computer and video game addiction weinstein
TRANSCRIPT
The American Journal of Drug and Alcohol Abuse, 36:268–276, 2010Copyright © Informa Healthcare USA, Inc.ISSN: 0095-2990 print / 1097-9891 onlineDOI: 10.3109/00952990.2010.491879
Computer and Video Game Addiction—A Comparisonbetween Game Users and Non-Game Users
Aviv Malkiel Weinstein, Ph.D.Department of Medical Biophysics and Nuclear Medicine, Hadassah Hospital, Ein Kerem, Jerusalem,Israel, and Department of Nuclear Medicine, Sourasky Medical Center, Tel Aviv, Israel
Background: Computer game addiction is excessive or com-pulsive use of computer and video games that may interfere withdaily life. It is not clear whether video game playing meets di-agnostic criteria for Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV). Objectives: First objective isto review the literature on computer and video game addictionover the topics of diagnosis, phenomenology, epidemiology, andtreatment. Second objective is to describe a brain imaging studymeasuring dopamine release during computer game playing. Meth-ods: Article search of 15 published articles between 2000 and 2009in Medline and PubMed on computer and video game addiction.Nine abstinent “ecstasy” users and 8 control subjects were scannedat baseline and after performing on a motorbike riding computergame while imaging dopamine release in vivo with [123I] IBZM andsingle photon emission computed tomography (SPECT). Results:Psycho-physiological mechanisms underlying computer game ad-diction are mainly stress coping mechanisms, emotional reactions,sensitization, and reward. Computer game playing may lead tolong-term changes in the reward circuitry that resemble the effectsof substance dependence. The brain imaging study showed thathealthy control subjects had reduced dopamine D2 receptor occu-pancy of 10.5% in the caudate after playing a motorbike ridingcomputer game compared with baseline levels of binding consis-tent with increased release and binding to its receptors. Ex-chronic“ecstasy” users showed no change in levels of dopamine D2 recep-tor occupancy after playing this game. Conclusion: This evidencesupports the notion that psycho-stimulant users have decreasedsensitivity to natural reward. Significance: Computer game ad-dicts or gamblers may show reduced dopamine response to stimuliassociated with their addiction presumably due to sensitization.
Keywords addictionx, brain imaging, computer game playing,dopamine, reward, video game playing
INTRODUCTION
Problem DefinitionComputer or video game addiction is excessive or compulsive
use of computer and video games that interferes with daily life.
Address correspondence to Aviv M. Weinstein,, Ph.D., Departmentof Medical Biophysics and Nuclear Medicine, Hadassah Hospital, EinKerem, Jerusalem, Israel. E-mail: [email protected]
Users may play compulsively, isolating themselves from otherforms of social contact, and focus almost entirely on in-gameachievements rather than broader life events.
Griffiths (1) has operationally defined addictive behavior asany behavior that features what he believes are the six corecomponents of addiction (i.e., salience, mood modification, tol-erance, withdrawal symptoms, conflict, and relapse). He furtherargued that video game addiction fulfils the criterion of addic-tion by virtue of meeting these criteria. In his view, since manyvideo game users are excessive users and not addicts, videogame addiction may be a medium for satisfaction of arousaland reward (see section on mechanisms of reward). In additionto the neurochemical basis for addiction, there are accompa-nied behavioral markers of dependence in adolescents such asstealing, truancy, not doing homework, irritability if unable toplay, etc. Finally, single case studies have shown the video gameaddiction was used in order to compensate for deficiencies inone’s life in areas such as interpersonal relationships, physicalappearance, disability, coping, etc. Griffith (2) argued that al-though there are educational, social, and therapeutic benefits tovideo games play, taken in excess they could lead to addiction,playing 24 hours a day 7 days a week and in some cases to agambling problem. Finally, Griffiths (3) concluded that adverseeffects of video game addiction are relatively minor and tempo-rary resolving spontaneously with decreased frequency of playor to affect a small group of players.
