Global level

There is a need to address these health issues in an optimum way by dealing with remaining challenges such as promoting global research and cooperation. An ethical committee recently approved an exploratory study protocol that we submitted to provide data on Internet-related disorders (gaming, gambling, and social networking) in older adults with a cross-cultural (Switzerland and Poland) comparative design.

Regarding the global monitoring of GD and IGD, we are involved, through our WHO collaborating center activities, in the data collection of addictive disorders in health systems at a global level. This monitoring is part of the Mental Health Action Plan 2013-2020 in which the objectives include the promotion and implementation of prevention strategies on the one hand, and the strengthening of evidence and research on the other (Saxena, Funk, &

Chisholm, 2013).

The development of cross-cultural public health guidelines and their implementation in any type of linguistic, politic, economic, or local priority setting is the culmination of the previous medical, scientific, and public health efforts. We expect from our work in progress with WHO (WHO, 2015), to achieve some of these important goals.

An outcome that is highly anticipated by clinicians and researchers is the release of the 11th edition of the ICD (ICD-11) scheduled in 2018. The release of the ICD-11 presents an opportunity to verify whether WHO aligns with the DSM-5 regarding the widening of the

31 addictive disorder spectrum to include so-called BAs. The loop will finally be closed with this categorization update, from the individual complaint to global clinical guidelines, which will then have an impact on diagnosis and research at the individual level.

References

Achab, S., Bertolini, M., & Karila, L. (2012). Developing Pharmacotherapy for cyberaddictions? The Open addiction Journal, 5, 20-23.

Achab, S., Chatton, A., Khan, R., Thorens, G., Penzenstadler, L., Zullino, D., et al. (2014).

Early detection of pathological gambling: betting on GPs' beliefs and attitudes.

Biomed Res Int, 2014, 360585.

Achab, S., Karila, L., & Khazaal, Y. (2014). Pathological gambling: update on decision making and neuro-functional studies in clinical samples. Curr Pharm Des, 20(25), 4000-4011.

Achab, S., & Khazaal, Y. (2011). Psychopharmacological treatment in pathological gambling:

a critical review. Curr Pharm Des, 17(14), 1389-1395.

Achab, S., Khazaal, Y., & Zullino, D. (2012). Jeu pathologique: Approches médicamenteuses Le jeu pathologique. Comprendre-Prévenir-Traiter.

Achab, S., Meuli, V., Deleuze, J., Thorens, G., Rothen, S., Khazaal, Y., et al. (2014).

Challenges and trends of identification and treatment of disorders associated with problematic use of Internet. Paper presented at the Public health implications of excessive use of Internet, computers, smartphones and similar electronic devices WHO meeting

Achab, S., Nicolier, M., Khazaal, Y., Zullino, D., & Haffen, E. (2012). Apport des sciences fondamentales: sciences cognitves, imagerie fonctionnelle. In Masson (Ed.), Le jeu pathologique. Comprendre-Prévenir-Traiter.

Achab, S., Nicolier, M., Mauny, F., Monnin, J., Trojak, B., Vandel, P., et al. (2011).

Massively multiplayer online role-playing games: comparing characteristics of addict vs non-addict online recruited gamers in a French adult population. BMC Psychiatry, 11, 144.

Achab, S., Simon, O., Muller, S., Thorens, G., Martinotti, G., Zullino, D., et al. (2015).

Internet addiction. In N. El-Guebaly, G. Carrà & M. Galanter (Eds.), Textbook of Addiction Treatment: International Perspectives (pp. 2700). Milan Heidelberg New York Dordrecht London Springer-Verlag.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC.

Banz, B. C., Yip, S. W., Yau, Y. H., & Potenza, M. N. (2016). Behavioral addictions in addiction medicine: from mechanisms to practical considerations. Prog Brain Res, 223, 311-328.

Bartle, R. (Ed.). (2003). Designing Virtual Worlds.

