________________________________________________________________________ Behavioral Addictions
program of recovery. Another 12-step program is Sex and Love Addicts Anonymous (SLAA) [140]. Most SAA, SLAA, and Sexual Recovery Anonymous (“S” meetings) groups admit new members only after screening and approval by the group mem- bers. Meetings focus on the goal of helping the new member stop or control his/her pathologic sexual behavior and learn new coping strategies. “S” meeting groups can play an impor- tant role in the recovery of patients by helping them become honest with themselves and their families in an atmosphere of support and fellowship [137]. INTERNET GAMING DISORDER The specific game genre is essential to understanding the behav- ioral addiction of Internet gaming disorder. The characteristics of genres attract online gamers with specific psychological and personality features. Gamers at risk for Internet gaming disorder gravitate to genres that deliver potent reward and reinforcement. This disorder develops from the interaction of gamer and genre factors over time. Massive, multiplayer, online role-playing games (MMORPGs) are unique in pathogenic potential among game genres. A 2015 report described a case of two brothers (22 and 19 years of age), high academic achievers from an intact, upper-middle class family who lived at home. Both began MMORPGs two years before hospital admission for Internet gaming disorder. In the initial months, time spent gaming progressed from 2 to 4 hours to 14 to 18 hours daily. Gaming interfered with their sleep and daily routine. Both deteriorated to the point that when engaged in MMORPGs, they urinated and defecated in their clothes, did not change clothes for days, did not bathe, skipped meals, and did not answer the phone. Fixated on gaming, they were indifferent to the presence of a burglar rob- bing their home. Both failed their classes, became abusive and violent when their gaming was disrupted, and were admitted to inpatient care by their parents [194]. INTERNET GAMING GENRES Despite a large variety of available games online, players typically prefer a specific game genre. With Internet gaming disorder, genre greatly matters, and MMORPGs are the most frequently reported genre among people seeking help for an Internet gaming problem [195]. Massive, Multiplayer, Online Role-Playing Games MMORPGs are played online by thousands of gamers simulta- neously, spanning vast time zone differences without spatial or temporal boundaries. The design of MMORPGs borrows from operant conditioning, incorporating random, unpredictable reward structures to maximize player engagement and time involvement. The same intermittent schedule of rewards is featured in slot machines and other gambling modes [194].
In MMORPGs, players assume the role of a fictional character and take control of that character’s actions while simultane- ously interacting with other gamers in a shared, virtual world. This virtual world persists independently of the players; events and interactions between other players continue when one player goes offline [8]. To advance, the player’s character acquires new powers, skills, special weapons, or currency as rewards for succeeding in a mission or special quest. Online social interactions occur among players in-game or by regroup- ing into clans (guilds), a persistent, virtual hierarchical social network of characters with shared backgrounds and objectives [8]. The aspects of a permanent world, reinforcement sched- ule, and online social interaction contribute to the addictive potential of MMORPGs [196]. The uniquely problematic potential of MMORPGs is under- recognized. A 2016 report stated that only 36.7% of surveyed Canadian psychiatrists believed there was an association between psychopathology and MMORPG engagement [197]. First-Person Shooter First-person shooter (FPS) is an action game genre and differs markedly from MMORPGs. Players engage in combat with enemies, primarily using firearms. The shoot-to-kill style of FPS games is considered highly arousing and violent, but little research has studied Internet gaming disorder in excessive FPS players [195]. Real-Time Strategy Real-time strategy games are strategic, combat-orientated games that often use forms of strategic simulation. In real-time strat- egy game matches, strategic decision-making ability directly influences the results and scores. For example, a gamer might hold a combat commander position that requires use of mul- tiple strategies to take over an enemy fortress [195]. Other Genres Other game genres include arcade games, online sports games, casual games, and other action games [195]. These games are rarely associated with Internet gaming disorder.
PATIENT CHARACTERISTICS AND GENRE PREFERENCE
To investigate Internet gaming disorder characteristics, genre preference, and their interaction, 212 Korean patients (18 to 23 years of age, 97.6% male) underwent extensive psychological testing after meeting criteria for Internet gaming disorder [170]. The researchers found five common themes [195]: • Involvement more than 4 hours per day or more than 30 hours per week • Young Internet Addiction Scale (YIAS) score >50 • Irritable, anxious, and/or aggressive when forced to stop • Behavioral problems, distress, and financial problems from excessive gaming
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