There is no evidence for genetic factors influencing videoor computer game addiction. Most studies describe a behaviorthat is independent of other psychiatric disorders (e.g., not justsecondary to another condition such as attention deficit hyper-activity disorder [ADHD] or mania). There is a single studysuggesting co-morbidity with depression (4) and for comorbid-ity with ADHD (5) but there is no evidence for co-morbiditywith substance use disorder. On the spectrum of impulsivityand obsessive-compulsive behavior, there is some evidence forimpulsivity on the Barrat Impulsiveness scale (4), and exces-sive computer and video game playing supports the notion ofobsessive-compulsive behavior although formal assessment ofobsessive-compulsive behavior in these individuals has not been
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COMPUTER/VIDEO GAME ADDICTION 269
done. According to Griffiths (6) case studies of individuals whouse the Internet excessively may also provide better evidence ofwhether Internet addiction exists, because the data collected aremuch more detailed than data from surveys. Case studies canhighlight the role of context in distinguishing excessive gam-ing from addictive gaming and can demonstrate that excessivegaming does not necessarily mean that a person is addicted. Itis argued that online gaming addiction should be characterizedby the extent to which excessive gaming impacts negatively onother areas of the gamers’ lives rather than the amount of timespent playing. It is also suggested that an activity cannot bedescribed as an addiction if there are few (or no) negative con-sequences in the player’s life even if the gamer is playing 14hours a day (7).
Currently, it is not clear whether video game playing meetscriteria for a syndrome, e.g., Diagnostic and Statistical Man-ual of Mental Disorders, Fourth Edition (DSM-IV) or ICD-10 definition of a clinically significant pattern (consistent co-occurrence and time course) of behavioral and psychologicalsigns and symptoms that cause distress or impairment. In 2007,the American Psychiatric Association reviewed whether or notvideo game addiction should be added to the new DSM to bereleased in 2012. The conclusion was that there was not enoughevidence to warrant the inclusion of computer game addictionas a disorder.
DIAGNOSIS AND PREVALENCEThe diagnostic assessment of internet or computer game
dependency remains problematic. Different studies in differ-ent countries have used different scales to assess prevalenceof computer game addiction. A national Harris Poll survey of1,178 U.S. youths ages 8–18 years found that 8.5% of computergamers were pathological players according to standards es-tablished for pathological gambling (Harris Interactive, 2007).Among 323 German children ranging in age from 11 to 14years, 9.3% (N = 30) met criteria for dependency and patholog-ical gaming using DSM-IV and ICD-10 criteria (8). A secondstudy of 7069 computer-game players reported that 11.9% metthree of the diagnostic criteria for addiction (9). Finally, among221 computer game players, 6.3% have met ICD-10 criterion ofaddiction (10). Among 2327 Norwegian youth, 2.7% (4.2% ofthe boys, 1.1% of the girls) fulfilled the criteria for pathologicalplaying following a “Diagnostic Questionnaire for Internet Ad-diction of Young;” 9.8% (14.5% of the boys, 5% of the girls)were considered to be engaging in “at risk playing” (11). In theUnited Kingdom, a survey of 387 adolescents (12–16 years ofage) found that 20% met computer dependence using a scaleadapted from the DSM-III-R criteria for pathological gambling(12). A German National survey of 7000 gamers found that12% met three of the criterion for internet addiction (9). Re-sults of a German nationwide survey of 44,610 male and femaleninth-graders in 2007 and 2008 have shown that 3% of the maleand.3% of the female students were diagnosed as dependent on
video games. Video game dependency (VGD) was accompa-nied by increased levels of psychological and social stress in theform of lower school achievement, increased truancy, reducedsleep time, limited leisure activities, and increased thoughts ofcommitting suicide. In addition, it becomes evident that per-sonal risk factors were crucial for VGD (13). Finally, a surveyof 3,975 Turkish undergraduate students found that the mostpreferred type of game was violent games; while preference forstrategy and fantasy role-play games has increased with age,preference for other games has decreased (14).
This review searched articles published between 2000 and2009 in Medline and PubMed using the key word computer andvideo game addiction over the topics of diagnosis, phenomenol-ogy, epidemiology, and treatment.
