like any other substance use disorder or addictive behavior that becomes a disorder like gambling disorder, it needs to cause significant distress and impaired functioning.

[00:34:33]So those things have to be present.

[00:34:35]And then also we see the list of criteria for gaming that at least five would be endorsed in the previous 12 months.

[00:34:46]And so these look a lot like substance use disorder criteria, it's preoccupation with gaming, withdrawal symptoms, tolerance.

[00:34:54]You can't control gaming.

[00:34:55]It seems that the individual's unable to limit their gaming, loss of other interests, so all of a sudden they don't care about school or they don't care about friendships offline.

[00:35:05]Continuing to game despite negative consequences, all these social, psychological problems, they may be lying to others about how much they game or deceiving others.

[00:35:16]So gaming through the night so that it's undetected by others, and then using gaming as the primary means of emotion regulation.

[00:35:25]So gaming as a way to escape negative emotions.

[00:35:29]And then the individual is risking important opportunities because of gaming.

[00:35:34]So you start to see that they are no longer pursuing their goals, that they are putting gaming in front of all activities, hobbies, relationships, and goals.

[00:35:46]So if five are endorsed within the previous 12 months, according to these proposed criteria, the individual would have internet gaming disorder.

[00:35:56]Now the "ICD-11" which is the "International Classification of Diseases" in the newest revision, which is the 11th Revision, they have a gaming disorder as a code.

[00:36:10]So they have the diagnosis, so that is actually in the "ICD-11" now.

[00:36:14]And it's in the section Disorders Due to Addictive Behaviors, and so you can see the criteria here, to have gaming disorder the individual would need to endorse these in the previous 12 months, a loss of control over gaming, prioritizing gaming to the neglect of other important things, continuing to game despite negative consequences and impaired functioning due to gaming.

[00:36:37]So you can see both the four Cs of addiction in the components models represented in these criteria in the "DSM-5" and the "ICD-11."

[00:36:48]So just wanna show you how these classifications of diseases and diagnostic manuals that are used globally, so the World Health Organization and APA are acknowledging that gaming can be an addiction.

[00:37:02]So it's something that we all need to add to our repertoire and our understanding 'cause we're seeing some of the most important diagnostic manuals that are used across the globe recognizing this particular addiction.

[00:37:16]Okay, so what are the negative consequences of gaming?

[00:37:19]Obviously time-spent gaming, now this can't be the only determining factor of whether or not someone has gaming addiction, but individuals with gaming addiction tend to game for a long periods of time daily or every week that they're able to have access to a computer or the internet.

[00:37:38]And so that means as people spend more and more time gaming with growing tolerance, they're not spending that time in other activities.

[00:37:45]So building relationships, engaging with peers, work and school.

[00:37:50]You also see for those with severe internet gaming disorder this neglect of self-care and personal hygiene.

[00:37:56]So you may find that individuals with gaming addiction are not sleeping 'cause they're gaming through the night.

[00:38:02]They may forego things like showering or eating properly in order to game, so that's why we also see high caffeine intake among those with gaming addiction, they're trying to stay awake and stay up so that they can game.

[00:38:15]They don't wanna withdraw from the game, and some have said they don't wanna disappoint their clan or their guild.

[00:38:21]We see some health concerns in injury that come from just a lack of physical activity.

[00:38:26]So if you're gaming all day or through the night, you're not engaging in exercise or other forms of physical activity, we actually see tendon and joint pain in the wrist and hands among those with gaming addiction.

[00:38:39]And then also neglect of offline relationships.

[00:38:42]And what's interesting, and we could spend a lot of time here, but what we're finding in the research is that these virtual relationships, although they can be rewarding, they don't seem to fill the same need as offline in-person relationships.

[00:38:57]And we know this because even those gamers who say they have a lot of virtual friends and other friends across the globe that they game with, they still have higher loneliness scores than others who don't have gaming addiction.

[00:39:10]So it's interesting that, yes, there are social connections through the game, but they don't seem to be as powerful or meeting that need for belonging that offline relationships do.

[00:39:21]We also see a lot of family conflict related to gaming.

[00:39:23]And so typically people think of conflict between adolescents or young adults and parents, but we also have this term gamer widow.

[00:39:31]And so that has to do with the relational conflict between spouses when one person is prioritizing gaming above the spousal relationship.

[00:39:39]And then we also see financial problems with gaming.

