________________________________________________________________________ Behavioral Addictions
ASSOCIATED FEATURES Hostility, defined as thoughts, feelings, and behaviors express- ing the negative affect state of anger, including aggression, irritability, rage, and resentment, is relatively common in adolescence. It is linked to the onset of substance use disorders, and the relationship between hostility and Internet gaming disorder in adolescence is bidirectional. Hostility may lead to Internet gaming escape-avoidance and withdrawal as a coping mechanism for emotional distress, while the anonymity and absence of oversight can make the Internet an outlet for more hostile adolescents to express aggression unacceptable offline [205; 206]. As an ineffective form of coping, Internet gaming disorder could lead to poor adjustment in early adulthood, precipitating hostility [205]. The emotional regulation strate- gies (e.g., suppressing emotions) that characterize individuals with Internet gaming disorder may be contributing factors to their hostile tendencies [207]. In one study, adults (mean age: 35.8 years) were assessed for “social media addiction” (presence of core addiction ele- ments), Internet gaming disorder, and risk factors for both. Social media addiction was associated with being female and single, younger age, ADHD, OCD, anxiety, and lower levels of depression. Internet gaming disorder was positively associated with being male and single, younger age, ADHD, OCD, and depression, and inversely related to anxiety symptoms. ADHD, OCD, anxiety, and depression contributed to the variance in social media addiction (15%) and Internet gaming disorder (7%) after controlling for age, sex, relationship status, and education [208]. Social media addiction and Internet gaming disorder had low inter-correlation and were associated with different variables, which along with many other studies dis- pels the idea of a unified construct of Internet use disorder or Internet addiction [208]. Adverse Outcomes Numerous studies indicate that, for a player subgroup, exces- sive online gaming can lead to diverse negative psychosocial consequences, including sacrificing work, education, hobbies, socializing, time with partner/family, and sleep, as well as increased stress, absence of real-life relationships, lower psy- chosocial well-being, loneliness, worse social skills, decreased academic achievement, increased inattention, aggressive/oppo- sitional behavior and hostility, maladaptive coping, decreases in verbal memory performance, maladaptive cognitions, and suicidal ideation [17]. One study evaluated children enrolled in grades 3 to 8 over two years. Higher Internet game involvement, lower social compe- tence, and greater impulsivity were risk factors for developing Internet gaming disorder, while depression, anxiety, social phobia, and declining academic performance were outcomes of Internet gaming disorder. The prevalence rate of Internet gaming disorder was 9%. The authors concluded that Internet gaming disorder can develop without premorbid disorders and persist for years in young Internet gamers [209].
When considering the applicability of cross-cultural epidemi- ology and risk factors in Internet gaming disorder, cultural differences in attitudes towards Internet use in East Asia and elsewhere should be noted. For instance, parents in East Asia tend to pathologize behaviors that interfere with family or educational pursuits, possibly inflating Internet gaming disorder prevalence rates in Taiwan and South Korea [210]. Individuals who appear addicted to using social media and social networking sites are often engaged online to psycho- logically compensate for the lack of offline social rewards [15]. Psychological Factors Significant predictors of pathologic gaming among adult MMORPG players include expressing “true self” in game, higher levels of social anxiety, larger numbers of in-game social supports, and fewer supportive offline relationships. The number of in-game supports was significantly associated with time spent playing [211]. CBT that addresses specific gaming-related cognitions in Internet gaming disorder may have greater benefit than general approaches that solely address “preoccupation with gaming” (a DSM-5-TR criterion for Internet gaming disorder). Maladaptive cognitions associated with Internet gaming disorder have been identified in cross-sectional studies, but the extent to which these cognitions predict future pathologic gaming behavior requires longitudinal data. In 465 Internet gamers (84% male, mean age: 26.2 years) followed over 12 months, those who developed Internet gaming disorder had significantly higher baseline scores in perfectionism, cognitive salience, and guilt compared with gamers remaining non-problematic. Pathologic gamers who successfully transitioned to being non-problematic gamers had lower baseline perfectionism scores compared with those whose use remained problematic. Cognitive changes accounted for 28% of variance in scores beyond contributions from gender, age, and gaming frequency. Maladaptive gaming- related cognitions could be assessed to better inform treatment targets for CBT [212]. Specific achievement- and immersion-related motives have been identified as strong predictors of problematic online gaming, addiction symptoms, and adverse impact on daily life. Of these motives, problematic use was consistently associated with “advancement” (e.g., the desire to gain power, progress rapidly, accumulate in-game symbols of wealth or status) and “mechanics” (i.e., interest in the rules and system to optimize performance). Immersion-related motives highlighted “escap- ism.” Escapers are motivated by immersion in a virtual reality instead of by reaching game-specific objectives; the game is a dissociative method to escape offline thoughts and problems. Social-related motives (e.g., playing to meet people, teamwork) were unrelated to problematic use [8]. Internet gaming disorder is linked to impulsivity and poor self-regulation, supported by the multidimensional UPPS-P model of impulsivity that describes impulsivity as five related but specific dimensions [213]:
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