WHY DO PEOPLE BECOME ADDICTED TO COMPUTERGAME PLAYING?
Although repetition of favorite activities has a moderate ef-fect upon computer game addiction, flow experience, the emo-tional state embracing perceptional distortion and enjoymentshows a strong impact on addiction in Taiwanese players (15).Responses of computer game players in Taiwan have qualita-tively reflected their psychological needs and motivations indaily life, but also to the interplay of real self and virtual self,compensatory, or extensive satisfaction for their needs and self-reflections (16). Social relationships and the specific time andflexibility characteristics (“easy-in, easy-out”) in multiplayerbrowser games have been suggested as the main cause for en-joyment in Germany (17). Game and internet addictions are alsoconnected with interpersonal relationship patterns (18). Compe-tition, in contrast, seems to be less important for browser gamersthan for users of other game types. There is only weak evidencefor the assumption that aggressive behavior is associated withexcessive gaming (9). Excessive computer game playing couldresult in deficient visual-spatial ability (19).
HEALTH HAZARDSThe medical profession, for over 20 years, has voiced a num-
ber of concerns about video game playing. Back in the early1980s, rheumatologists described cases of “Pac-man’s Elbow”and “Space Invaders’ Revenge” in which players have sufferedskin, joint, and muscle problems from repeated button hittingand joystick pushing on the game machines (20). Early researchby Loftus and Loftus indicated that two-thirds of (arcade) videogame players examined complained of blisters, calluses, soretendons, and numbness of fingers, hands, and elbows directly asa result of their playing. There have been a whole host of casestudies in the medical literature reporting some of the adverseeffects of playing video games (21, 22). These have includedauditory hallucinations (23), enuresis (24), encoprisis (25),wrist pain (26), neck pain (27), elbow pain (27), tenosynovitis-also called “nintendinitis” (28–31), hand-arm vibration syn-drome (32), repetitive strain injuries (33), and peripheral
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neuropathy (34). Recently, there is a study describing ten pa-tients who experienced epileptic seizures while playing thenewest genre of electronic games Massively Multiplayer OnlineRole-Playing Games (MMORPGs) (35). Patients were predom-inantly young, male adults, and most of the events were gener-alized tonic-clonic seizures, myoclonic seizures, and absences.The author suggested that while the prevalence of MMORPG-induced seizures remains unknown, there should be an aware-ness of this special form of reflex seizures in order to providean appropriate health warning to MMORPG players.
PREVENTION AND TREATMENTThere is preliminary evidence for success of an “initiated ab-
stinence” program in 12–15 year old pupils in Austria, Germany,and Italy (36). Some countries like the United States, Canada,China, Korea, and the Netherlands have opened treatment cen-ters for video game addiction. In 2009, ReSTART has set upa residential treatment center in Seattle, WA for pathologicalinternet use. There is little evidence for psychological or phar-macological treatment for video and computer game addiction.A study using methylphenidate in 62 Korean children diagnosedwith ADHD and internet video game addiction was reported (2).After 8 weeks of treatment, measures of internet use scores andinternet usage times were significantly reduced, and these mea-sures were positively correlated with measures of attention. Theauthors suggest that internet video game playing might be ameans of self-medication for children with ADHD. In addition,they cautiously suggest that Methylphenidate (MPH) might beevaluated as a potential treatment of Internet addiction. In sum-mary, there are very few clinical trials and no meta-analyses ontreatment for excessive computer game addiction.
MOTORBIKE-RIDING COMPUTER GAME FORQUANTIFYING DOPAMINE RELEASE: RATIONALE ANDAIMS OF THE STUDY
Chronic use of psycho-stimulants such as cocaine andmethamphetamine results in long-term effects to the dopaminereward system. For example, compared to healthy subjects,detoxified cocaine-dependent subjects exhibit reduced striatalD2 receptor availability (37–39) and decreased drug-induceddopamine release (39, 40). Currently, there is evidence that ab-stinent “ecstasy” users with a history of using sequential “ec-stasy” doses had no reductions in striatal dopamine transporter(DAT) binding (41). Since other stimulant drug abusing popu-lations show evidence of diminished dopamine responsivenesswe have decided to test whether this observation extends to“ecstasy” abusers in response to a non-drug reward/challenge.We hypothesized that chronic use of “ecstasy,” similar to otherpsycho-stimulants such as cocaine and methamphetamine mightresult in long-term changes to the dopaminergic reward system.The effects of “ecstasy”-induced alterations on the dopaminereward circuit (basal ganglia-thalamo-cortical circuit) are
potentially secondary to the neurotoxic effects of “ecstasy” on5-HT signaling.
