Videogame, Social Media and Tech Dependence
(c)2021 Kenneth M. Woog, Psy. D.
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Kenneth Woog, BS EEE, MBA, Psy.D.
Computer Addiction Treatment Program
of Southern California
computeraddictiontreatment.com
(949) 422-4120
Videogame, Social Media and Tech Dependence
(c)2021 Kenneth M. Woog, Psy. D.
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Kenneth Woog, BS EEE, MBA, Psy.D.
Other affiliations:
Sentinel Gaming Systems, Partner
Pepperdine University GSEP, PRYDE
Program Director and Clinical Supervisor
Agenda
(c)2021 Kenneth M. Woog, Psy. D.
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Problematic Videogame and Social Networking Research Brief Review of Worldwide Research
Review of the Science of Addiction
Proposed Simplified Model of Behavioral Addiction and Dependency Treatment targets
Gaming Disorder Treatment Protocol Also applicable to Social Networking Site Addiction
Case Studies
Questions
Dependency and Addiction are Different
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Addiction is a very stigmatizing term that
patients may resent. It carries significant
negative implications that a patient has
poor moral character, is weak or lacking
self-control. It is also a term with specific
research, diagnostic and clinical uses.
Dependence is a less stigmatizing term.
Almost 100% of my clients admit to being
dependent but very few will admit to being
addicted.
These two different terms are often used
interchangeably.
Dependency and Addiction Definitions
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NIDA Addiction Definition Behavioral Definition:
Covers both substance and behavioral addictions.
NIDA Dependence Definition: Withdrawal Proposed Psychological Dependence:
A state in which an organism functions
normally only in the presence of a drug or when
able to engage in a behavior that regulates
mood. Manifested as an emotional disturbance
when the drug is removed or the behavior is
restricted.
Dependency and Addiction are Different
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Addiction is a state where the dopaminergic
reward pathways have been stimulated by a
substance or behavior to a degree that it
causes the organism to engage in the behavior
or use of the substance and is ultimately
unable to limit such behavior or substance
despite resulting negative consequences.
Psychological Dependence is the need to
intake a substance or engage in a behavior in
order to maintain an adaptive emotional state.
Symptoms of negative mood states will result
from discontinuance of the substance or
behavior.
Both Addiction and Dependency must be
addressed for effective treatment of
behavioral or substance use disorders.
Benefits of Gaming, Social Media and Tech
(c)2021 Kenneth M. Woog, Psy. D.
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Video Gaming Benefits Hand/eye coordination, cognitive skills, increased
creativity, spatial visual skills, problem solving skills,
multitasking, leadership/teamwork, socializing
opportunities, learning strategies, improved mood
Social Media Benefits Develop/improve social skills, stay connected to friends
and family, learn about new cultural and societal ideas
and issues, increase creativity - share ideas with friends,
becoming better equipped to be active citizens in
society, improve mood
Technology Benefits Improve personal productivity and knowledge, learn new
skills, stay connected to the world, plus so many more…
Is Screen Time Beneficial?
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Yes! But only to a point - then it is all downhill from there on
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Problematic Video Gaming Vision problems, repetitive stress injuries, disordered
sleep/eating, anxiety, depression, social phobia, Gaming
Disorder, cognitive fatigue, academic failure, reduced
socialization, family/marital conflict, becoming
disconnected from the real world, isolation
Social Networking Problems Disordered sleeping, anxiety, depression, eating
disorders, addiction/dependency, FOMO, academic
failure, online bullying/harassment, damage to online
reputation, lowered self esteem, online misinformation,
online scams
Technology Costs Dependency on devices to deliver content, distracted
living, avoiding friends and family, 24/7 work availability
But is Too Much of a Good Thing a Disorder?
Yes: For Gaming Disorder
ICD-11 (2018)
Social Networking Addiction
no consensus
A Public Health Problem: The Research
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Worldwide research however majority of research from China, Taiwan, South Korea
Gaming Addiction serious problem in China and South Korea
Two major areas of study: Gaming Addiction and Social Networking Addiction
SN Addiction research very limited and conflicting
24% of youth constantly on the internet
Estimates 25% of work internet use is social networking
No agreed upon definition or criteria as a mental illness
Gaming Addiction much better researched: prevalence: US/Europe 1.5%-8.2% of gamers in the US, higher in Asia
No high quality clinical treatment outcome studies
Technology 1981
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1-2 phones
per household
Atari 2600 Console
IBM PC
Space Shuttle Launch
40 Years Later: 2021
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iPotty
PS5
Xbox Series X
Massive Video Gaming Industry
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Forecasted $250B+ by 2023
Growing at 9-18% annually, huge growth in mobile gaming
63% increase in video game sales during pandemic
DFC Intelligence 2019
Video Gaming Goes Pro
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• $100s of Millions Committed to League Play • Fierce Competition Between Top Gaming Companies
• Streaming and television viewing income
• eSports Leagues Now at High School and Colleges • College Scholarships Now Available
Problem: Games played and amount of play (hours) put
players at risk of addiction and other health problems
• 16 y/o teen wins $3 million Fortnite Championship 2019!
