This document discusses internet gaming addiction and problematic online gaming. It begins by describing how online gamers are more likely to demonstrate problematic use compared to offline gamers. It then provides a history of internet and video game addiction, describing early concepts from the 1970s onward. The document outlines different typologies of games and their associated addiction risks, such as massively multiplayer online role-playing games (MMORPGs) posing the highest risk. Several models of internet gaming addiction and issues with related research and screening/assessment are also summarized.

1. Internet Gaming Addiction
LEIGH HOLMAN, PH.D., LPCS, RPTS, NCC, SCS
AMHCA DIPLOMATE AND CMHC
PRESIDENT-ELECT INTERNATIONAL ASSOCIATION OF
ADDICTION & OFFENDER COUNSELORS

2. Typology
 70% prefer online games to offline games (DePrato et al., 2010)
 Online gamers are more likely to demonstrate problematic use (Griffiths,
Davies, & Chappell, 2004; Griffiths & Meredith, 2009); Rehbein, Psych,
Kleimman, Mediasci, & Mossle, 2010).
 Online
 Typically played simultaneously by players
 Players can communicate with one another in real time
 Players can cooperate or compete at will
 Do not have predetermined end point
 No real loss, and tasks can be repeated several times
 Competing leads to immediate social comparison (Griffiths, 2010; Kim & Kim, 2010)
 Social nature results in more time spent playing
 Offline
 Usually played alone
 Well-defined start and finish point
 Goals are usually achieved by the players themselves without external help from any
other player.

3. History
1970s: MUDS (Multi-User Domains) (Bartle, 2003;
Barnett & Coulson, 2010).
 Text based virtual worlds
 Several players present at the same time
 Use imaginations rather than graphics
 Created real-time chat, interaction between players, parallel
activities, cooperation, competition, social comparison
1986: Suggested term: “Video game addiction”
1989: Comparison to SUD: “Computer dependency”
1994: Arcade video game dependency conceptualized
as pathological gambling in the DSM-III

4. History (Cont.)
1996: “Internet addiction disorder” described in first
issue of CyberPsychology & Behavior
2000: First study of online gaming addiction
2004: Release of World of Warcraft – 12 million players
(peak)
2008: Special issue in IJMHA on video game addiction
2009: Internet addiction critiqued in several psychiatry
journals
2010: First randomized controlled trial of IA treatment
2012: Proposed inclusion of Internet Use Disorder

5. History (Cont.)
MMOGs or MMOs (Massively Multiplayer Online
Games)
 100s or 1000s of players
 People play simultaneously in the same online world, not in an
individual copy of it
 Can only be played through an internet connection (Barnett &
Coulson, 2010).
 MMOGs most complex (more people and synchronic spaces
and MOGs are simpler (no synchronic spaces & only 4-16
players)

6. Types of Games (Cyber Junkies, Roberts)
 Puzzle Games:
 deal with logic, language, trivia, mindless repetition, and visual-spatial skills
– no themes or characters
 Addiction Risk: 2
 Physical Simulations:
 help remedy physical inactivity – Dance Dance Revolution or Guitar Hero –
recommend all homes with video game system have at least one physical
game
 Addiction Risk: 2
 Old School Games
 Nintendo64, Playstation1, Sega’s Dreamcast
 Cartoonlike characters in mazes, races, and battles
 Families & friends can play together
 Some fantasy role-playing games (Legends of Zelda) and first person shooter
games (GoldenEye 007) low potential for addiction
 Addiction Risk: 3

7. Types of Games (Cyber Junkies, Roberts)
Educational Games
 May offer very accurate historical representations and give players an in-depth
education on historical periods
 Addiction is increased when the educational component is combined with other
gaming elements (role play or real-time strategy)
 Addiction Risk: 4
Mange and Control Games (God Games)
 The Sims Life Simulation Model- make all housing, finance, food intake, and
relationship decisions of the characters in the game.
 Roller Coaster Tycoon, player makes decisions to construct, maintain and grow
an amusement park.
 Black and White – players take on role of a god and act to influence the lives of a
group of islanders
 Usually have no win-or-loose scenario
 User does not directly control the characters
 Opportunity to exert complete dominance over people and places in the game
 Addiction Risk: 5