We, therefore, decided to investigate dopamine release in thebrain during playing of a motorbike riding computer game. Be-cause some subjects were former chronic users of MDMA (“ec-stasy”), we were also able to evaluate whether past chronic useof “ecstasy” had any long-term effects on game performance,levels of dopamine receptor occupancy, or dopamine release inthe striatum during game playing.
Unfortunately, our study did not include computer game play-ers since our grant was limited to investigate drug addiction.
BEHAVIORALLY-INDUCED DOPAMINE-RELEASE IN THEBRAIN’S REWARD SYSTEM
The quantification of dopamine release in the human brainis now possible due to brain imaging techniques that mea-sure dopamine D2 receptor availability in human subjects usingdopamine competition with either [123I] IBZM (a D2 receptorantagonist radiotracer) in single photon emission computed to-mography (SPECT) (42) or [11C] raclopride in positron emissiontomography (PET). Either [123I] IBZM or [11C] raclopride bind-ing is sensitive to endogenous DA concentration; this procedurecan also be used to measure relative changes in DA concentra-tion secondary to pharmacological or behavioral interventions.Playing a computer tank riding game can release dopamine invivo in the human brain comparable to the dopamine released asa result of pharmacological challenge with amphetamines (43).Behavioral paradigms, such as playing a video game (43), mon-etary reward tasks (44), and non-hedonic food motivation (45)also release dopamine in brain meso-limbic reward centers.
PROCEDURE
SubjectsNine former “ecstasy” users (mean age 25 years (SD = 3.5);
8 males, 1 female) verified abstinent up to 1.5 years (mean = 5months, range 1–18 months) and eight control subjects (meanage 35.75 years(SD = 6.5); 7 males, 1 female). Former “ecstasy”users had less education (12 (.9) years) than control subjects(13.75 (1.6) years). Ex-“ecstasy” users used on average 220“ecstasy” tablets (range 30–600) in their life, and total numberof tablets in their lifetime was 428.5 (range 30–1500). Theyused “ecstasy” on average for 12 years and 3 months (SD =.92). They reported on average 7 times of using “ecstasy” in amonth during their last year of use before treatment (SD = 3.3)and time since last use was on average 5 months (range 1–18months). A list of all substances used by ex-”ecstasy” users ispresented in Table 1.
The former “ecstasy”-users, recruited from drug treatmentcenters. Control subjects were recruited through advertisementin treatment centers and the hospital. They reported no currentor recent use of “ecstasy” or marijuana. Five of the ex-“ecstasy”patients were treated with antidepressant medication (Sertraline,
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TABLE 1.List of drugs and alcohol use among ex-“ecstasy” users.
Drug Mean SD Range
Cigarettes (per day) 17 6.75 5–30Alcohol units per week 2.95 2.54 0–9Amphetamines: lifetime number of tablets 2.8 4 0–10Cocaine: lifetime number of times used 25 3.6 0–50L.S.D.: lifetime number of tablets 75 80 0–500Marijuana: number of cigarettes per day 11.8 11 1–30Inhalants 20.8 62 0–200Opiates: number of times used 2.4 3 0–8PCP 0 0 0Magic mushrooms: lifetime number of use 9.4 16 0–50
Venlafaxine, Fluoxetine, and Escitalopram) and six of them weretreated with relaxants (Clonazepam and Diazepam). They werescanned six months after treatment when they were not takingmedication.
Behavioral Computerized GameCommercially available motorbike-riding computerized
video game by “motogp” ultimate racing technology(www.THQ.Co.UK) using a joystick. The time it took to com-plete each track on the racing field was recorded on the computer.