Advertising and Social Networking
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Social Networking Has Become THE Dominant Marketing Industry
SmartInsights.com (2017)
Teenagers USA Screen Time 2015
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Common Sense Media Survey (2015)
26% of teens in front of
a screen 8 hours/day
Media Consumption and Tech Has Helped Us Cope During the Pandemic but…
(c)2021 Kenneth M. Woog, Psy. D.
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• Dramatic increase in screen time for teens:
Video game Internet traffic up 75%
Online Zoom classes adds hours/day
• Less direct face time with friends
• Less sports, enrichment extracurricular
• Less life transition events/ceremonies
• Less travel, vacations
• Less “Real World” interactions
Result:
• Elevated depression, anxiety and
loneliness
• 150% Increase in suicidal ideation and
attempts
• Online media consumption all time high
• Increase in academic failure
Rock Center 20
Copyright© 2013 NBC Universal All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107)
Video Game Definition
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“A game in which you press buttons to control and move images on a screen.” (Oxford 2019)
Video Game Technical Definition
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Commonly provided in exchange for financial compensation, the application of these interventions is intended to facilitate the stimulation of the mesolimbic dopamine pathways of the brain to enhance motivation
for the repeated application of the interventions. (Woog 2021)
Behavioral interventions, often designed using principles of psychology, applied to individuals, often
in groups, through electronics means which may include visual images, sound and user interaction.
Video Games 2021
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Sophisticated behavioral interventions Designed using principles of developmental, social and behavioral psychology
High user involvement through Powerful sensory stimulation
Social involvement through significant personal relationships
High user involvement is very valuable financially - billions of dollars at stake New business models require as much screen time as possible
Critical that users do not get satiated and change to different games Highly competitive industry
Many parents unable to monitor and or limit the delivery of these interventions Delivered through a variety of devices that are difficult for parents to manage:
Computers, laptops, tablets, game consoles, handheld gaming devices, cell phones
Parents may often give up trying
Excess use results in serious problems for users and their families Health problems, psychiatric and psychological problems, academic, career and social
problems including serious family conflict
Computer Addiction Research 1980s & 1990s
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1980s - Anecdotal reports emerging
Computer Addiction? Shotton, 1989
Surveyed 127 teen/young adult males
Looked at all computing activities
Multi-user Dungeons and Dragons “…the MUD players hours were perhaps the most disruptive of their family lives than any other group”
1990s Self report surveys
Fisher, Griffiths - Prevalence: 6% , 20%
Problematic Gaming Research 2000s
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Worldwide Prevalence Research: 2.5-34%
2005, 2007 Germany Grusser 15+y/o (n>7000) 9.3-11.9%
2007 S. Korea. Lee & Han 5/6th graders (n=2584) 2.5%
2007 Taiwan. Wan & Chiou 17-24 y/o (n=416) 34%
2008 China. Xu & Yuan 13-18 y/o (n=623) 21.5%
2009 Austria. Battrhyany 13-18 y/o (n=1068) 2.7%
2009 Holland. Lemmens 12-18 y/o (721) 1.4-9.4%
2009 US. Gentile 8-18 y/o (1178) 8.5%
Nationwide Harris Poll Online survey
Criteria similar to pathological gambling
Problems correlated to 25 hrs./week of game play
2010 Australia. Thomas, Porter 14-54 y/o, 5-8%
Survey of Mental Health Professionals Exposure to Problematic Computer Use Woog (2004)
Post Card Mail Survey, postage paid 2003/2004
5000 MD, Psych, MFT (229 responses) across US
How many clients seen, what age groups?
Clinicians saw 3 clients/yr., avg, 0.66 (11-17)
What problematic uses seen (by age group)
How diagnosed? Successful treatment methods?
Did they know someone personally with these problems? >50%
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(c)2021 Kenneth M. Woog, Psy. D.
Problematic Uses by Age Group Woog (2004)
Age 11-17 Age 18-25 Age 26+
Games 41% 18% 13%
Chat 34% 21% 19%
Sexual 25% 32% 54%
Online Relations 23% 28% 32%
Web Surfing 11% 12% 13%
Gambling 0% 4% 13%
Shopping 0% 4% 10%
Programming 0% 4% 3%
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Reported Successful Treatment Methods Woog (2004)
Psychotherapy (CBT) - (45%)
Family / Marital Counseling (34%)
Behavior Therapy (33%)
Medication (32%) 11% respondents were psychiatrists
Abstinence (18%)
12 step programs, on-line, gameaholics anon (18%)
Controlled Use (moderation) (17%)
Parent Counseling (15%)
Social Skills Training (12%)
Addiction Counseling (11%)
Control / Monitoring Software - (8%)
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(c)2021 Kenneth M. Woog, Psy. D.
"Do you believe computer/Internet addiction is a distinct disorder” Woog (2004)
% of respondents
No Yes Can be Don't Know
Treated prior 12 months 28 19 33 20
Not Treated 44 15 15 26
Responded “Yes” or “Can be” a distinct disorder:
Treated within past 12 months: 52%
Not treated within past 12 months: 30%
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(c)2021 Kenneth M. Woog, Psy. D.
