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Epidemiology of Game Addiction

Edited by
Dr. Selim Gunuc
Epidemiology of Game Addiction

Chapter: Prevention and Treatments of Games Addiction: Non-Pharmacological

Approaches for Game Addiction
Edited by: Selim Gunuc

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First published March, 2014

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Prevention and Treatments
of Games Addiction: Non-
Pharmacological Approaches for
Game Addiction
Ayten Doğan*
Merkez Efendi State Hospital Moris Sinasi Children’s Clinic, Manisa,
*Corresponding author: Ayten Doğan, Merkez Efendi State Hospital
Moris Sinasi Children’s Clinic, Akmescit District, Izmir Street, No: 335
Manisa, Turkey, Tel: +90 536 731 38 16; E-mail: aytend04@hacettepe.

Computer games have become the activities of developing the critical thinking and producing active learning field and have become
one of the most popular leisure time activities for adolescents and young adults. Playing games can be beneficial in coping the problem
in the short run, but in the long run it can show addiction symptoms and person can be game addicted. Game addiction can be treated
through non-pharmacological approaches. Cognitive behavioral therapy, couple or family therapy, motivational interview, 12 steps
program and alternative treatments are approaches that used in the treatment of internet and game addiction.

Playing games is among the basic characteristic of humans [1]. Game is a job for the child, and is an activity of entertainment
and recreation for the adult. Game is system defined by rules in which the players have an artificial conflict and which results in a
measurable winning state [2]. According to Prensky [3], what makes game a game is the rule, purpose, feedback, difficulty, race,
challenge, opposition, interaction, presentation and the story. Computer games, on the other hand, are generally defined as the ones
played through personal computers [4,5]. The term digital games are used other than computer games and video games in literature.
The term game addiction in the literature is also used as pathological gaming, video game addiction, video game dependence, and
problematic game playing [6,7].
Playing games makes the brain gain the reward of feeling good because of the secretion of dopamine -a neurochemical which
enables one to feel good and dopamine, a neurochemical, rewarding enough to make addiction. Brain wants more because it likes this
and therefore individual always plays more games by trying to catch the excitement of the next game. The individual will increase the
time and frequency of the game at every turn, in which case the game will cause addiction. Computer games give a one-time experience,
which can increase power of effect in each play because games can be experienced many times. Playing games may cause addiction
when played excessively although it provides psychological, social, and educational benefit for the individual.
Game addiction is thought to be more innocent than drug addiction. An individual may not believe that gaming can cause addiction,
because there is not any used substance according to him/her; he /she is just gaming. Gaming for once may not have any harm but if the
individual cannot help gaming he/she will of course face its harms. No individual starts gaming saying “I will be a game addict; I want
to be a game addict” but after starting to game he may be a “game addict” if he /she loses control.
Prevention is the best solution in the game addiction. If prevention is not possible, person should take support from professionals.
The professionals generally use non-pharmacological approaches. These are approaches cognitive behavioral therapy, couple or family
therapy, motivational interview, 12 steps program and other alternative treatments.

The 20th century is describes as the age of cinema, while the 21st century is defiend as the age of computer games [8]. The fact that
the industry of computer games has a more market share than the industry of cinema clearly shows its place among the media products
for entertainment purposes [9,10].
Technological developments have caused changes in our lives in many fields. Actually, technological developments have changed
the individuals’ habits of playing games. In recent years, computer games have become the activities of developing the critical thinking
and producing active learning field and have become one of the most popular leisure time activities for adolescents and young adults
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Individuals of all ages can be easily carried away cyber/virtual fantasy world where they can readily escape from the problems in
their real lives [12]. Gamers’ playing games enable them to forget their problems for a moment [13]. Playing games can be beneficial
in coping the problem in the short run, but in the long run it can worsen the problem. For a game addict, playing games can trigger
the addiction for getting rid of the thought temporarily in such cases as personal problems, job loss, death or divorce. Kirriemuir [14]
presented imaginary environments, challenge, and curiosity as the reasons for individuals’ playing games; [15] on the other hand,
presented spending time, relief, getting rid of stress, and having nothing to do as the reasons. According to DSM 5, “boredom” has been
stated as the reason for gaming [16]. 003
Prevalence of Game Addiction
Young brains are those which suffer the effects of digital technology at most and which are the most sensitive to these effects at the
same time [17]. All individuals who do and do not make normal progress can be sensitive to game addiction but its prevalence in male
adolescents is more common. Separately, computer games are the most popular way of entertainment among 12-25 year old males [18].
The prevalence of internet gaming disorder is unclear due to the varying questionnaires, criteria and thresholds employed. The point
prevalence in adolescents (ages 15-19 years) was 8.4% for males and 4.5% for females [16].