ProcedureEligible subjects gave written informed consent and were
admitted to the hospital at 10 a.m. Starting at 10:30 a.m., theyreceived a bolus injection of 5–6 mCi of [123I] IBZM, followedby constant infusion of 5–6 mCi of [123I] IBZM (1.7–2 mCi/hrfor three hours while resting on a hospital bed. Due to problemswith radiation safety in our brain imaging facility, we were notable to continue with constant infusion beyond 3 hours postin-jection. We are not aware of any literature precedents for usingan altered [123I] IBZM infusion protocol like ours. In healthyvolunteers who were injected with bolus [123I] IBZM withoutconstant infusion, pseudo-equilibrium was achieved at 90 minpost-bolus injection of [123I] IBZM, and it was maintained un-til the end of the SPECT session at 3 hours postinjection (46).In our study, due to the termination of constant infusion after3 hours, there is a possibility of a higher rate of washout ofthe tracer from the plasma, which might have affected the re-sults. However, there is evidence that postinfusion equilibriumis maintained, and the washout rate of the tracer from the plasmamay have been minimal, and it may have not affected our results(47). After a baseline SPECT scan, they returned to their roomand played the motorbike-riding computer game for 40 minutes.After game playing, they had a second SPECT scan, followedafter 15 minutes of rest by a third SPECT scan.
Image AnalysisA measure of dopamine receptor occupancy obtained without
plasma measurements is the specific to nonspecific equilibriumpartition coefficient, V3”, which is a measure of dopamine D2
receptor availability and can be calculated from: V3” = (S –O)/O, where S and O are activity concentrations in the striatumand occipital cortex, respectively (42). This calculation has beenshown to give accurate values of V3” under equilibrium condi-tions. Its accuracy is not known under the conditions of thisstudy, where infusion was stopped before the first scan. All im-ages were registered and normalized to an IBZM template (48)using the preprocessing tools of Statistical Parametric Mapping(SPM). The image comparisons were then performed using theMarsBaR tool within SPM.
RESULTSFirst, at baseline, there was no significant difference in D2
receptor occupancy, i.e., partition coefficient (V3”), in absti-nent “ecstasy” users compared with control subjects (.71 and.86, respectively). Second, during performance of the videogame, there was a 10.5% reduction, compared to baseline, inthe partition coefficient (V3”) in control subjects in the cau-date, consistent with increased dopamine release and binding tothe D2 receptors. In control subjects, there were lower rates ofbinding potential after motorbike riding game compared withbaseline (scan 1 versus scan 2) in the right caudate t (1,7) = 2.56;p < .05. There was no reduction in the abstinent “ecstasy” usersafter performance of the video game in all parts of the striatum.Third, D2 receptor levels have not returned to baseline after thethird scan in control subjects consistently with results reportedby a previous study (22). Fourth, there was significant correla-tion between performance measures (reaction time on the videogame) of all subjects and baseline measures of binding poten-tials (scan 1) in the right caudate (r = .70; p < .001), left caudate(r = .67; p < .01), right putamen (r = .68; p < .01), and leftputamen (r = .72; p < .001). Finally, there was no difference
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Right caudate
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Figure 1. Measures of partition coefficient (V3”) in control subjects and ex-“ecstasy” patients in the caudate and putamen divided by laterality in all scans (1, 2,and 3).
in performance (reaction-time) between the two groups on themotorbike video game.
Figure 1 shows measures of partition coefficient (V3”) incontrol subjects and abstinent “ecstasy” patients in the caudateand putamen divided by laterality in all scans (1, 2, and 3).
Table 2 shows average V3” measures and standard deviationsin the caudate putamen in control subjects and ex-“ecstasy”users in all scans.