8. Types of Games (Cyber Junkies, Roberts)
Shoot ‘Em Up and Adventure Games
 Deepening sense of connectedness to the characters they control.
 Higher levels of realism equal heightened sensory stimulation
 Unceasing potential for new missions and adventures ensures that
players do not quickly tire of these games
 First-Person Shooter (FPS) Games
 Public enemy number one – high levels of violence – M-rated
 A player’s view is the same as in real-life – 3D cyberworld
 Require a high level of concentration & quick reflexes
 Virtual death awaits
 Make their way through mazes, cities, or battlefields to search out and
destroy their enemies
 Counter-Strike, Halo, Call of Duty
 Form Clans and meet online for team battles
 Addiction Risk: 7

9. Types of Games (Cyber Junkies, Roberts)
Shoot ‘Em Up and Adventure Games
 Real-Time Strategy (RTS) Games
 Building a civilization & amassing technology to advance to higher
levels of development
 Prepare an army for war
 RTS players control and entire battlefield as well as make overall
strategic decisions
 Multitasking skills, manages economy, controls armies, and may keep
peasants happy or face revolt
 Gateway Games
 Can be played alone or with others
 Players who derive satisfaction from the online multiplayer feature of
these games often crave greater interaction and connection with other
players than RTS games can supply.
 Addiction Risk: 7

10. Types of Games (Cyber Junkies, Roberts)
Shoot ‘Em Up and Adventure Games
 Adventure and Role Playing Games (RPGs)
 Contains many gateway games because players seem to quite
easily move to more addictive MMORPGs
 Draw discovery-oriented players and those motivated by role
playing
 Fantasy character embarks on a quest that progresses through
many trials and obstacles, usually toward a goal
 In some games there is no ultimate goal, no win-or-loose scenario,
but rather simply an opportunity to exist as the character
 A player’s choices help shape the direction of the game – appeals
to control-oriented gamers
 Examples: Legend of Zelda, Final Fantasy. Anmd Warhammer
 Addiction Risk: 8

11. Types of Games (Cyber Junkies, Roberts)
MMORPGs
 Board with life
 Control an avatar, choose the race, class, and sometimes profession
 Interact with each other in persistent worlds that operate 24 hours a
day
 Join clans and guilds of like-minded avatars – cooperate on quests
and adventures & chat through headsets
 Bond that transcends previous relationships
 May think about the game constantly
 May shift perception from fantasy to reality
 Relationships, career, family may all suffer
 Rune Scape: 10 million active users – most use a free version -
Addiction Risk: 7
 World of Warcraft: 9 million users internationally – pay $13-
$15/month w/ first month free - Addiction Risk: 10

12. 6 technical and design characteristics of MMOS
(Chan & Vorderer, 2006)
Persistence
 the game world may change between sessions because it exists even
when the player isn’t present.
Physicality
 Realistic world with consistent set of rules
Avatar-Mediated Play
 Use of an avatar character to interact with others and the game world –
usually has characteristics/skills that the gamer wants to have but
doesn’t in real life
Vertical Game Play
 Even when the highest level is attained, players remain in the game
world and complete more challenges or participate in social activities
Perpetuity
 Game never ends
Social Interaction
 Cooperation and rivalry between players is an essential part of the game

13. 3 Major Groups of MMOs & Other
(Nagygyogy et al., 2012; Rice, 2006)
 79% have a clear preference for type of game, which may indicate the type of game
meets certain needs the gamer has
 Massively Multiplayer Online Role-Playing Games (MMORPGs)
 Traditional role-playing games
 Players control avatar – virtual self
 Choose a profession that determines their role and abilities
 Through fulfilling different tasks or missions in the game, the avatars develop & acquire precious
objects that lead to the differentiation status between avatars (Leveling Up)
 Massively Multiplayer Online First Person Shooter (MMOFPSs)
 Skill-demanding action games
 Players control a single avatar from a first-person perspective
 Rely on reaction time and attention
 Several cooperation & competition (individual and group) opportunities
 Massively Multiplayer Online Real-Time Strategy (MMORTSs)
 Player oversees large troups &/or territories in a virtual world, engage in battles, or conclude
alliances with other players
 Players establish status in the game world and gain esteem through successes
 Other online games
 Sport, racing, music/rhythm games
 Multiplayer online social games or turn-based strategy games
 Attract fewer players
 Many more female players

