Behavioral Addictions _ _______________________________________________________________________
• U rgency: Acts rashly during intense positive and nega- tive emotions • P remeditation: Considers consequences of an act before engaging in that act • P erseverance: Capacity to remain focused on boring and/or difficult tasks • S ensation seeking: Tendency to enjoy and pursue new and exciting activities • P ositive urgency: Tendency to act rashly under extreme positive emotions Many studies highlight the strong links between these impul- sivity factors and psychiatric disorders such as substance use disorders, gambling disorder, compulsive buying, suicidal ideation/attempts, and aggressive behaviors. The “urgency” subtype of impulsivity may predict pathologic MMORPG use. Urgency, poor premeditation, and poor perseverance impede the executive functioning required for self-control, inhibitory control, decision-making ability, and resistance to cognitive interference [8]. Internet gaming disorder symptom severity may be highly relevant in adolescents 16 to 18 years of age, which precedes the age of highest Internet use (18 to 24 years). In one study, individuals more hostile at 18 years of age continued MMORPG involvement with higher Internet gaming disorder symptom severity after two years. These results agree with other longitudinal studies that show stability in addictive behavior during adolescence and onset of Internet gaming disorder coinciding with increased real-life problems [209; 214]. In contrast, Internet gaming disorder is more transient in adults; this disparity may reflect age-related differences in the progression of addiction [205; 215]. Among 3,041 adult recent Internet gamers (60% male), 13.8% met DMS-5 criteria for Internet gaming disorder. Compared with healthy gamers, the Internet gaming disorder group used gaming significantly more often to escape reality and specific issues or as a coping mechanism. They also scored significantly higher on measures of obsession-compulsion, depression, somatization symptoms, interpersonal sensitivity, and impulsiv- ity. Adults with Internet gaming disorder experienced more frequent difficulty in concentrating, loneliness, and insomnia, and were five times more likely to attempt suicide and exhibit aggression. Unlike youth with Internet gaming disorder, no game genre was dominant in adult Internet gaming disorder [216]. Maladaptive Cognitions in Internet Gaming Disorder Internet gaming disorder-related cognition is more complex than “preoccupation.” The primary underlying cognitive fac- tors in Internet gaming disorder (and therapeutic targets for CBT) include [217; 218]:
• Persistent overvaluation of video gaming rewards, activi- ties, and identities • Over-reliance on gaming to meet self-esteem needs • Gaming as a method to gain social acceptance • Maladaptive, inflexible adherence to internal rules dictating gaming behavior In a study of adolescents, those with Internet gaming disorder reported significantly more maladaptive gaming beliefs than non-disordered respondents. The association between gaming cognitions and Internet gaming disorder symptoms was very large and independent of gaming activity and psychological distress. The distinct problematic cognitions of adolescents with Internet gaming disorder should be addressed in any therapeutic intervention [219]. PATHOPHYSIOLOGY Neuroimaging studies comparing patients with Internet gam- ing disorder to matched controls have repeatedly identified the following pathophysiology [8; 196; 218; 220]: • Resting-state imaging: Alteration in brain regions that mediate attentional control, impulse control, emotional regulation, and sensory-motor coordination • Presentation of gaming images (cue exposure): Altera- tion in reward inhibition mechanisms and loss of control • Functional studies: Abnormal dopamine release, altered dopamine levels, decreased dopamine trans- porter availability, and decreased dopamine receptor D2 occupancy that reflect an overall reward deficiency involving decreased dopaminergic activity • Structural studies: Decreased white matter density in regions involved in decision-making, behavioral inhibi- tion, and emotional regulation; altered orbitofrontal cortex gyrus with greater Internet gaming salience and loss of control; ventral striatum (centrally involved in brain reward mechanisms) volume alterations related to changes in reward sensitivity • Treatment studies: Reduction in Internet gaming crav- ing and reductions in associated brain activity In aggregate, these findings show that Internet gaming disorder is associated with neuroadaptation of reward and reinforce- ment pathways that develop from prolonged hyper-stimulation and structural alteration in brain regions that mediate executive functioning. While Internet gaming disorder pathophysiology highly resembles that of substance addiction, this research is early-stage and such conclusions are tentative [220; 221]. One review of adolescents with Internet gaming disorder found distinct neurophysiologic changes identified by EEG that are similar to those identified in patients with substance abuse disorders [222].
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