DISCUSSIONControl subjects had significant 10.5% reduction in bind-
ing potential measure in the caudate after performance com-pared with their baseline measure, consistent with the resultsreported by a previous study (43) that showed 13% reduction ofbinding potential in the ventral striatum after video game perfor-mance. This is comparable to measures of dopamine release pro-duced by amphetamine (49) or methylphenidate (50, 51). This
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COMPUTER/VIDEO GAME ADDICTION 273
TABLE 2.Average V3” measures in the caudate putamen in control subjects and ex-“ecstasy” users in all scans.
Left caudate Scan 1 Scan 2 Scan 3 Right caudate Scan 1 Scan 2 Scan 3
Controlsubjectsmean
.64 .53 .44 mean .75 .65 .56
SD .29 .26 .17 SD .36 .29 .23Ex-“ecstasy”
subjectsmean
.53 .50 .48 mean .61 .59 .54
SD .24 .13 .19 SD .16 .22 .20Left putamen Scan 1 Scan 2 Scan 3 Right putamen Scan 1 Scan 2 Scan 3Control
subjectsmean
.95 .88 .71 mean 1.10 1.00 .84
SD .40 .36 .30 SD .44 .36 .28Ex-“ecstasy”
subjectsmean
.80 .79 .78 mean .91 .92 .84
SD .26 .17 .29 SD .25 .20 .26
finding implies that video game playing is capable of significantdopamine release that is comparable to the effects of psycho-stimulant drugs on the brain. It is plausible that individuals whoare addicted to video-game playing derive much pleasure fromplaying these games due to extensive dopamine release. In con-trast, former “ecstasy” users showed little change in D2 bindingpotential in the caudate/putamen in response to video game per-formance. This finding implies low brain dopamine responseto natural reward presumably due to previous sensitization tostimulant drugs that release a great amount of dopamine in theirbrain over time.
The finding of correlation between reaction time measure-ments and the baseline scan V3” for both cohorts merits furtherconsideration. Our findings suggest that there was no effect ofgame playing on changes in V3” in ex-“ecstasy” users, eventhough their reaction times like comparison subject reactiontimes were correlated with baseline scan V3”. These findingstaken altogether may imply at least a partial dissociation be-tween the reward and motor system consequences of “ecstasy”use.
There are several limitations to our study. First, our ex-“ecstasy” patients have used other drugs than “ecstasy,” whichmay have affected measures of binding potential especiallyin the case of marijuana. Secondly, most ex-“ecstasy” usershave been treated with Selective Serotonin Reuptake Inhibitors(SSRIs) or relaxant medication (benzodiazepines), and thesemedications are known to interact with the dopamine system,although they were not medicated during scanning. Thirdly,the ex-“ecstasy” users were younger than control subjects, butthat would only mean that their dopamine receptor occupancyshould be higher than control subjects (dopamine transporter
availability measures decline about 6.6% every 10 years) (52).Fourthly, since there was only one female subject in each group,and they were both pre-menopausal, this may have affectedthe results, but there is no evidence for any menstrual-cycle-dependent variation in D2 receptor density detectable with singlePET [11C] Raclopride (53). Fifthly, the second and third scanswere not performed under ideal conditions of equilibrium, andthis may have affected the results due to higher rates of washout.Finally, this is a small sample even for a brain imaging studydue to strict selection criteria.
OVERALL DISCUSSIONComputer or video game addiction, which is excessive or
compulsive use of computer and video games with resultingadverse consequences, is not clinically defined as a part of be-havioral addictions in DSM-IV. There is no official diagnosisor definition of the disorder in any official diagnostic system.There were several studies investigating the prevalence of thisdisorder; however, they used different scales adapted from theDSM-III-R criteria for pathological gambling or other addic-tions to create diagnostic questionnaires. People like computergame playing and become addicted to it due to repetition offavorable activities or emotional experiences, experiences offulfillment, social relationship, and flexibility, while the aspectsof competition and aggression have been discounted.