Billieux, J., Achab, S., Savary, J. F., Simon, O., Richter, F., Zullino, D., et al. (2016).

Gambling and problem gambling in Switzerland. Addiction(National gambling experiences).

32 Billieux, J., Thorens, G., Khazaal, Y., Zullino, D., Achab, S., & Van der Linden, M. (2015).

Problematic involvement in online games : A cluster analytic approach. Computers in Human Behavior, 43, 242-250.

Billieux, J., Van der Linden, M., Achab, S., Khazaal, Y., Paraskevopoulos, L., Zullino, D., et al. (2013). Why do you playWorld of Warcraft? An in-depth exploration of self-reported motivations to play online and in-game behaviours in the virtual world of Azeroth. Computers in Human Behavior, 29(1), 103-109.

Bondolfi, G., Jermann, F., Ferrero, F., Zullino, D., & Osiek, C. (2008). Prevalence of pathological gambling in Switzerland after the opening of casinos and the introduction of new preventive legislation. Acta Psychiatr Scand, 117(3), 236-239.

Cantin, L., Lenoir, M., Augier, E., Vanhille, N., Dubreucq, S., Serre, F., et al. (2010). Cocaine is low on the value ladder of rats: possible evidence for resilience to addiction. PLoS One, 5(7), e11592.

Carroll, M. E., Lac, S. T., & Nygaard, S. L. (1989). A concurrently available nondrug reinforcer prevents the acquisition or decreases the maintenance of cocaine-reinforced behavior. Psychopharmacology (Berl), 97(1), 23-29.

Chung, T. (2014). Internet-related health problems. Paper presented at the Public helath implications of excessive use of the Internet, computers, smartphones and similar electronic devices meeting.

Clark, L. (2014). Disordered gambling: the evolving concept of behavioral addiction. Ann N Y Acad Sci, 1327, 46-61.

Deleuze, J., Rochat, L., Romo, L., Van der Linden, M., Achab, S., Thorens, G., et al. (2015).

Prevalence and characteristics of addictive behaviors in a community sample: A latent class analysis. Addictive Behaviors Reports, 1, 49-56.

Evans, L., & Delfabbro, P. H. (2005). Motivators for change and barriers to help-seeking in Australian problem gamblers. J Gambl Stud, 21(2), 133-155.

Gainsbury, S. M. (2015). Online Gambling Addiction: the Relationship Between Internet Gambling and Disordered Gambling. Curr Addict Rep, 2(2), 185-193.

Griffiths, M. D., & Meredith, A. (2009). Videogame Addiction and its Treatment. J Contemp Psychother, 39, 247-253.

Griffiths, M. D., van Rooij, A. J., Kardefelt-Winther, D., Starcevic, V., Kiraly, O., Pallesen, S., et al. (2016). Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addiction, 111(1), 167-175.

Hernandez, L., & Hoebel, B. G. (1988). Food reward and cocaine increase extracellular dopamine in the nucleus accumbens as measured by microdialysis. Life Sci, 42(18), 1705-1712.

Jeanrenaud, C., Gay, M., Kohler, D., Besson, J., & Simon, O. (2012). Le coût social du jeu excessif en suisse: Institut de recherche économique de l'université de Neuchatel.

Khan, R., Chatton, A., Nallet, A., Broers, B., Thorens, G., Achab-Arigo, S., et al. (2011).

Validation of the French version of the alcohol, smoking and substance involvement screening test (ASSIST). Eur Addict Res, 17(4), 190-197.

Khazaal, Y., Achab, S., Billieux, J., Thorens, G., Zullino, D., Dufour, M., et al. (2015). Factor Structure of the Internet Addiction Test in Online Gamers and Poker Players. JMIR Ment Health, 2(2), e12.

Khazaal, Y., Billieux, J., Thorens, G., Khan, R., Louati, Y., Scarlatti, E., et al. (2008). French validation of the internet addiction test. Cyberpsychol Behav, 11(6), 703-706.