According to DSM 5, internet gaming disorder is excessive and long play that results in a cluster of cognitive and behavioral symptoms,
including progressive loss of control over gaming, tolerance and withdrawal symptoms. Addict person devote 8-10 hours or more per
day and at least 30 hours per week to game activities. Moreover, internet gaming disorder is persistent and recurrent participation in
computer gaming for many hours [16].
The role of norepinephrine and dopamine neurotransmitters is accepted in drug addiction [19,20], while the role of dopamine and
serotonin is accepted in behavioral addiction [21]. Mitchell [22] clearly indicated the increase of dopamine release in ventrium striatum
as a function of video games. The existence of dopaminergic nerve conduction in playing games can be of use in explaining the basic
addiction process of playing video games.
The gamers who are addicted to games clearly show addiction symptoms. In some of the studies made, computer games have benefits
as instruments that have psychomotor, physiological, cognitive, social and affective influences; that improves and motivates the mind;
that entertains, while in many studies it can be possible to mention their negative influences. The addiction of computer games have been
determined to lead to aggressive behavior and violence [23]; to cause concern and anxiety, to have physical, psychological, and social
negative influences [24]; to give rise to negative results such as epileptic attack, blood circulation and heart disorders, social isolation,
and retardation in social skills and negligence in school studies [25]. Also playing video games have negative rare effects such as auditory
hallucinations [26], enuresis [27], encoprisis [28], wrist pain [29], neck pain, elbow pain [30], tenosynovitis also called “nintendinitis”
[31,32] hand-arm vibration syndrome [33], repetitive strain injuries [34] and peripheral neuropathy [35].
Other symptoms of addiction are giving priority to games, telling lies or hiding to have played games, opposing the time limits, losing
the interest in other activities, social withdrawal from family and friends, psychological withdrawal from the game when forced away
from it, using the game as an escape, and continuing the game despite its results [36].
The psychological symptoms of computer addiction are having a sense of well-being or euphoria while at the computer, inability to
stop the activity, craving more and more time at the computer, neglect of family and friends, feeling empty, depressed, irritable when
not at the computer, lying to employers and family about activities, problems with school or job. Physical symptoms are carpal-tunnel
syndrome, dry eyes, migraine headaches, back aches, eating irregularities such as skipping meals, failure to attend personal hygiene, sleep
disturbance, and change in sleep pattern [37]. As seen in the symptoms, the symptoms of “Computer Addiction” coincide with those of
“Video Game Addiction” [38].
Other diagnoses related to game addiction are major depressive disorder and obsessive compulsive disorder [16], bipolar disorders,
substance-induced mood disorder, social phobia, generalized anxiety disorder, anxiety disorder, attention deficit hyperactivity disorder,
and substance use disorder. Also, it is reported that the children with attention deficit hyperactivity disorder can hardly give up playing
on their own, and when their families tell them to give up, 66% of the attention deficit hyperactivity disorder children group can give up
and once they have given up they show reactions such as crying, and anger [39].

Treatments of Games Addiction

The number of empiric studies about game addiction is not so high, so the detailed information about applied operations is limited
[38]. In the studies made, addiction can be treated through psychotherapy and psychopharmacological operations. Cognitive behavioral
therapy used for drug addiction and pathological addiction for gambling, couple or family therapy (short strategical family therapy)
[13], motivational interview, 12 steps program and alternative treatments are used in the treatment of internet and game addiction [38].
In the treatment of game addiction, it must meticulously be investigated why the individual is addicted. “Does the individual play
because of boredom, or because he/she doesn’t have any other thing to do, or in order to get rid of depression, anxiety, or other personal-
psychological problems?” One of the most important stages in the history of individual’s coming to the therapy is why the individual is
playing games. After the individual’s story of coming to the treatment is taken, personal treatment program should be produced, because
there is not “illness” but “patient” and the purpose is to treat the “patient”.

Short strategical family therapy

Short strategical family therapy is a short therapy method which is used for treating the adolescent drug use observed with other
behavioral disorders, which interferes in a problem oriented way, which changes the behavior of family members. Among these behavioral
disorders are conduct disorder, skipping from school or house, oppositional defiant disorder, being with antisocial peers, behavior prone
to violence, risky sexual behavior, eating disorder. Also, this therapy model can be used for online gaming addiction among adolescents
[13]. Therapy lasts for 8-28 sessions. The methods of intervention are;
• Joining is the process of connecting to each member of the family. And Joining has three special types. These are tracking,
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accommodation and mimesis.