Iowa State University National Institute of Media and the Family
Survey of Video Game Play (2009)
Nationwide Harris Poll Online survey, Gentile et al. (2009)
Sample of 1178 youth 8-18 years of age
11 Questions Similar to Criteria for Pathological Gambling:
Negative Consequences of Play
Avoiding important academic, occupational or social responsibilities
Problematic behaviors as a result of play
8.5% of respondents met 6 or more criteria
Male : Female 4:1
Problematic use correlated to 25+ hours/week of play
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(c)2021 Kenneth M. Woog, Psy. D.
Make Love, not Warcraft - Southpark
Copyright© 2007 Paramount Pictures All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107)
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(c)2021 Kenneth M. Woog, Psy. D.
1. Attempts at Controlling Excesses
Child Abuses Computer
Parents remove
keyboard/mouse/power cord/router
or install/use parental control software
Child’s obtains hardware or
defeats parental
controls/software
Period of escalating
anger, poor school
performance, sleep
issues
Child challenged to find covert
solution to bypass control.
Highly reinforcing for both
Child and Parent!
Technology divide a parental
vulnerability!
Repeated
cycles
damage
relationship
Options:
1. Play BTPG for months/years
2. Parents give up
3. Remove computer from home
4. Seek professional tx
“Beat the Parents Game!”
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(c)2021 Kenneth M. Woog, Psy. D.
2. Abstinence / Relapse Cycle
Child Abuses Computer
Parents remove computer
from home
Child’s attitude improves
Parents return computer to home
Period of escalating
anger, poor school
performance, sleep
issues. Deprivation
effects if child addicted.
Period of child
working to get
computer back
Repeated
cycles
damage
relationship
Options:
1. Give up
2. Remove computer long term
3. Seek professional tx
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(c)2021 Kenneth M. Woog, Psy. D.
3. Parent-Child Power Struggle
Child Abuses Computer
Parent demands child’s
performance improves as
condition to return computer
Child demands computer
as condition for school
improvement or attendance
OR shuts down, sleeps
excessively in apparent
“depression”
Period of escalating
anger, poor school
performance, sleep
issues. Parents finally
have had enough!
Sometimes this is
encouraged by mental
health professionals.
Period of parents
and child locked
in power struggle
Parent removes computer Longer term
cycle
Options:
1. Give up
2. Seek (new) professional Tx
3. Send child away for Tx
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(c)2021 Kenneth M. Woog, Psy. D.
“Harm Reduction” Treatment Model - 2007
Addict Completes Daily
Responsibilities
Addict is frustrated or angry about
limits. Has extra free time to
pursue other activities.
Total gaming/media time
reduced
Addict learns to accept feelings
of frustration, cravings, while
accruing significant real-life
rewards
Addict Uses Computer with limits
until time runs out
Repeated daily
cycles + real world
rewards =
Harm Reduction
Gaming / Media use not allowed
until after responsibilities are
completed.
• Behavior Therapy:
• Computer use contingent on meeting other daily responsibilities (i.e. homework). Reduce gaming /media rewards through reduction of game play or media time
• Taper down use limits to reduce chance of serious abreaction, depression, self-harm
• PC Moderator was helpful to enforce limits, reduce conflict: minimize “Beat the Parents” game
• Apply as long as possible, limits removed and Addict reassessed
• Individual Psychotherapy / Family Counseling
• Limited or no participation by younger clients
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(c)2021 Kenneth M. Woog, Psy. D.
Harm Reduction Clinical Observations
Adults not allowed to play videogames as a child can still face issues as an adult.
Problematic use resumed after periods of forced abstinence - sometimes even worse! – Deprivation effect.
Psychotherapy in the absence of behavioral intervention showed poorer outcomes. Poor engagement.
Brief behavioral intervention did not show lasting treatment effects
Premature conclusion of “successful” treatment problematic
Consistent application of the behavioral intervention, even in the absence of psychotherapy resulted in a reduced motivation for play for some clients, and these effects seem to persist long term.
Why? What were the processes that resulted in these treatment effects?
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Problematic Gaming Research 2010-2019 Brain Imaging: Videogame Play and Addiction
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Copyright© 2013 NBC Universal All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107)
Problematic Gaming Research 2010- Brain Imaging: Videogame Play and Addiction
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Striatal Dopamine confirmed reward center involvement
Structural / behavioral differences found
Game Players of Difference Game Genres
Positive changes observed showing improved functioning in logic or puzzle games
Negative changes observed in action based role-playing games. Problem solving relying on repetitive visual cues (memory)
Gaming Addicts vs. Controls
Negative changes linked to deficits in impulse control, behavioral inhibition, attentional capabilities, and cognitive functioning
Differences in observed activation to presented cues
Problematic Gaming Research 2010-2019
• CBT Models of Internet Addiction and Gaming Disorder Emerging
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• CBT Treatment Methods Proposed Based on These Models
• Methods followed those of substance abuse treatment
• Poor Outcome Study Quality
• Small sample sizes, lack of experimental controls
• Limited specificity of use: Internet Addiction vs. Gaming Addiction
• High dropout rates
• Consensus building for diagnostic criteria for distinct disorder
Gaming Disorder ICD-11 (6C51) (2018)
Gaming disorder is characterized by a pattern of persistent or recurrent gaming
behaviour (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the
internet) or offline, manifested by:
1. impaired control over gaming (e.g., onset, frequency, intensity, duration,
termination, context);
2. increasing priority given to gaming to the extent that gaming takes precedence
over other life interests and daily activities; and
3. continuation or escalation of gaming despite the occurrence of negative
consequences.