Khazaal, Y., Chatton, A., Bouvard, A., Khiari, H., Achab, S., & Zullino, D. (2011). Internet Poker Websites and Pathological Gambling Prevention Policy. J Gambl Stud.

33 Khazaal, Y., Chatton, A., Horn, A., Achab, S., Thorens, G., Zullino, D., et al. (2012). French Validation of the Compulsive Internet Use Scale (CIUS). Psychiatr Q, 83(4), 397-405.

Koob, G. F., & Le Moal, M. (2001). Drug addiction, dysregulation of reward, and allostasis.

Neuropsychopharmacology, 24(2), 97-129.

Ladouceur, R., Boutin, C., Doucet, C., Dumont, M., Provencher, M., Giroux, I., et al. (2004).

Awareness promotion about excessive gambling among video lottery retailers. J Gambl Stud, 20(2), 181-185.

Lorains, F. K., Cowlishaw, S., & Thomas, S. A. (2011). Prevalence of comorbid disorders in problem and pathological gambling: systematic review and meta-analysis of population surveys. Addiction, 106(3), 490-498.

M’hiri, K., Costanza, A., Khazaal, Y., Khan, R., Zullino, D., & Achab, S. (2015). Problematic Internet use in Older Adults, A Critical Review of the Literature. J Addict Res ther, 6(4), 253.

Marazziti, D., Presta, S., Baroni, S., Silvestri, S., & Dell'Osso, L. (2014). Behavioral addictions: a novel challenge for psychopharmacology. CNS Spectr, 19(6), 486-495.

Marmet, S., Notari, L., & Gmel, G. (2013). Suchtmonitoring Schweiz. Lausanne: Sucht Schweiz.

Marshall, D. (2009). Gambling as a public health issue: the critical role of the local environment. Journal of Gambling Issues(23), 66-80.

Martinotti, G., Corazza, O., Achab, S., & Demetrovics, Z. (2014). Novel psychoactive substances and behavioral addictions. Biomed Res Int, 2014, 534523.

Miedl, S. F., Buchel, C., & Peters, J. (2014). Cue-induced craving increases impulsivity via changes in striatal value signals in problem gamblers. J Neurosci, 34(13), 4750-4755.

Moeller, S. J., Konova, A. B., Parvaz, M. A., Tomasi, D., Lane, R. D., Fort, C., et al. (2014).

Functional, structural, and emotional correlates of impaired insight in cocaine addiction. JAMA Psychiatry, 71(1), 61-70.

Noori, H. R., Cosa Linan, A., & Spanagel, R. (2016). Largely overlapping neuronal substrates of reactivity to drug, gambling, food and sexual cues: A comprehensive meta-analysis.

Eur Neuropsychopharmacol.

Petry, N. M., Rehbein, F., Gentile, D. A., Lemmens, J. S., Rumpf, H. J., Mossle, T., et al.

(2014). An international consensus for assessing internet gaming disorder using the new DSM-5 approach. Addiction, 109(9), 1399-1406.

Pfaus, J. G., Damsma, G., Nomikos, G. G., Wenkstern, D. G., Blaha, C. D., Phillips, A. G., et al. (1990). Sexual behavior enhances central dopamine transmission in the male rat.

Brain Res, 530(2), 345-348.

Potenza, M. N. (2006). Should addictive disorders include non-substance-related conditions?

Addiction, 101 Suppl 1, 142-151.

Rehm, J., Marmet, S., Anderson, P., Gual, A., Kraus, L., Nutt, D. J., et al. (2013). Defining substance use disorders: do we really need more than heavy use? Alcohol Alcohol, 48(6), 633-640.

Richter, F., & Walker, H. (2016). « Cyberaddiction » in Switzerland, intermediate report of the expert group in cyberaddiction: Swiss Federal Office of Public Health.