Three different mechanisms have been suggested as drivingexcessive computer gaming, although there have been very fewpsycho-physiological investigations of these underlying mech-anisms. First, it has been suggested that computer games areinadequate means of coping with frustration, stress, and fears
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(5). The excessive usage of computer and video games is seen asa rewarding behavior which can, due to learning mechanisms,become a prominent and inadequate strategy for 11 to 14 yearold children to cope with negative emotions like frustration, un-easiness, and fears. Like substance abuse or addiction, excessivecomputer and video game players use their excessive rewardingbehavior specifically as an inadequate stress coping strategy. It isalso known that computer game addiction decreased the qualityof interpersonal relationships and the amount of social anxietyincreased as the amount of time spent playing online gamesincreased (54). Secondly, and consistent with the stress-copingexplanation, it has been suggested that in-game reinforcementand skill significantly influence a number of affective measures,most notably excitement, arousal, and frustration (55). Thirdly,excessive computer game playing may be maintained througheffects on reward and sensitization (56), similar to the long-term changes in the brain reward circuitry thought to maintainsubstance dependence. Electroencephalographic recordings incomputer game players have shown increased emotional pro-cessing of computer-related cues in parietal brain regions inpathologically excessive players compared with casual play-ers. Furthermore, when participants with online game addictionwere presented with gaming pictures and mosaic control pic-tures while undergoing functional magnetic resonance imaging(fMRI), they have shown activation of the brain’s craving areasincluding the right orbito-frontal cortex, right nucleus accum-bens, bilateral anterior cingulate and medial frontal cortex, rightdorso-lateral prefrontal cortex, and right caudate nucleus (57).Thus, the results suggest that the gaming urge/craving in onlinegaming addiction and craving in substance dependence mightshare the same neurobiological mechanism.
Finally, in an functional Magnetic Resonance Imaging(fMRI) study contrasting a space-infringement game with acontrol task, males showed greater activation and functionalconnectivity compared to females in the meso-cortico-limbicsystem (58). These findings may be attributable to higher moti-vational states in males, as well as gender differences in rewardprediction, learning reward values, and cognitive state duringcomputer video game playing. These gender differences mayhelp explain why males are more attracted to, and more likelyto become “hooked” on video games.
The reward and sensitization explanation is consistent withgrowing evidence that computer game playing addiction, sim-ilar to other behavioral addictions like compulsive gambling,overeating, sex, and shopping, leads to long-term changes inthe reward circuitry that resemble the effects of substancedependence. Advanced brain imaging techniques using thedopamine-competition paradigm can quantify dopamine re-lease as result of computer game playing. So far, playing com-puter games in healthy volunteers has shown dopamine releasein the striatum to a similar extent as pharmacological chal-lenge, whereas we have shown that former chronic users of“ecstasy” released very little dopamine after performance of acomputer game. We speculate that, similar to psycho-stimulant
abusers, individuals diagnosed with behavioral addictions suchas gambling and computer game addiction would show reduceddopamine release after performance of video games or gam-bling presumably due to sensitization. Future research couldinvestigate these individuals and could give a psycho-biologicalexplanation to this emerging object of scientific research.
ACKNOWLEDGMENTWe would like to thank Shaul Schreiber, Isachar Herman,
Omri Frisch, and Eitan Ekstein for providing access to theirpatients. We would like to thank the staff at the Departments ofNuclear Medicine at Sourasky Medical Center and HadassahHospital, particularly Einat Even-Sapir, Mazal Greemland,Hedva Lerman, Yodphat Krausz, and Boris Bakunin. We wouldalso like to thank David Nutt and Paul Grasby for early dis-cussions and initiation of the study, John Seibyl for adviceconcerning imaging, Nanette Freedman and Elisheva Deutz forimage analysis, and Marko Leyton and Mike Morgan for usefulcomments on the manuscript. Preliminary results of this studywere presented at the College of Problems of Drug Dependenceannual meeting, Orlando, FL, June 2005 and the European Col-lege of Neuropsychopharmacology annual meeting in Vienna,Austria, October 2007.
Declaration of InterestThe reported research was funded by a grant from the “Adams
Trust” in Tel Aviv University and a grant from the Israeli Anti-Drug Authority.
Dr. Weinstein is now supported by the Israeli Anti-DrugAuthority and the National Institute for Psychobiology in Israel.The authors report no conflict of interest. The authors alone areresponsible for the content and writing of this paper.
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