The behaviour pattern is of sufficient severity to result in significant impairment
in personal, family, social, educational, occupational or other important areas of
functioning.
The pattern of gaming behaviour may be continuous or episodic and recurrent.
The gaming behaviour and other features are normally evident over a period of at
least 12 months in order for a diagnosis to be assigned, although the required duration
may be shortened if all diagnostic requirements are met and symptoms are severe.
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Gaming Disorder: ICD-11 (2018)
World Health Organization
Addiction Disorders Restructured
to Include Behavioral Addictions
Disorders due to substance use +
Disorders due to addictive behaviors
Moved Gambling Disorder
Added Gaming Disorder
“gambling” changed to “gaming”
Online vs. offline dropped
Once and for all!
Severity not defined
Not Implemented until 1/1/2022 US perhaps not until 2025 or 2027
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What is Social Media?
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Websites and applications that enable users to create and share content or to participate in social
networking. (Oxford 2021)
Social Media Technical Definition
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Providers of these interventions are often compensated by selling access to these individuals via advertising. The application of these interventions is intended to
facilitate the stimulation of the mesolimbic dopamine pathways of the brain to enhance motivation for the
repeated application of the interventions. (Woog 2021)
Behavioral interventions, often designed using principles of psychology, applied to individuals, often
in groups, through electronics means which may include visual images, sound and user interaction.
Social Dilemma
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Social Media/Networking Research
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1980’s – No research Chat and messaging in infancy
1990’s – 2009 “Internet Addiction” Captured essence of many different applications of Social
Networking
Emerging awareness of problems related to Social Media
FOMO, body image issues
2010’s – Social Networking Site (SNS) Addiction 2011 – First published literature review of SNS Addiction
Prevalence surveys conflicting, poor sampling: 1-2% US adults
2020’s - Hopefully better research Growing excess use of social networking
Hooked on Facebook:
The Role of Social Anxiety and Need for Social
Assurance in Problematic Use of Facebook Roselyn J. Lee-Won, PhD, Leo Herzog, BA, and Sung Gwan Park, PhD (2015)
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Cyberbullying, Depression, and Problem Alcohol
Use in Female College Students: A Multisite Study Ellen M. Selkie, MD, MPH, Rajitha Kota, MPH, Ya-Fen Chan, PhD,
and Megan Moreno, MD, MSEd, MPH (2015)
Exploring the Role of Parents and Peers in Young Adolescents’
Risk Taking on Social Networking Sites Wonsun Shin, PhD, and Nurzali Ismail, ME (2014)
Instagram #Instasad?: Exploring Associations Among
Instagram Use, Depressive Symptoms, Negative
Social Comparison, and Strangers Followed Katerina Lup, MA, Leora Trub, PhD, and Lisa Rosenthal, PhD (2015)
Social Media Research
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The Facebook Experiment: Quitting Facebook Leads to Higher Levels of
Well-Being. Tromholt M., Cyberpsychology, behavior and social networking, 19(11), 661–666.
https://doi.org/10.1089/cyber.2016.0259 (2016)
Prolonged Mobile Phone Use Is Associated with Poor Academic
Performance in Adolescents. Xianchen Liu, MD, PhD,1 Yachen Luo, MS,2 Zhen-Zhen Liu,
MD,3 Yanyun Yang, PhD,2 Jianghong Liu, PhD,4 and Cun-Xian Jia, PhD (2020)
Social Media Research
Summary of SNS Addiction Andreassen, C.S. Online Social Network Site Addiction: A Comprehensive Review.
Curr Addict Rep 2, 175–184 (2015).
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Bergen Facebook Addiction Scale
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1. You spend a lot of time thinking about Facebook or planning how to use it.
2. You feel an urge to use Facebook more and more.
3. You use Facebook in order to forget about personal problems.
4. You have tried to cut down on the use of Facebook without success.
5. You become restless or troubled if you are prohibited from using Facebook.
6. You use Facebook so much that it has had a negative impact on your job/studies.
Captures essence of addiction and dependency
Research Summary 2021
Gaming and Social Networking problematic uses distinct but significant overlap Gaming Disorder has been researched more and longer
Gaming contains a Social Networking component
Social Networking integrating gaming applications
Both predict increased Depression and Anxiety (males)
Gaming Disorder is a defined Mental Disorder China/South Korea (15%), US – likely >3%
Negative life outcomes correlate to >25 hours /week
Social Networking excesses lead to problems: Elevated risk of depression, anxiety, body image issues, cyber bullying
and lowered self-esteem
Social Networking Addiction Research Limited Obviously problematic uses, limited prevalence research
Insufficient research to support it as a mental disorder
Dependency symptoms clearing observed
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We Need a Simplified Model
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Informs assessment Assessment focused on causes (i.e. excess use), reinforced
problematic behavior and current client functioning
Informs treatment Interventions apply to specific processes and deficits
Educates client and families Externalizes the problem and its causes. Addiction result is normal.