Robbins, T. W., & Clark, L. (2015). Behavioral addictions. Curr Opin Neurobiol, 30, 66-72.

Saunders, J. B. (2013). The concept of substance use disorders. A commentary on 'Defining substance use disorders: do we really need more than heavy use' by Rehm et al.

Alcohol Alcohol, 48(6), 644-645.

Sauvaget, A., Trojak, B., Bulteau, S., Jimenez-Murcia, S., Fernandez-Aranda, F., Wolz, I., et al. (2015). Transcranial direct current stimulation (tDCS) in behavioral and food addiction: a systematic review of efficacy, technical, and methodological issues. Front Neurosci, 9, 349.

34 Saxena, S., Funk, M., & Chisholm, D. (2013). World Health Assembly adopts Comprehensive Mental Health Action Plan 2013-2020. Lancet, 381(9882), 1970-1971.

Selby, E. A., Anestis, M. D., & Joiner, T. E. (2008). Understanding the relationship between emotional and behavioral dysregulation: emotional cascades. Behav Res Ther, 46(5), 593-611.

Sescousse, G., Barbalat, G., Domenech, P., & Dreher, J. C. (2013). Imbalance in the sensitivity to different types of rewards in pathological gambling. Brain, 136(Pt 8), 2527-2538.

Suchtmonitoring. (2014). Continuous Rolling Survey of Addictive Behaviours and Related Risks: Addiction Suisse and Institut d'études de marché et d'opinion.

Suurvali, H., Cordingley, J., Hodgins, D. C., & Cunningham, J. (2009). Barriers to seeking help for gambling problems: a review of the empirical literature. J Gambl Stud, 25(3), 407-424.

Suurvali, H., Hodgins, D. C., & Cunningham, J. A. (2010). Motivators for resolving or seeking help for gambling problems: a review of the empirical literature. J Gambl Stud, 26(1), 1-33.

Thorens, G., Achab, S., Billieux, J., Khazaal, Y., Khan, R., Pivin, E., et al. (2014a).

Characteristics and treatment response of self-identified problematic Internet users in a behavioral addiction outpatient clinic. J Behav Addict, 3(1), 78-81.

Thorens, G., Achab, S., Billieux, J., Khazaal, Y., Khan, R., Pivin, E., et al. (2014b).

Characteristics and treatment response of self-identified problematic Internet users in a behavioral addiction outpatient clinic. Journal of Behavioral Addictions.

Thorens, G., Wullschleger, A., Khan, R., Achab, S., & Zullino, D. (2012). What is Addictive in Internet? The Open Addiction Journal, 5, 14-19.

Tomei, A., Tichelli, E., Ewering, N., Nunweiler-Hardegger, S., & Simon, O. (2015). A Descriptive Study of Gambling Among Emerging Adult Males in French-Speaking Switzerland. J Gambl Stud, 31(3), 607-620.

Tozzi, L., Akre, C., Fleury-Schubert, A., & Suris, J. C. (2013). Gambling among youths in Switzerland and its association with other addictive behaviours. A population-based study. Swiss Med Wkly, 143, w13768.

Trojak, B., Meille, V., Achab, S., Lalanne, L., Poquet, H., Ponavoy, E., et al. (2015).

Transcranial Magnetic Stimulation Combined With Nicotine Replacement Therapy for Smoking Cessation: A Randomized Controlled Trial. Brain Stimul, 8(6), 1168-1174.

Trojak, B., Sauvaget, A., Fecteau, S., Lalanne, L., Koch, S., Bulteau, S., et al. (Under review).

Outcome of Non-Invasive Brain Stimulation in Substance-Related and Addictive Disorders: a review of randomized sham-controlled clinical trials Drug Alcohol Depend.

Trojak, B., Zullino, D., & Achab, S. (2015). Brain stimulation to treat Internet addiction: A commentary. Addict Behav.