• Diagnosis [13] or activating family transaction patterns.
• Restructuring [13] or restructuring the family transaction patterns [40-42].
Keepers [43] analyzed a 12 year old video game addict boy. He plays games 4-5 hours a day, he goes to game arcades to play and spend
some 30-50 dollars a day there, he steals when he has no money, he skips school and makes friend with other boys playing video games. 004
In the treatment it was determined that the boy had problems with his father, the father physically abused the boy as was the mother
and he pathologically played video games to escape from these problems, and he was enabled to get rid of the pathology through family
therapy [38].
“An 18 months old baby-girl was brought to child development department for developmental assessment by her grandmother.
Grandmother brought her grandchild because of the attitudes of her son-in-law. He plays the game Metin2 as soon as he comes home
from work without changing his clothes; his wife brings his meal to him near the computer (he prefers the meals that can be eaten by
hand instead of spoon or fork); he sleeps in the computer room; he sometimes go to work without changing he previous clothes; he plays
games at weekends more than 10 hours. When he gets off the computer, he makes his son sit on the computer and wants him to continue
the game. Grandmother stated that her son-in-law takes his 18 month old child on his lap and plays game for some hours, when mother
or grandmother wants to take the baby, he continues to play with the baby on his lap saying “she is my child, can’t I enjoy her?” The game
addict individual affects not only himself but also family members as can be seen in the case and the youngest member was bought to the
consultant and solution was tried. The development of 18 months old baby was normal but it was advised that family take family therapy
and father take individual therapy and they were directed to psychiatrist.

Cognitive behavioral therapy

Cognitive behavioral therapy moves from the assumption that “the thoughts that the individual say to himself considerably affect
how the individual feels and how he will behave in a situation. The therapist who implements the cognitive behavioral therapy has two
purposes; 1) to learn the individual’s negative feelings and thoughts about himself in a situation and 2) to turn the individual from
negative thoughts and to replace more positive thoughts in the negative ones [44]. Therapy consists of sessions of 3 months approximately
12 weeks. Cognitive Behavioral therapy is one of the treatment steps of game addiction.

Motivational interview
Motivational interview is a therapy approach which is used in addiction, which is effective, short-termed, permanent, and consulter-
centered. It is beneficial in persons reluctant to change and it enables them to understand their problems and to move for a change.
Motivational interview technique is a way of communication between therapist and consulter and aims to solve the ambivalence, form
the motivation and change the behavior [45]. Main strategies of motivational interview:
• Trying to understand the individual through reflected listening
• Stating acceptance and approval by supporting the consulter
• Using the statements motivating the consulter’s intend and wish and the consulter about the skill to change
• Determining the consulter’s degree of readiness to change and detecting the presence of resistance. If the consulter does not care for
the interview, or if he interrupts the interview, denies it and starts to argue, these are the indicators of resistance.
• Letting the consulter choose his own way.
There are some similarities and differences between motivational interview and cognitive behavioral therapy. Cognitive behavioral
therapy contains what will change and how it will change and that the change must be continual, while motivational interview focuses
of what will change and why it will change and on the importance of the change. Change talk (to empower, define, discover, summarize
and decide the goal) in motivational interview refers to negative automatic thoughts (to arrange, define, evaluate, the goal and to produce
choices) in cognitive behavioral therapy. “Assets” in motivational interview are the schemes [46].
Online Gamers Anonymous organization was established so that the people who play excessively or on the degree of addiction will
help themselves. The basis of treatment philosophy of the twelve steps programme depends mainly on Minnesota model but it still seems
to be informal therapeutic technique. The twelve steps programme allows individuals to give up gaming on their own [6].