Lack of ability to limit use IS the disorder, not a moral failing
Rationale for interventions that non-professionals can understand Explains why certain parenting interventions not helpful Increases empathy for client struggling with the disorder Helps create realistic expectations for treatment and outcome Helps define the “end” of treatment
Integrates both Addiction and Dependency Understandable and acceptable
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The Science of Addiction
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Sufficient Activation Results in Addiction
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What is Addiction?
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Excess reward pathway activation
Altered brain wiring associating the addicting substance or behavior with pleasure
The amount of the brain wiring makes it dominant
Cues in environment trigger reward pathway involvement
Brain changes that result in behavioral deficits:
Behavioral inhibition, impulsivity
Decision making difficulties
The bad news: The brain wiring does not go away
Learning theory
The good news: New wiring can mediate old wiring
Structural Changes and Dependency
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Video to follow discusses cocaine but applies equally to all addictive substances or behaviors
Real-life Rewards Fade to Gray
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The Secret Life of the Brain © 2001 PBS All rights reserved Reproduced under Fair Use (Title 17: Chapter 1 § 107)
Range of Pleasure Perception Narrows (conceptual)
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Recall /Anticipate
Pleasurable Event
Video Gaming
Academic/Occupational
Sports, Exercise
What is Dependence?
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• The negative feelings
associated with withdrawal
are thought to come from
two sources:
• Diminished activation in
the reward circuitry of the
basal ganglia and
• Activation of the brain's
stress systems in the
extended amygdala.
• Dependence is experiencing withdrawal symptoms, (negative
feelings) upon discontinuing an addictive substance or behavior
Problematic Adolescent Internet Use Research 2014
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Depressive Symptoms and Problematic Internet Use Among Adolescents: Analysis of the Longitudinal Relationships from the
Cognitive–Behavioral Model Manuel Gamez-Guadix, PhD (2014)
Negative outcomes at an academic, family or social level due to problematic internet use predicted increase in depression symptoms 1 year later
Depressive symptoms at time 1 predicted problematic internet use with negative outcomes one year later
Simplified Dependency Model
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Dependency Model Treatment Targets
Simplified Addiction Model
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After sufficient play, reward
pathway is hijacked and
structural brain changes
lead to reduced coping and
self regulation functioning
Addiction Model Treatment Targets
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Decrease consumption levels,
Increase competing activities:
Sports, academics, off-line
socializing, family involvement
Decrease rewards directly via
reduced use (loot, ranking, likes),
punish use through less desired
contingencies. Reduced use time
over extended period to restore
structural deficits
Limit access (strongly enforced) to
(ERP), Mindfulness based
cognitive psychotherapy.
Medications an option to reduce
craving, mood disturbance and
impulsivity
Premack Principle (aka Grandma’s Rule)
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Contingency Established
Less Preferred Activity (Homework)
Videogame play causes
Homework behavior to increase
BUT as importantly in this case
Motivation for Videogame Play is reduced
To increase the frequency
of a less preferred activity,
a more preferred activity is
made contingent upon the
occurrence of the less
preferred activity.
But less known relationship:
This contingency will also
decrease the frequency of
the more preferred activity.
More Preferred Activity (Videogame Play)
+
-
Unified Gaming* Disorder Treatment Model
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1. Physical activity, diet, sleep, hygiene,
other leisure activities, psychotherapy,
family counseling, medication
2. Counseling / coaching - identify
enrichment activities (occupational,
educational, social, spiritual, recreational
etc.), establish daily schedule
3. Restrict access to gaming until end of day,
contingent on other activities and responsibilities
and for a reduced amount of time, tapering down
as needed for safety and efficacy
4. Game play daily but with reduced
rewards as a consequence of reduced
play. No play when it needs to be zero.
5. Scheduled wind down after play ends,
psychoeducation, psychotherapy to deal
with urges and impulses.
Interventions Outcome
External Cues
* Substitute any addicting substance or behavior
ERP
Treatment Protocol Overview
Intake Assessment (2 hour session) Initial Sessions (2-6 sessions)
ACT psychotherapy as skills building, coaching, self-help guidance Ongoing assessment Refer out for medication evaluation or adjunctive psychotherapy Agree upon usage limits/goals Socialize to individual and family psychotherapy
Establish Weekly Schedule and Behavioral Contracting (2-4 sessions) Work out issues with behavioral contracting, monitor progress Ongoing Individual and family therapy
Follow up Sessions (6-12 sessions) Taper sessions down to 30 min, then every other week, etc.