[00:39:43]Like I mentioned before, gamers are using real currency to buy in-game rewards, and they can spend money on loot boxes or changing skins, meaning how their avatar looks, or they could also purchase things that they think would make them more successful in the game.

[00:40:02]So a recent study found that almost 90% of MMO players spent real currency in the game.

[00:40:08]So something else for us to be assessing.

[00:40:10]Gamer rage is a term that refers to this outburst of anger, a very strong anger that is felt by gamers who are either forced to stop gaming or perform poorly in the game.

[00:40:24]It can lead to just these outbursts of rage.

[00:40:28]And then finally, we know gaming addiction correlates with a lot of mental health concerns.

[00:40:32]So, a lot of these are correlational studies, so we don't know if the mental health concern proceeded gaming or if they co-occurred, or if they're the result of gaming.

[00:40:41]But we see these correlations between gaming addiction and depression, gaming addiction and anxiety, and some other things like phobias.

[00:40:52]Okay, so, now let's get into, so what do we do with this as clinicians?

[00:40:56]So first of all, I wanna ask, does your intake have an item for gaming or other behavioral addiction?

[00:41:03]So as these behavioral addictions become more and more prevalent in society, it can be really helpful to just have an intake item related to things like gaming.

[00:41:14]It helps to normalize, it helps to communicate to clients that we anticipate this is an issue for some people.

[00:41:20]So take a look at your intake forms, and do they have things like a gaming addiction, sex addiction, social media addiction, food addiction?

[00:41:30]So are we making it easier for our clients to have a conversation about behavioral addictions like gaming?

[00:41:38]Then also we wanna engage in informal broaching about engaging in a variety of rewarding behaviors.

[00:41:46]So I like to do this by saying things like, it sounds like you've had a lot of difficulties lately and people cope in a variety of ways.

[00:41:53]Some people cope through drugs of abuse like alcohol or marijuana, other people cope by escaping into things like gaming or gambling or engaging in sexual activity.

[00:42:03]Have you used any of these as a form of coping?

[00:42:06]And that can just be a way to give the client permission to say, well, I do rely on this particular rewarding behavior to help me cope with life's adversities.

[00:42:16]We can use the diagnostic criteria that we just went through in the "DSM-5" and the "ICD-11" to see if a client would meet criteria for internet gaming disorder.

[00:42:26]And then there are also some formal assessments.

[00:42:29]So the Internet Gaming Disorder Scale is a short-screening instrument that is based on the "DSM-5" criteria and has items like, have you lost interest in previous hobbies and other entertainment activities as a result of your engagement with the game?

[00:42:44]So just using the "DSM" criteria to assess for internet gaming disorder.

[00:42:50]The Gaming Disorder Test is related more to the "ICD-11" criteria an example item, I've had difficulties controlling my gaming activity.

[00:43:00]And there's also a motives for online gaming questionnaire.

[00:43:03]And I like this one because it gets to really the heart of why the individual games, not just frequency or amount of time-spent gaming.

[00:43:12]An example item here is I play online games because it makes me forget real life.

[00:43:17]So you have a variety of assessment instruments available to you.

[00:43:20]Many are in the public domain, so we can use in our work as clinicians.

[00:43:27]Okay, so spend the last couple of minutes talking about treatment considerations.

[00:43:30]So first of all, we want to assess our clients holistically.

[00:43:35]So, do they have co-occurring mental health concerns?

[00:43:38]Do they have suicidal ideation?

[00:43:40]Are there other addictions that we need to be attending to?

[00:43:43]And that will help us determine the level of care.

[00:43:46]So we have a residential treatment for gaming addiction in the U.S.

[00:43:52]You can look up reSTART, which is a program in Washington State that offers residential treatment for particularly adolescents with gaming disorder.

[00:44:01]And there are other residential treatment facilities that are emerging across the U.S.

[00:44:06]And then we also have outpatient services for internet gaming addiction.

[00:44:11]So it's important for us to really assess our client holistically, to determine what level of care do they need to be successful.

[00:44:19]And if they start at residential, they may step down to outpatient care, intensive outpatient, and then finally outpatient meeting once a week.

[00:44:28]We also wanna consult with a primary care physician, especially for severe gaming addiction where our clients may be under or overweight, they may have depletion in certain vitamins and minerals because they are spending a lot of time just in front of the computer all day long, we see day night-sleep reversal, which is basically if they are gaming all through the night, they are now sleeping through the day.