14. Conflict Over what constitutes Problematic Online Gaming?
Video games as the starting point for examining the
characteristics of a specific pathology (Charlton &
Danforth, 2007; Griffiths, 2005; Griffiths &
Meredith, 2009; Peters & Malesky, 2008).
VS.
Internet is the main platform that unites different
addictive activities, including online games (Van
Rooij, Schoemakers, Vermulst, Van den Eijnden, &
Van de Mheen, 2011; Young, 2009).

15. Griffiths, 2010) Video Game Addiction Theory
Indicators of High Engagement (Charlton & Danforth, 2007, 2008)
1. Salience
 Gaming becomes the most important activity in the person’s life and dominates his/her thinking, feelings (i.e.
cravings), & behavior
 Preoccupation & Cognitive Distortions
 Deterioration of Socialized Behavior
1. Mood Modification
 Gamers report both an arousing ‘buzz or high” and
 Distressing tranquilizing feeling of “escape or numbing”
1. Tolerance
 Increasing amounts of time are required to achieve the former effects
Central Role in Addiction (Charlton & Danforth, 2007, 2008)
4. Withdrawal Symptoms
 Unpleasant feeling states or physical effects when not gaming or reduced time gaming
 Shakes, moodiness, irritability
5. Conflict
 Interpersonal conflict with important relationships
 Conflict with time spent on other activities (hobbies, work, school, social life)
 Intra-psychic conflict – feelings of loss of control
6. Relapse
 Tendency for repeated reversions to earlier patterns of gaming after abstinence or control has been established

16. Other models
Porter et al. (2010)
 Excessive use of one/more video games resulting in a
preoccupation with and a loss of control over playing video
games, and resulting negative psychosocial and/or physical
consequences
Integrated Models
 Problematic Online Game Use model (Kim & Kim, 2010)
 5 dimensions: euphoria, health problems, conflict, failure of self-control,
and preference of virtual relationship
 Demetrovics et al. (2012) Integrative Approach
 6 Dimensions: preoccupation, overuse, immersion, social
isolation, interpersonal conflicts, and withdrawal

17. Issues with Research
No consistency in literature on gaming addiction:
 Theory
 Conceptualization
 Screening and Assessment Measures
 Methodology
 Population
 Sampling

18. International Prevalence Rates

19. Prevalence
Meta-analysis: About 3% of the general population meet addiction
criteria
 Limited evidence suggests that most addicts (about 80%) stay addicts
for at least 2 years in the absence of treatment
 Prevalence rates vary according to: Type of digital technology activity
 How addiction is assessed (measurement)
 Demographic factors
 Cultural context (Far East Asian > Western)
 Country
 Recruitment and sampling method psychiatric sample vs. community sample;
 self-selection vs. random selection
 Type of video game typically played
 ↑among online video games, especially MMORPGs

20. Screening and Assessment
Many scales developed out of scales used for other
behavioral addictions such as Internet Addiction
without consideration for unique aspects of gaming.
Many have ambiguous or questionable
psychometrics.
Because of continued differences regarding what
constitutes problematic gaming, scales may measure
different things.