Termination Session Maintain behavioral plan past termination Follow up sessions as needed
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How to Classify and Code Diagnosis ?
No Current Gaming Disorder Diagnosis or ICD Code
We can use:
Diagnosis ICD-10 Adult
Other impulse disorders F63.89, Impulse disorder, unspecified F63.9
Diagnosis ICD-10 Children/Adolescents
F98.9 Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence
Other mood, developmental or behavioral disorders
2025 or 2027 - Gaming Disorder ICD-11 (6C51) Will still need to use ICD or behavioral codes for SNS Addiction
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Intake Assessment
Assess the problem – questionnaires, interviews (2 hours)
Include parents/significant others if possible/necessary
Identify the negative impact on health, academic, occupational and social domains (Motivational Interviewing)
Identify the impact on the family/couple
Assess for related mental health issues Depression, anxiety, system, developmental delays, other
Identify the amount and times of play AND pseudo-play
5 15 25 35 45 55 65
hrs/week
Not addicted Likely Addicted Very Likely Addicted
Serious Impairment Little Impairment from gaming
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Intake Assessment (continued)
Brief psycho-education
Science of Addiction, game culture, treatment methods
Practical advice - “Never pull plug on game play”
Discuss goals for treatment
Ask both parents/spouse and addict separately:
“What do you think is a reasonable amount of time?”
“What important responsibilities have suffered as a result of gaming?”
Abstinence or moderation?
Negotiate to starting point - how much and when each day
Discuss reasonable expectations for parents/significant others
Develop a simplified treatment plan
Educate client and family, seek buy-in from client
Contract for specific number of sessions
Limited emphasis on broadcasting a DSM or ICD diagnosis
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Three Interventions Elements
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Acceptance and Commitment Therapy
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Individual-Focused ACT Treatment with Parental Participation Suitable for clients aged 13 (depending on maturity) to 35 Parent(s) attends initial assessment and sessions
Some private sessions with client or parents ACT Model explained as tool to deal with dependency
Normalized - everyone faces this just in different ways Specific issues targeted – parents often willing to share their issues
Initial sessions focus on skills building, later on results May evolve to individual work with client or parent
Between Session Assignments Involve Family Everyone reading “The Happiness Trap” or “Acceptance and
Commitment Therapy in 7 Weeks” watching assigned videos, doing Yoga or guided meditation together as family
Dinner discussions Shared experiences to bring parents/child
together
Acceptance and Commitment Therapy
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• Benefits: • Improved client attendance and participation • Improved compliance with between-session assignments • Daily in-home monitoring of client’s involvement • Engenders hope and involvement for parents,
improving willingness to continue in treatment • ACT work with parents reduces codependency
• They gain skills, understanding, empathy from the sessions • Regular weekly treatment outcome assessment
• Risks, Challenges • Unwillingness of parents to participate
• Fix my kid or they are an adult! • Parental burnout, schedule conflicts • Parental psychopathology • Excess family or marital conflict
Behavioral Therapy
Identify academic, career, social/relational values and set long/short term goals
Define the activities and milestones in support of goals
Make gaming/media consumption contingent on completing activities in support of client’s goals. Currently using Sentinel Gaming System if needed.
Reduce rewards of gaming/media consumption by reducing time spent
Increase motivation for pursuing goals by linking them to tangible rewards
Client Uses
Computer/Games
Client has frustration about
limits. Now has extra free time
to pursue other activities.
Reduce amount of ALL
media time according to
agreed upon “safe” limits
on a daily basis.
Client learns to have
feelings of frustration
cravings, while accruing
significant real-life rewards
Use is limited each day
Repeated daily
cycles + real
world rewards
= dependency
broken
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What is a Safe Level? What is not safe…
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5 15 25 35 45 55 65 hrs/week
Not dependent Likely dependent Dependent
Serious Impairment Little Impairment Modest Impairment Mild Impairment
• No single number - varies individual to individual
• Genetic/individual variability, life circumstances
• Impairment above 15 hours/week • Time includes all related activities – Twitch, YouTube, Discord
• Significant impairment found at 25 hours/week
• Safe does not mean appropriate for lifestyle / commitments • College, high school students, athletes, parent, spouse
• Never binge for more than 5 hours in any one day!
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How Much Screen Time is Appropriate?
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Pre-school age children
Parents and technology Many parents use technology
as a parent helper.
Elementary, Middle School, High School
No guidance from WHO or AAP on amount of time Lifestyle balance, AAP has Media Time Calculator (Hint: just leftover
time)
Guidance on limits to video gaming + other technology screen time*
Gentile et al. (2009), 25+ hrs./week significantly problematic 8 -18 y/o
6-7 (Elementary) <1 hr./day, maximum 6 hrs./week
8-11 (Elementary) <1.5 hrs./day, maximum 9 hrs./week
12-13 (Middle School) <2 hrs./day, maximum 12 hrs. /week
14-18 (High School) < 2.5 hrs./day 15 hrs. /week
Screen time recommendations
0-1 y/o 2-4 y/o 5-18 y/o
0 <1 N/A
0-2 2-5 y/o 6-18 y/o
0 <1 “Balance”
Life Balance Worksheet
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What does the number 168 represent?