The twelve steps programme

• We admitted we were powerless over gaming, and that our lives have become unmanageable.
• Came to believe that a Power greater than ourselves could restore us to sanity.
• Made a decision to turn our will and our lives over to the care of God as we understood God.
• Made a searching and fearless moral inventory of ourselves.
• Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
• Were entirely ready to have God remove all these defects of character.
• Humbly asked God to remove our shortcomings.
• Made a list of all persons we had harmed, and became willing to make amends to them all.
• Made direct amends to such people wherever possible, except when to do so would injure them or others.
• Continued to take personal inventory and when we were wrong promptly admitted it.
• Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for
knowledge of Gods will for us and the power to carry that out.
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• Having had a spiritual awakening as the result of these steps, we carried this message to others who game excessively and practiced
these principles in all our affairs [47].
In a study performed with 12 volunteer patients who were addicted to internet and were having difficulties controlling their internet
use behavior, the interventions focused on controlling and reducing the internet use. An intervention programme was prepared
including the activities such as expanding social relations, regaining the order with a proper diary, spending leisure time constructively,
reframing religion. Therapists have determined that there is a certain degree of development in the patients to whom these treatments are 005
implemented, and the patients are satisfied with the treatment and the recovery in their behavior [48].
Volunteer patients applied with the complaints of online games, erotic sites, forum usage, surfing, blogging, social network usage, and
mail usage. Also, most of the patients have some psychological problems depending on internet use [48].
First of all, patients established an initiative point for a change through the medium of following internet usage by using the internet
during a day and this enabled the patients to develop a realistic thought regarding how much time or money they spend on the internet.
Secondly, the precautions that the patients have taken to control themselves can be useful for the coming treatment. Thirdly, after
reducing the usage, focusing of alternative methods and enlarging social environment is necessary for recreation. Finally, the techniques
to prevent internet behavior to become reverse have been quite beneficial for example determining what to do in free time. It has been
reported that the applied treatment is particularly effective in the treatment of internet addiction in its various ways [48].
During the treatment, therapists encouraged the patients not to have internet completely one day in a week, but this situation didn’t
fit many patient in the early stages of treatment. Also, another factor that aggravates the job is the fact that internet is necessary in daily
life. Therefore, it is not a way of solution to avoid fully or not to use internet any time. In pharmacological treatment, selective serotonin
reuptake inhibitors and atypical antipsychotic drugs have therapeutic effect alone and together [48].
Techniques and methods used in the treatment of game addiction can be applied alone or as a whole. The purpose in the treatment
of game addiction is not to play games at no time but teaching “to control” gaming and enabling them not to gravitate to the game
for escaping from problems and to find alternative solution ways [48]. After the treatment, reminding interviews can be arranged and
permanency of the treatment can be provided and the motivation of the individual who has got over the addiction can be enabled not
to decline. The most important step that will enable the individual not to come to the degree of being treated is to prevent him/her from
becoming a game addict. At this point, important tasks fall to those who provide services of protection and prevention. Those who
provide these services not just prevent the individual from becoming “a game addict” but protect the budget of their countries allocated
for treatment spending, prevent the crimes caused by game addiction, help the specialists who provide treatment to assign their time for
other treatments.

Prevention of Games Addiction

Prevention is the best solution in the game addiction [49]. Several studies can be carried out to prevent. These are:
1. Informing
2. Education
3. Creating alternative activities
4. Social studies
Using internet (computer, mobile phones etc.) is a necessity for the individual in carrying out many jobs and a life cannot be thought
without internet. Through internet an individual can also play games. In parallel, the prohibition of internet in order to prevent the game
addiction may prevent the individual from doing his/her other jobs and from making use of the positive aspects of the internet. Gaming
can be controlled with limitations, rules and external warnings in order to prevent game addiction. After these limitations are taken,
the rest of the time of the individual should be filled with various occasions and activities. For example, individual can make activities
including physical movements everyday such as walking, jogging, swimming, meditation, aerobic, housework etc. Also, directing the
individual to the activities in which social relations are experienced may be helpful in the prevention of game addiction. The participation
of children and adolescents in more educational and sportive pursuits may prevent them from gaming [50]. Determination of the rules
accepted by all family members about gaming is thought to be effective in preventing addiction. The rules prepared by the family members
is put in writing and is posted; external warnings such as usage timetables, reminding cards and clock are used and thus gaming can be
prevented from being an addiction.
The steps below are suggested to prevent game addiction to parents [51] and person:
• Parents should accompany and monitor the children’s game.
• Parents should spend some hours with children and to select beneficial games for them.
• Parents should help children to develop self-control in selecting playing hours and games.
• Parents should provide more attractive leisure options.
• Parents should discuss content and amount of time for playing with games with their children.
• Parents should check the content of the gaming activity [52].
• People should participate regularly in sports activities.
• Computer should take place of common areas of house.
• People should rest breaks: 20/20/20 rule - after every 20 minutes of computer viewing, one should look into the distance 20 feet away
for 20 seconds to allow the eyes to refocus.
• Controlled and limited internet use creates in the prevention of game addiction [49].
In online gaming, there is no end to the game [52]. “Male adolescent at the age of 17 came to the department of child development
with the complaint of declining interest in classes. The friends of the adolescent play online group games; he is isolated by his friends
because he can’t play as much as his friends. The adolescent, on the other hand, can play games with the limited permission of his parents
for using internet in order to be accepted by his friends. The adolescent plays games in private before going to school in the mornings, at
night by waking up, and when his family isn’t at home. The adolescent expresses himself as “I don’t play so much, I can give up if I want
to do so”. As the reason for his gaming at night, he explains “ my friends call (when their internet connection goes off or their parents pull
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out the plug of the computer) and say I’ll give you my password and you sign in the game, play on my behalf, they are now battling, I don’t
want to lose land and etc.”. And he states that he plays because his friends want him to do so. Because online games continue 24 hours 7
days and the game doesn’t end, the mind of the individual is continuously busy with the game. The fact that these games are continuing
can cause the individual to become an addict, instead of these games, the games which can be stopped by clicking on “pause” may not
occupy the mind of the individual and consequently game addiction will have been prevented.
Countries such as Holland and South Korea have seen the opening of dedicated treatment clinics for gaming addiction [38]. If person
is a game addict, person should take support from professionals. 006
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