21. Screening & Assessment Issues
 Review of all studies published 2001-2012
 Search logic: (pathology* OR problem* OR addict* OR compulsive OR
dependent*) AND (video OR computer) gam*
 Academic Search Premier (967 results), PubMed (235 results), PsychINFO
(957 results), Science Direct (1677 results), and Web of Science (284
results)
 Studies were not necessarily excluded on the basis of methodological
shortcomings. However, a study was excluded if:
 instrument name was not identified,
 a composite measure was used,
 case note material or anecdotal evidence
 not published in English or Dutch.
 •TOTAL: 18 instruments across 63 studies

22. Screening & Assessment Issues
 Instrument analysis
 Review framework:
 Cicchetti's (1994) and Groth-Marnat's (2009) criteria
 JARS criteria
 Psychometric information:
 components (i.e., underlying theoretical construct),
 dimensionality,
 validity (convergent, predictive, and criterion),
 reliability (internal consistency, inter-rater),
 availability of normative and prevalence data.
 Practical considerations: number of items,
 administration time,
 reading age level,
 item sensitivity,
 time-scale,
 diagnostic categories,
 country of origin,
 language versions.

23. Screening & Assessment Issues

24. Screening & Assessment Issues
 No two instruments were alike with respect to their profile of diagnostic
features
 Interpersonal conflict was the only addiction indicator that was assessed across
all 18 instruments
 Financial conflict not generally assessed
 Few instruments assessed use despite harm (SD criterion)
 Instruments do not ask: “Do you think you have a problem?”
 DSM-IV-TR criteria include the most indicators (13 ind.)
 Game Addiction Scale and Young Internet Addiction Test each assess 11 criteria
 Only the PVP Scale mapped all criteria of DSM-5 Internet Use Disorder –
instruments tended to miss: (i) use despite harm and (ii) deception/secrecy

25. Improving Measures
 Inclusion of items to assess:
 whether the individual personally believes that their video-gaming behavior is problematic
(i.e., a validity check),
 an item that asks whether significant others would consider that their video-gaming is
problematic (i.e., a reliability check)
 Inclusion of measures to assess co-morbidity
 Guidelines for scoring and interpretation
 Establishment of norms
 Assessing harm/conflict across several domains
 Research - No instrument measures all indicators, therefore: •include
additional items
 Use more than one measure

26. Gentile (2009)
Pathological Gaming Scale
 Over time, have you been spending much more time thinking about playing video games,
learning about video-game playing, or planning the next opportunity to play?
 Do you need to spend more and more time and/or money on video games in order to feel the
same amount of excitement?
 Have you tried to play video games less often or for shorter periods of time, but are
unsuccessful?
 Do you become restless or irritable when attempting to cut down or stop playing video games?
 Have you played video games as a way of escaping from problems or bad feelings?
 Have you ever lied to family or friends about how much you play video games?
 Have you ever stolen a video game from a store or a friend, or have you ever stolen money in
order to buy a video game?
 Do you sometimes skip household chores in order to spend more time playing video
 games?
 Do you sometimes skip doing homework in order to spend more time playing video games?
 Have you ever done poorly on a school assignment or test because you spent too much time
playing video games?
 Have you ever needed friends or family to give you extra money because you spent too much
money on video-game equipment, software, or game/Internet fees?
Convergent & Divergent Validity

27. Lemmens et al. (2009)
Game Addiction Scale for Adolescents
Salience (GA 1-3)
Tolerance (GA 4-6)
Mood Modification (GA 7-9)
Relapse (GA 10-12)
Withdrawal (GA 13-15)
Conflict (GA 16-18)
Problems (GA 19-21)
Randomly distributed in the scale
5 point Likert scale
Second-order factor structure of 21 item Game Addiction Scale
(N = 351)
EFA, Convergent & Criterion Validity

28. Online Game Addition Diagnostic Scale (Lee & Han, 2007)
Factor 1: Psychological Dependence
Factory 2: Daily Life Disorder
Factor 3: Interpersonal Relationship Toward Online
Factory 4: Tolerance
Factor 5: Negative Behavior & Emotions
Factor 6: Mental Disorder
Factory 7: Physical Disorder
Integrative Approach
30 items, EFA, criterion validity