WHO. (2015). Public Health Implications of Excessive Use of the Internet, Computers,Smartphones and Similar Electronic Devices Meeting report.

Williams, R. J., Volberg, R. A., & Stevens, R. M. G. (2012). The population prevalence of problem gambling:Methodological Influences, standardized rates, jurisdictional differences, and worldwide trends Report prepared for the Ontario Problem Gambling Research Centre and the Ontario Ministry of Health and Long Term Care.

Wise, R. A., Leone, P., Rivest, R., & Leeb, K. (1995). Elevations of nucleus accumbens dopamine and DOPAC levels during intravenous heroin self-administration. Synapse, 21(2), 140-148.

35 Yau, Y. H., & Potenza, M. N. (2015). Gambling disorder and other behavioral addictions:

recognition and treatment. Harv Rev Psychiatry, 23(2), 134-146.

R E S E A R C H A R T I C L E Open Access

Massively multiplayer online role-playing games:

comparing characteristics of addict vs non-addict online recruited gamers in a French adult

population

Sophia Achab^1,2,3, Magali Nicolier¹, Frédéric Mauny^4,5, Julie Monnin^1,6, Benoit Trojak⁷, Pierre Vandel^1,2, Daniel Sechter^1,2, Philip Gorwood^8,9and Emmanuel Haffen^1,2,6*

Abstract

Background:Massively Multiplayer Online Role-Playing Games (MMORPGs) are a very popular and enjoyable leisure activity, and there is a lack of international validated instruments to assess excessive gaming. With the growing number of gamers worldwide, adverse effects (isolation, hospitalizations, excessive use, etc.) are observed in a minority of gamers, which is a concern for society and for the scientific community. In the present study, we focused on screening gamers at potential risk of MMORPG addiction.

Methods:In this exploratory study, we focused on characteristics, online habits and problematic overuse in adult MMORPG gamers. In addition to socio-demographical data and gamer behavioral patterns, 3 different instruments for screening addiction were used in French MMORPG gamers recruited online over 10 consecutive months: the substance dependence criteria for the Diagnostic and Statistical Manual of Mental Disorder, fourth revised edition (DSM-IV-TR) that has been adapted for MMORPG (DAS), the qualitative Goldberg Internet Addiction Disorder scale (GIAD) and the quantitative Orman Internet Stress Scale (ISS). For all scales, a score above a specific threshold defined positivity.

Results:The 448 participating adult gamers were mainly young adult university graduates living alone in urban areas. Participants showed high rates of both Internet addiction (44.2% for GIAD, 32.6% for ISS) and DAS positivity (27.5%). Compared to the DAS negative group, DAS positive gamers reported significantly higher rates of tolerance phenomenon (increased amount of time in online gaming to obtain the desired effect) and declared significantly more social, financial (OR: 4.85), marital (OR: 4.61), family (OR: 4.69) and/or professional difficulties (OR: 4.42) since they started online gaming. Furthermore, these gamers self-reported significantly higher rates (3 times more) of irritability, daytime sleepiness, sleep deprivation due to play, low mood and emotional changes since online gaming onset.

Conclusions:The DAS appeared to be a good first-line instrument to screen MMORPG addiction in online gamers.

This study found high MMORPG addiction rates, and self-reported adverse symptoms in important aspects of life, including mood and sleep. This confirms the need to set up relevant prevention programs against online game overuse.