[00:44:52]So there's a lot of things we might wanna consult with a primary care physician in our work with those with severe gaming addiction.

[00:44:59]We also need to be prepared for withdrawal symptoms and help our clients anticipate them and know that they are the result of neuroadaptations that we'll go back to baseline.

[00:45:12]So as they get through these withdrawal symptoms, they're not gonna last forever.

[00:45:16]It's something that as they get more healthy, their brain heals, and they're able to rely more on natural rewards.

[00:45:24]We're gonna see these withdrawal symptoms dissipate, but withdrawal can include irritability, anxiety, anger, loss of other interests, and that comes from just dopamine depletion or a downregulation of the dopamine system.

[00:45:39]Most with internet gaming addiction are going to need some help with emotion regulation skills and social skills.

[00:45:46]So if we think about it, gaming may have been the individual's primary means of regulating their emotions or modifying their mood for years.

[00:45:54]And so now they don't have the game as a way to feel better or not feel bad.

[00:45:59]So really helping our clients identify, label and express their emotions, find ways to engage in emotion regulation strategies that work for them that are successful, and then helping our clients develop social skills.

[00:46:14]So if an individual feels very skilled at online relationships, but extremely inept in offline relationships, that can be a barrier to them creating natural rewards with offline friendships and peer groups.

[00:46:29]So just helping with some basic social skills of, how do we make eye contact again?

[00:46:33]How do we communicate with people in the offline world?

[00:46:39]It's important for a lot of individuals with internet gaming disorder to develop a technology plan.

[00:46:45]So, how are they going to engage with technology, particularly with mediums that are connected to the internet when that could be a trigger for gaming?

[00:46:55]So there might be an initial abstinence from all devices and screens.

[00:47:00]Depending on the severity of gaming addiction, this might be for 90 days or more just to allow, again, the brain to kind of return to baseline and to heal from some of those neuroadaptations or to revert back from some of those neuroadaptations.

[00:47:15]And then you can slowly reintroduce technology, but with a very particular plan.

[00:47:20]So how are they going to avoid gaming and also avoid cues and triggers for gaming?

[00:47:27]You wanna also monitor emergence of a new addictive behavior during this time.

[00:47:31]So we did a study recently with gamers and ask them if gaming was not available, how likely are you to use addictive substances or engage in sexual behaviors or engage in non-suicidal self-injury?

[00:47:43]And it was really interesting that we found that if gaming was not available, a lot of gamers said they would try to change the way they feel through a different mechanism.

[00:47:55]So that can be a chemical addiction or a different addictive behavior.

[00:47:59]So as clinicians, we wanna be monitoring that.

[00:48:01]So how are they coping?

[00:48:03]How are they regulating emotions?

[00:48:04]Has a new potentially addictive behavior becomes salient in the client's life?

[00:48:10]We also wanna engage in some cognitive restructuring.

[00:48:13]So there's a lot of distortions that can develop with internet gaming addiction, like I'm only worthwhile in the online world.

[00:48:20]The offline world is unpredictable and dangerous, but the online world is safe and comfortable.

[00:48:25]I can't trust people in the offline world, I can only trust folks online.

[00:48:30]So there's a lot of potential automatic beliefs that can arise, that we can do some hypothesis testing in cognitive restructuring to help make those beliefs a little bit more adaptable and rational.

[00:48:43]Identify triggers and antecedents for gaming and develop coping strategies.

[00:48:47]So this is pretty simple, like functional behavior analysis of what triggers your urge to game and how do we develop ways to cope with those cues or triggers or urges?

[00:49:00]And then we also wanna help our clients just increase their reliance on natural rewards.

[00:49:05]So if you think back to that concept of a supernormal stimulus, they are finding so much reward in that all immersive, very stimulating virtual world.

[00:49:14]So how do we help them increase their reliance on natural rewards?

[00:49:18]So what are some natural rewards that can be, show a kind of a balance in life, and are adaptive and are healthy without reliance on that really potent supernormal stimulus?

[00:49:31]There's also a 12-step program for internet gaming addiction.

[00:49:36]So I recently wrote a book on treating behavioral addictions, and for each chapter I interviewed folks who specialized in the addictive behavior.

