Findings and future steps

The five published papers that we have presented here contribute to a better understanding of the features of GD and IGD within the addictive spectrum in psychopathology, as well as assessment and treatment that could help enhance consideration of these disorders and improve support for affected individuals. These two goals are the common thread of our

25 research and clinical and public health activities. We present some ongoing projects in line with this below after we summarize our principal findings.

2.1 Gambling disorder (GD)

The review papers on GD summarize and discuss recent findings on brain correlates of cognitive biases, control inhibition and motivational processes (Achab, Karila, et al., 2014)), and pharmacological trials in clinical samples (Achab & Khazaal, 2011). These reviews provide researchers and clinicians with recent elucidations about the neurocognitive and emotional mechanisms of GD, as well as the effective and promising drugs that could be helpful for future research and for clinical purposes. Indeed, understanding the development and evolution of GD from a neural, environmental, behavioral, and psychological perspective could have therapeutic applications in the treatment of patients with this disorder, in consideration of the interconnection between biology, psyche, and behavior. Moreover, the interactive relationship between clinical practice and research is vital to bring light to the phenomenological understanding of GD.

Beyond phenomenological understanding and the availability of relevant treatment options, an important area of concern is the weak proportion of treatment seekers within problem gamblers despite the physical, mental, and social harms, as we previously discussed.

We explored the hypothesis that primary care professionals could be unaware of the reality of GD, the related health risks and screening tools, or the specialized care system to which potential screened patients can be referred.

GD has consensual, simple-to-use screening tools. Nevertheless, the study that we conducted (Achab, Chatton, et al., 2014) primary care professionals’ self-perception about their knowledge of GD and their reported fluency in screening for it among their patients highlighted the need for training and information to enhance screening practices. These

26 pivotal professionals in the care system reported being interested in such information and training. We ended the survey with a rapid (two-item) screening tool as an example that they could easily integrate in their care setting, which could be a good starting point to reduce disordered gamblers’ delays in seeking treatment, which could avoid the detrimental psychological, financial, and social consequences of GD.

The social cost of GD in Switzerland, for example, has been estimated to be between 551 and 648 million CHF (Jeanrenaud, Gay, Kohler, Besson, & Simon, 2012). A public health framework would have two main goals: (a) harm reduction through prevention strategies and regulation policies and (b) care through specifically designed help, counseling, and treatment facilities. To these ends, key factors to be considered regarding BAs from a public health perspective are the interconnected compositional and contextual determinants (Marshall, 2009). The compositional determinants consist of characteristics (e.g., socio-demographic and economic) of the subjects living in a determined geographic area associated with problem gambling (e.g., unemployment, social isolation, low socioeconomic groups, youth, mental disorders in immediate relatives) (Marshall, 2009), whereas the contextual determinants are related to characteristics of the local, regional, and national environment, where the individual experiencing gambling problems lives (e.g., type of gambling offer, type of gambling regulation, type of preventive measures against problem gambling, alternative available leisure activities) (Marshall, 2009). We recently published an inventory paper presenting the needs and perspectives of the public health issues of GD in Switzerland (Billieux et al., 2016).

2.2 Internet Gaming Disorder (IGD)

Running an online study with in-game recruitment of adult online gamers was an innovative research design that illustrated the methodological features of Internet-related disorders. We were able to collect interesting data on a representative sample of online gamers, avoiding the usual age and recruitment biases that are present in the literature. Our

27 study provided descriptive psychological (e.g., impact of gaming on social functioning, health, and emotional states) and socio-demographic data covering the whole range of gamer profiles from casual (i.e., gaming for a few hours weekly for fun) to highly problematic (i.e., gaming as the sole activity with major adverse consequences in their lives).,Internet addiction has been shown to be distinct from IGD, in favor of the working hypothesis that Internet addiction is an umbrella construct comprising heterogeneous disorders (e.g., IGD, online GD, cyber porn addiction). Subjects presenting with IGD showed good consistency between self-perception of problematic gaming engagement and IGD scores, establishing a difference between IGD and SUDs in terms of the concept of denial.

Withdrawal and tolerance symptoms in gaming activity were self-reported, which favors IGD belonging to the addictive spectrum and the presence of dependence symptoms even without substance intake.

The lack of a gold standard to identify is an issue for researchers when studying vulnerability factors and characteristics of disordered subjects, as we previously discussed. It is also an issue for practitioners who have to decide who to treat or not in treatment-seeking patients. Furthermore, this is problematic for prevention and early detection, even though many attempts have been made to develop and validate screening tools (Achab, Meuli, et al., 2014; Khazaal, et al., 2015; Khazaal et al., 2008; Khazaal et al., 2012)

The adaptation of substance dependence criteria to online gaming activity in the first published paper that we presented (Achab, et al., 2011) has shown good psychometric properties for identifying IGD. This could be a screening tool that is easy to remember (identical to SUD assessment criteria) and to use (7 items only) for non-specialists.

We also tested the factorial structure of the Internet Addiction Test adapted for IGD and online GD in the fourth paper (Khazaal, et al., 2015) in the present work. It proposed a

data-28 driven shorter version of a widely used questionnaire, addressing some of its psychometric limitations.

For further knowledge of an individual’s determinants to develop problematic (excessive or addictive) patterns of Internet and electronic device use, data from the clinical population, face-to-face interview settings, and objective measurements (e.g., using tasks) are crucial yet still scarce. We are currently developing a cohort study project on outpatients seeking treatment for Internet-related complaints (e.g., gaming, social networking, pornography viewing, and gambling). The aims of this study are organized around several key challenges in the field, as mentioned earlier in the conclusion.

Patients will be diagnosed by using structured interviewing, which will be compared with self-administered questionnaires and with subjective problem rating by a key relative.

Structured interviews and experimental tasks are planned to collect data on factors related to the patient (e.g., socio-demographic, perceived quality of life, motivations to engage in the problematic activity and benefits sought in it, depression, anxiety disorders, impulsivity, self-esteem, coping strategies, and attachment patterns) and factors related to the patient’s environment (e.g., family history of mental and addictive disorders, accessibility of the problematic activity, and availability of alternative leisure activities). These data will be correlated to problematic use dimensions to explore risk factors. Protective factors from problematic use of other online activities will also be investigated.

The cohort project will provide useful data on the motivators to seek help, as well as on referral modalities, the efficacy of treatment approaches (e.g., evolution of problematic behaviors, clinical impression of the psychotherapist, quality-of-life improvement, satisfaction of relatives), follow-up characteristics (e.g., dropouts, duration, remissions, and relapses), and recovery factors.

29 Besides psychotherapeutic and pharmacological approaches, we want to develop new treatment approaches to alleviate patients’ suffering. The use of noninvasive brain stimulation has shown efficacy in SUDs (Trojak et al., 2015; Trojak et al., Under review) and in some BAs (e.g., eating disorders) (Sauvaget et al., 2015). They could represent interesting therapeutic tools to be tested in IGD (Trojak, Zullino, & Achab, 2015). We are currently drafting a multicentric protocol between Switzerland and France on the efficacy of transcranial direct-current stimulation in IGD. The expected treatment outcomes include craving reduction as observed for SUDs, control recovery of online involvement, and reduction of risk taking and impulsivity as assessed by experimental tasks.