The number of hours in a week
Where we spend our 168 matters
This is how we get back in the
game of life
Behavioral Treatment
Behavioral Contracting
Create a weekly schedule
Use gaming/social media time as reward for participation in completing daily activities. Parents provide accountability
Younger clients start with parental controls
Older Clients allow initial attempt at self regulation
Add sports, extracurricular, social activities fill gaps
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Parental Control Challenge 2021
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• Parents not tech-savvy
• Too Many Devices To Track!! • Some you may not
know they have
• 24/7 Content Access
• Many Ways to Connect • Cell Data, WIFI
• Downloadable content
• Device Controls Not That Secure
• Many Ways to Bypass – Google it!
• More “Beat the Parents Game”! • Its fun and they often win!
• Good controls in the hands of non-tech parents
• Internet/Gaming Cafes, Coffee Shops with
WIFI Hotspots
Simplify Media/Gaming Device Availability 93
Consolidate client’s gaming/media use to one device
Other user’s computers/tablets/smartphones in home must be secured (password protected, locked away)
Client’s other computers must be removed These allows secretive use and use in bed, bathroom, etc.
Other media devices except smartphone must be removed
No more Tablets, Ipods (except Nano)
Additional gaming consoles or handheld system must be removed
If possible move computer system into a common area Install/configure limit setting tool (parental control) on System
Agreement that use would not start until certain time
Set to agreed upon daily limits If user cannot self-limit, then they meet the definition of addict
For adults: allow attempt to self regulate smartphone first
If unsuccessful then they must give up the device
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Sentinel Gaming System - Designed for the Prevention and Treatment of Videogame Addiction
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High Performance Gaming Desktop PC Windows 10 OS, VR, 4K ready Plays PC, XBOX One*, PS4/5* Games &
Your Phone (Android)
Designed for behavioral treatment protocol Automate behavioral contingencies, Gradual tapering down use automatically Tools to monitor and encourage productive computer time Web based controls can be operated from anywhere with internet View current status or modify settings/limits in real time Usage monitored (when, how long and even view screen images)
Settings for when, how long and how users can operate system Gaming Mode, Study Mode, No Video Modes, GamePlay+
Users may remain System Administrator of the computer system Highly Secure – Tamper and hack resistant Began field testing in 2015 with videogame addicted clients Presented to clients as last resort, the “threat” alone has motivated
some clients!
*Running a Windows 10 app and you
must have the console and games
Mobile Device Parental Controls
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Carrier Based Best Option Cannot be defeated by child (except jailbreak) Some carriers not useful if WIFI available
Data based applications for voice, text, Social Media
Free or monthly fees (varies by carrier) Change carriers if necessary
Application Based Installed app Android “Uninstall protection” prevents removing app
Factory Reset Protection – Android Lolipop+
Apple products provide remote notification of uninstall Features and support vary by product
Be careful … child may get prepaid phone Always be on the lookout for contraband devices
Bottom Line: If you can’t manage it, get rid of it!
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Case Studies Representing the Treatment
Model Presented
Sampling of Clients of 2005 - 2019
Some details modified to ensure confidentiality
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Copyright© 2012 CBS Corporation All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107)
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Case Study - 17 years old 99
17 y/o male WOW Addiction
Declining / failing grades in high school
Therapist recommended parents remove computer from home until client attended school reliably for two weeks and brought grades up
Parent: “2 weeks of attending school and doing h/w, get computer back”
Child: “Give me back computer or I won’t go to school
30 days later… still not in school
Setup PC Moderator with computer time allowed for attending school, even part day
1 hour school= 1/2 hour computer time
Back in school full time within 1 week
Limits set to daily (2 hours) and weekend (5 hours) use and contingent on doing h/w each weekday
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Case Study – 25 years old 100
Had been attending local university for a long time, completed all the credits to graduate but his GPA was below 2.0. Had retaken so many classes could only take 400 level courses to bring up GPA. Parents brought him for treatment for videogame addiction.
Had started new school term with 2 classes, parents worried this would be his last and not graduate. Client claimed he could regulate on his own.
Had done a few family sessions, then parents not willing to participate and continued with individual sessions. Was open, honest and participated in therapy. Recommended Sentinel early on but was refused by client and parents.
Despite client’s self report of good school performance, at midterm, client had an F and a D+ in his courses.
All agreed to Sentinel and behavior plan of studying 8 hours/day and getting 3 hours of gaming time. Parents could not support the behavioral plan, so I did it myself.
Client ended term with an A and B in his classes.
(c)2021 Kenneth M. Woog, Psy. D.