[00:49:46]So for gaming addiction, I got to interview Hilarie Cash, Dr. Hilarie Cash who is the Director of the reSTART Program that I mentioned in Washington.

[00:49:55]And then I also talked to folks who are members of Computer Gaming Addicts Anonymous and asked what it does for them, how they find it helpful.

[00:50:03]And a lot of what we heard was what you would anticipate from other 12-step programs, is I realized I wasn't alone, that there are others who struggle with gaming just like I do.

[00:50:13]We kind of instilled hope in one another.

[00:50:16]There was some validation of experiences and normalization that happened through the meetings.

[00:50:21]So this is a newer 12-step program that you might wanna explore to see if it's a potential referral to your clients.

[00:50:31]Okay, so that brings us right up to 11:50, well, Eastern Time.

[00:50:36]And just wanted to give you a little bit of information here.

[00:50:39]So if you have any questions or you want to dialogue further about internet gaming addiction, you can email me at [email protected].

[00:50:49]Also, I have some information about gaming and other addictions that I try to keep updated on my Facebook Author Page anytime that they're speaking engagements or resources for you.

[00:51:02]Also I did write a book on behavioral addictions that you can see here.

[00:51:06]And if you are interested in it, if you purchase it through the Springer Publishing website and use the discount code, Giordano25, then you can get 25% off of the book.

[00:51:17]And then finally, I write for Psychology Today and have some blogs about behavioral addiction and things like gaming and gambling that you may find helpful or interesting for you or your students.

[00:51:31]All right, so we have some time for Q&A.

[00:51:44]- So, again, if you guys have any questions for Dr. Giordano, you can just go ahead and put those in the question box and I will read them to her.

[00:52:00]- While we're waiting on any potential questions, I also wanted to note that there are some really good resources on internet gaming addiction.

[00:52:08]If you are interested in learning more, there have been scholars who've been studying internet gaming addiction for a decade or more, and they have some really interesting resources for how to recognize it and conceptualize it.

[00:52:22]So I really encourage you just to do some exploration so that you can learn more about internet gaming addiction, so that again, you have the vocabulary with your clients, you kind of know what questions to ask and what to explore.

[00:52:35]And I also have just found that it's very helpful when you show genuine curiosity in what is important to the client.

[00:52:41]So if they are gaming for a couple hours a week, it is an important activity for them.

[00:52:47]They may have very important social connections, their avatar may be really important, so showing genuine curiosity in the gaming experience, I think can help build trust and rapport with our clients as well.

[00:53:01]- Okay, we do have a question from Keith.

[00:53:03]He asked, what is your favorite brief intervention that we can offer to clients dealing with behavioral addiction?

[00:53:10]- Yeah, so a brief intervention.

[00:53:13]I think there's been a lot of, especially with gaming, there's been a lot of work with CBT, but also motivational interviewing.

[00:53:20]I love MI, I think it can be really helpful for a lot of things in the chemical and the behavioral addiction world.

[00:53:26]We do know that MI has been effective with gaming and gambling and some other things.

[00:53:31]So I think an MI approach, and then using some of our CBT skills.

[00:53:36]I do a lot of cognitive work, so I really like the cognitive restructuring, especially with some of our clients who have distorted beliefs about themselves, the world or others that really perpetuate their gaming, it's helpful to bring those to light and do some hypothesis testing in exploring some of those distortions.

[00:53:56]So I would say CBT and MI.

[00:54:00]- Thank you.

[00:54:02]Jen asked, are you finding that clinicians or primary physicians are diagnosing?

[00:54:09]- Yeah, so that's really interesting since with the "DSM-5" we still don't have a diagnosis for internet gaming disorder.

[00:54:17]So one of the things when I was writing the book, I interviewed clinicians who specialize in gaming addiction and ask them, how are you diagnosing since we don't have that "DSM" diagnosis right now?

[00:54:27]And a lot said that it's rare that gaming addiction or internet gaming disorder is gonna occur without an accompanying mental health condition.

[00:54:36]So they said that there is typically depression, or sometimes an eating disorder, sometimes another, a substance use disorder or anxiety.

[00:54:46]And if not, then they look at the impulse control diagnoses.

[00:54:50]So, if I get on my advocacy soapbox, I think that's why it's so important for us to have diagnostic criteria for these behavioral addictions.

[00:54:59]And now we have gambling in the section for behavioral addictions, but it's slow moving with the "DSM."