29. DSM 5 Section III: Internet Gaming Disorder
Proposed Criteria:
Persistent and recurrent use of Internet to engage in games, often with other players, leading
to clinically significant impairment or distress as indicated by 5 or more of the
following in a 12 month period:
1.Preoccupation with Internet games.
2.Withdrawal symptoms when Internet gaming is taken away.
3.Tolerance: the need to spend increasing amounts of time engaged in internet games.
4.Unsuccessful attempts to control the participation in Internet games.
5.Loss of interests in previous hobbies & entertainment as a result of, and with the exception
of, Internet games.
6.Continued excessive use of Internet games despite knowledge of psychosocial problems.
7.Has deceived family members, therapists, or others regarding the amount of Internet
gaming.
8.Use of Internet games to escape or relieve a negative mood.
9.Has jeopardized or lost a significant relationship, job, or educational or career opportunity
because of participation in Internet games.
Specify Severity:
 Mild, Moderate, or Severe

30. Comorbidity
2x more likely to be diagnosed with ADD/ADHD than gamers
who play recreationally (Batthyany, Muller, Benker, &
Wolfling, 2009; Bioulac, Arfi, & Bouvard, 2008; Chan &
Rabinowitz, 2006; Gentile et al., 2011; Han et al., 2009).
Depression (Gentile et al., 2011; Peng & Liu, 2010).
 MMORPG depressive symptoms (sadness, hopelessness, crying spells,
insomnia, concentration problems) are related to habitual computer
gaming at night b/t 10-6 (Lemola et al., 2011)
Anxiety & Social Phobia – longitudinal data suggest
pathological gamers exhibit higher levels of depression,
anxiety & social phobia during follow-up than normal gamers
(Gentile et al., 2011), but the relationship may be reciprocal.

31. Etiology
 Neurobiological Aspects:
 Cue induced gaming urge activates the same brain regions activated by gambling in pathological gamblers and
substance use in substance addicts (Han et al., 2011; Ko et al., 2009).
 Working memory may be affected similarly as is in substance dependence (Kim et al., 2012).
 Need more studies
 Personality Aspects:
 Low Emotional Stability (Charlton & Danforth, 2010; Mehroof & Griffiths, 2010; Nagygyorgy, Mahalik, &
Demetrovics, 2012; Peters & Malesky, 2008).
 Low Agreeableness (Charlton & Danforth, 2010; Peters & Malesky, 2008).
 Low Extroversion (Charlton & Danforth, 2010).
 Neuroticism
 Amount of time playing – Decreased quality of interpersonal relationships and increased social anxiety (Lo, Want,
& Fang, 2005).
 Problematic Gaming is negatively correlated with offline social self-efficacy and positively correlated with online
social self-efficacy (Jeong & Kim, 2011, Porter et al., 2010).
 Inadequate self-regulation (Seay & Kraut, 2007)
 Low Self-Esteem ( Ko, Yen, Chen, Chen, & Yen, 2005); Lemmens et al., 2011)
 Low Emotional Intelligence (Herodotou, Kambouri, & Winters, 2011)
 Above Average State Trait Anxiety (Mehroof & Giffiths, 2010)
 Increased Loneliness (Lemmens et al., 2011; Seay & Kraut, 2007)
 Narcissistic Personality (Kim et al., 2008)
 Aggression (Kim et al., 2008; Mehroof & Griffiths, 2010)
 Lower life satisfaction (Ko et al., 2005; Wang, Chen, Lin, & Want, 2008)
 Decreased Psychosocial Well-being compared to other gamers (Lemmens et al., 2011)

32. Etiology
Motivational Aspects:
 Motives play in important role in the development and maintenance of
problematic online gaming (Demetrovics et al., 2011; Kuss & Griffiths,
2012)
 Bartle (1996) 4 motivational types: achievers, explorers, socializes, &
killers of MUD players
 Yee (2006) tested Bartle’s model with MMORPG players. Using EFA,
identified 10 motivational components that belong to 3 main factors:
 Achievement: advancement (desire to gain power, progress rapidly &
accumulate in-game symbols of wealth/status), mechanics, and competition;
 Social Factor & Discovery: socializing, relationship, and teamwork;
 Immersion: role-playing, customization, and escapism (use of online
environment to avoid thinking about real-life problems)
 Demetrovics et al. (2011): Motives for Online Gaming Questionnaire
(MOGQ): 7 factors
 Social, escapism, coping, fantasy, skill development, recreation, competition