Video Gaming Addiction Treatment Cases Sample of those presented at 2019 Southwestern School for Behavioral Health Studies
Age Referral Behav. Tx Ind. Tx Family Tx Current Status
25 College suspension Sentinel yes as needed ongoing, successful college term
22 College suspension self no no failed recent college term
22 College suspension Sentinel yes 1/month ongoing, successful college term
31 No school, no work Sentinel no 1/week successful college term, employed, moved out
20 College suspension self no as needed failed college, returning to cc college
27 Unemployed, gaming self yes as needed employed, gaming 5-10 hrs./week
16 Declining academics self no 3 sessions schoolwork improved, refused Sentinel
23 College suspension abstinence yes 10 sessions working full time, no gaming, returning college
23 College suspension Sentinel no 1/week working, successful college term, stopped gaming
27 Unemployed, gaming self no 1/month part time employment, gaming >35 hrs/week
23 Failing college Sentinel yes 1/week successful college term
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Chris Revisited
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Credits / References / Resources 108
Andreassen, C.S. Online Social Network Site Addiction: A Comprehensive Review. Curr Addict Rep 2, 175–184 (2015). https://doi.org/10.1007/s40429-015-0056-9
Cash, H. (2012). Internet Addiction: A Brief Summary of Research and Practice. Current Psychiatry Reviews. Vol .8, No. 4.
DSM-5 (2013) American Psychiatric Association
DFC Intelligence (2019) Worldwide Video Game Market Forecasts
Dong, G. et al (2014) A cognitive-behavioral model of Internet gaming disorder: Theoretical underpinnings and clinical implications. Journal of Psychiatric Research. Nov;58: 7–11.
Gamez-Guadix, M. (2014) Depressive Symptoms and Problematic Internet Use Among Adolescents: Analysis of the Longitudinal Relationships from the Cognitive–Behavioral Model. Cyberpsychol ology Behavior and Social Networking Nov;17(11):714-9. doi: 10.1089/cyber.2014.0226.
Griffiths, M. (2012) Video Game Addiction: Past, Present and Future. Current Psychiatry Reviews. Vol 8, No. 4.
Kuss, D. J., & Griffiths, M. D. (2017). Social Networking Sites and Addiction: Ten Lessons Learned. International journal of environmental research and public health, 14(3), 311. https://doi.org/10.3390/ijerph14030311
Harris, R. (2009). ACT Made Simple: An Easy-To-Read Primer on Acceptance and Commitment Therapy. Oakland, CA: New Harbinger
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Credits / References / Resources
King, Daniel & Delfabbro, Paul. (2018). Internet Gaming Disorder: Theory, Assessment, Prevention, and Treatment (1st Edition). 10.1016/C2016-0-04107-4.
NBC News.com Rock Center (2012) Tangled Web. retrieved from: http://www.nbcnews.com/video/rock-center/49754151#49754151
NIDA (2007) The Science of Addiction. Retrieved from: http://www.nida.nih.gov/scienceofaddiction/
Palaus, Marc et al. (2017) Neural Basis of Video Gaming: A Systematic Review. Frontiers in Human Neuroscience Vol 11
Southpark - Comedy Central, Season 10, “Make Love, Not Warcraft”
Substance Abuse and Mental Health Services Administration (US); Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health [Internet]. Washington (DC): US Department of Health and Human Services; 2016 Nov. CHAPTER 2, THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION. Available from: https://www.ncbi.nlm.nih.gov/books/NBK424849/
Thompson, C. (2020) Schools confront ‘off the rails’ numbers of failing grades. Associated Press. https://apnews.com/article/distance-learning-coronavirus-pandemic-oregon-7fde612c3dbfd2e21fab9673ca49ad89\
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Credits / References / Resources
Tromholt M. (2016). The Facebook Experiment: Quitting Facebook Leads to Higher Levels of Well-Being. Cyberpsychology, behavior and social networking, 19(11), 661–666. https://doi.org/10.1089/cyber.2016.0259
Wölfling, Klaus, et al. (2019). Efficacy of Short-term Treatment of Internet and Computer Game Addiction. A Randomized Clinical Trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.1676.
World Health Organization (2018), Gaming Disorder http://www.who.int/features/qa/gaming-disorder/en/
Woog, K. (2004) A survey of mental health professionals clinical exposure to problematic computer use. http://www.pcmoderator.com/research.pdf
Woog, K. (2016). Proposed gaming addiction behavioral treatment method. Addicta: The Turkish Journal on Addictions, 3, 271–279.
Young, Kimberly et al. (2010) Internet Addiction: A Handbook and Guide to Evaluation and Treatment. Hoboken NJ: John Wiley & Sons
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Longest Running Dedicated Technology Addiction Treatment Programs in US
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David Greenfield, Ph.D. - The Center for Internet and Technology Addiction West Hartford, CT 06119 860-561-8727 Hillarie Cash, Ph.D. - Internet/Computer Addiction Services, reStart Redmond, WA. 98052, (425) 861-5504 Kenneth Woog, Psy.D. - Computer Addiction Treatment Program Lake Forest, Ca 92630, (949) 422-4120 Kimberly Young, Ph.D. - Center for Internet Addiction Recovery Bradford, PA 16701 814-451-2405
Questions? 112
“With technology we are bringing boredom to the brink
of extinction. Satisfying this with the immediate
gratification of media consumption may have tragic
consequences for mankind” (c)2021 Kenneth M. Woog, Psy. D.