[00:55:05]It seems like the "ICD" is a little bit faster, they also have a code for compulsive sexual disorder.

[00:55:11]So I think as we get that uniform diagnostic criteria, then we'll be able to open access to treatment for folks who have internet gaming disorder or some of these other behavioral addictions, because we'll be able to diagnose, and then bill insurance.

[00:55:30]- We have a question from Alan.

[00:55:32]He asked, how do you get an addictive gamer, excuse me, to begin to accept help?

[00:55:40]- Yeah, so that's the same as pretty much all addictive behaviors.

[00:55:45]Initially, we see a lot of clients starting in precontemplation if you think back to the stages of change of the transtheoretical model.

[00:55:52]So there's a lot of individuals, especially adolescents who don't want to stop gaming, that is the most rewarding thing in their life.

[00:56:01]And so some of the work has to do with building that rapport, assessing the consequences of gaming in their life.

[00:56:10]Using an assessment can be really helpful to kind of give them a concrete example of, okay, most individuals score here, you scored here which is indicative of problematic gaming or pathological gaming.

[00:56:24]And looking at some of those negative consequences can be a motivator to help people want to make a change.

[00:56:29]But just like any addictive behavior, there's a lot of folks who come to treatment or come to counseling in precontemplation.

[00:56:35]So we work with them where they are, and the goal is to develop some discrepancy, help them move into the contemplation stage of change.

[00:56:43]That's where I think motivational interviewing can be really helpful.

[00:56:46]We're not judging the client, we're not just another person in their life telling them you should stop gaming, but we're really helping to explore what gaming does for them, and then explore ways in which there's a discrepancy between their gaming behavior and the goals they have for themselves, the values they have for themselves.

[00:57:05]And in that way, we can help move them into contemplation where they might be more open to different levels of treatment and different types of care.

[00:57:17]- Okay.

[00:57:18]I think we have time for at least one more question.

[00:57:20]- Okay.

[00:57:21]- Diana asked, she's wondering if harm reduction approach for internet gaming disorder, or if there is, sorry, a harm reduction approach for internet gaming disorder, and if so, how effective is it, or what are your thoughts?

[00:57:37]- Yeah.

[00:57:38]So that's a great question.

[00:57:39]And there's been some research that shows for, if you think of that continuum of gaming, for folks who are kind of in the middle, they're not really on that far end of pathological play, then a harm reduction model might be helpful.

[00:57:52]It could just be that this individual really enjoys gaming.

[00:57:56]And because there may be an adolescent or young adult, they're not making the best choices around how to use their time.

[00:58:01]So that's what like we see in China with limiting the amount of time that individuals can game and putting those restrictions on, that would be a form of harm reduction.

[00:58:10]You're not eliminating gaming, but you are reducing the amount of time-spent gaming.

[00:58:15]For those who have severe internet gaming addiction, it's likely that harm reduction is not going to be effective.

[00:58:24]And that's why we see for residential treatment, and for some of the more intensive outpatient programs for internet gaming disorder, there is a complete abstinence from all screens and technology for a duration of time, and then typically it looks like abstinent from gaming for the duration of the individual's life that they acknowledge that I have an addiction to this particular behavior, the gaming is the compulsive out of critical behavior I'm gonna abstain from.

[00:58:53]I also would note that you need to pay attention to if they're not gaming, but they're watching others game.

[00:59:00]And so I just did a study that looked at, if individuals game and how long they game, but how long they watch others game either live or on things like YouTube or Twitch.

[00:59:12]So if we're talking about a harm reduction approach, you might want to consider limiting not only their own gaming, but watching others game, and then if you're taking an absence approach, it's gonna be abstaining from gaming themselves or watching others game.

[00:59:30]- Alrighty.

[00:59:31]Well, thank you so much Dr. Giordano for putting together that wonderful presentation.

[00:59:36]I know I definitely learned a lot from you today.

[00:59:38]- Yeah, thanks for having me.

[00:59:40]- Of course, we greatly appreciate your time.

[00:59:42]If you have any questions that we weren't able to get to today, you can email Dr. Giordano.

[00:59:47]She has graciously provided her email as she mentioned on the slide.

[00:59:51]And thank you to our audience for being here today, being present and for asking some really great questions.

[00:59:57]Please don't forget to complete the survey linked in the chat box, and check out our YouTube channel, we are Strengthening the Heartland.