33. Etiology
Motivation (Cont.) Cyber Junkie by Kevin Roberts
 Achievement – increases self-esteem – good at something
 Escape – emotional escape, interpersonal difficulties
 Role Playing: “Their online persona often possesses attributes that they
wish they had in real life” (p. 14). “Driven to become someone else, to
exist in a different time, or to live lives filled with meaning.” Rely on the
game for social interaction.
 Control: often products of strict/helicopter parenting - cyber world as a
refuge where they have a sense of power and purpose
 Aggression: Teabagging – kneeling over an opponent’s on-screen
character after you kill them to show dominance & humiliate them –
Aggression and anger management issues precede online gaming – a way
to act out aggression – generally suffer from emotional avoidance
 Discovery: satisfaction comes from finding new twists to a game or
uncovering a glitch that no one has yet discovered. Often genius level IQ
and underachieving/bored in life/school/job – desire to feel fully alive &
game is a substitute

34. Etiology
Structural Characteristics in Online Gaming:
 High degree of realism (realistic sound, graphics, and setting), a rapid
absorption rate, character development, the ability to customize the game,
multiplayer features, winning and losing features, and ability to save the
game at regular intervals viewed as essential by gamers (Weed et al., 2004).
 King et al. (2010) Theoretical Model of 5 Structural Features:
 Social Features: how players communicate, creation of cooperative &
competitive community of players.
 Manipulation & Control Features: how players interact with and control in-game
properties using a physical control scheme
 Narrative & Identity Features: how players take on another identity in the
game – sense of self
 Reward & Punishment Features: how players are reinforced for skillful play
(winning) and punished for loosing – Problem gamers report significantly
higher enjoyment of management of in-game resources, earning points,
getting 100% in the game, and mastering the game – leveling up (earning
meta-game rewards) – fast loading times
 Presentation Features: Aesthetics – Realism of sound and look

35. Etiology
Structure Continued:
 Instant but Intermittent Reinforcement (people keep
responding in the absence of reinforcement hoping that
another reward is just around the corner).
 Magnitude of the Reinforcement (high points score for doing
something in-game – large rewards lead to fast responding and
greater resistance to extinction
Amount of Time
 Excessive game play is not a sufficient condition of addiction
 More time = higher risk

36. Prevention
 Family & friends should initiate direct conversations with problematic
players by showing true interest toward the game, the gamer, and
everything the gamer likes in the virtual environment.
 Facilitates communication and emotional attachment with the user.
 Parents choose games with children/adolescents
 Encourage children to play with other real life friends because it helps
develop personal relationships & communication & cooperation skills
learned online can be transferred more easily to real-life situations.
 Set gaming time together.
 Follow game manufacturer’s recommendations for monitor brightness,
distance from the monitor, taking short and frequent breaks, and not
playing if fatigued.
 Gamers need other recreational activities in addition to gaming.
 Positive effects: increased self-esteem; improved reflexes, reaction time,
memory, logical and strategic thinking, social and communication skills;
etc.
(Griffiths, 2003, 2008, 2010; Griffiths & Meredith, 2009)

37. Treatment
 Support forums:
 Parents & other family members who discuss the nature of the problem, share their
experiences, & support each other
 Self-help forums (Online Gamers Anonymous)
 Established & administered by professionals
 Specialty Addiction Clinics
 Improve pro-social skills through social activities & real-life activities that replace time spent
gaming.
 Psychotherapy to address co-morbid or underlying issues
 Management skills development to help players control their behavior
 Support Groups
 Couples and/or Family Therapy
 Medication:
 Buproprion SR – decrease problem behavior & depression (Han et al., 2011;
Ko et al., 2009; Kuss & Griffiths, 2012).
 China & South Korea – High Intensity Physical Activity in natural
surroundings

38. Treatment of Internet Addiction: 2000-2012