* Correspondence: emmanuel.haffen@univ-fcomte.fr

1Clinical Psychiatry Department, Besançon University Hospital, 25030 Besançon Cedex, France

Full list of author information is available at the end of the article Achabet al.BMC Psychiatry2011,11:144

http://www.biomedcentral.com/1471-244X/11/144

© 2011 Achab et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background

Dependence involves a complex system of bio psychoso-cial factors affecting individuals, their actions and their culture, and has also been referred to as a syndrome with multiple expressions [1]. In 1964 the World Health Organization (WHO) introduced the concept of depen-dence to replace addiction and habituation. The term dependence can be used generally with reference to the whole range of psychoactive drugs (drug, chemical or substance use dependence) or with specific reference to a particular drug or class of drugs (alcohol or opioid dependence) and refers to both physical and psychologi-cal elements [2]. According to the Diagnostic and Statis-tical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR), substance dependence may involve several symptoms (tolerance, withdrawal, adverse repercussions on social and professional areas, loss of control of the consumption, and persistence despite the adverse effects engendered). The concept has since undergone major revision with the appearance of new types of entities, entitled non-chemical (i.e. behavioral) addictions such as eating disorders, compulsive buying, exercise abuse [3] and pathological gambling. Clinicians tend to distinguish between abuse, dependence and addiction, referring to either substance or behavior. This distinction is sustained by recent neurobiological find-ings on the different neuronal processes involved in dependence or addiction [4]. Dependence could be defined as an adaptive neural response to the pharmaco-logical effect of substance abuse, and is associated with withdrawal when the substance is not accessible. This definition corresponds to what was previously called

“physical dependence”, that is inadequate to explain sub-stance and non-subsub-stance addiction. The previous “psy-chological dependence” is more likely to be a “choice disorder”in the addiction disorder, in which loss of con-trol and inadequate decision making leads to an auto-matic and compulsive behavior which is pursued despite adverse psychological, physical and/or social conse-quences [5]. Several types of behavior, besides psychoac-tive substance use, produce a short-term reward that may engender persistent behavior, despite knowledge of adverse consequences. These disorders have been con-ceptualized as lying along an impulsive-compulsive spec-trum or an addiction specspec-trum such as “behavioral” addictions. In support of the second hypothesis, growing evidence suggests that behavioral addictions resemble substance addictions in many domains, including natural history, phenomenology, tolerance, and comorbidity, overlapping genetic contribution, neurobiological mechanism, and response to treatment [6]. The Ameri-can Psychiatric Association (A.P.A) press release quoted O’Brien, chair of the Substance-Related Disorders Work

Group, as saying: “substance research supported that pathological gambling and substance use disorders were very similar because both were related to poor impulse control and brain’s system of reward and aggression” [7]. These findings support the forthcoming DSM fifth edition (DSM-V) that may propose a new category of Addiction and Related Disorders encompassing both use disorders and non-substance addictions. Current data suggest that this combined category may be appropriate for pathological gambling and a few well studied beha-vioral addictions,e.g. Internet addiction (IA) and video/

computer game addiction [6]. IA was described as a joke by Goldberg in 1994 by reproducing the DSM-IV criteria for substance dependence [8]. Since then, this

“new disorder” has been the subject of scientific interest until the recent call for it to join the ranks of DSM V classification. Davis’s theoretical model on Problematic Internet Use (PIU) distinguishes two different entities: i) Specific PIU, related to a particular content and which could exist independently from the Internet vector, such as gambling and videogames and ii) Generalized PIU which is related to specific Internet content such as chats, e-mails and social networks [9]. The Internet has provided a wide range of possibilities for traditional video games and the attraction is clearly common worldwide, particularly with the Massively Multiplayer Online Role-Playing Games (MMORPGs). An example of this popularity is World of Warcraft^©(WoW), which has over 11.5 million active subscribers [10] and accounts for an estimated 62% of the online video game market [11]. These games are the latest Internet-only gaming experience, and are typically represented by large, sophisticated and evolving virtual worlds set in different environments [12]. However, as the popularity of MMORPG has grown, questions are being raised about their potential for excessive use. MMORPGs are played for much longer periods of time than other games [13], which could also indicate a potential for greater negative effects on players [14].

Up to now, little research has been carried out on online video games, particularly on the different aspects of online gaming, the characteristics of adult gamers and their addiction level. Previous studies mainly focused on the demographics of MMORPG gamers. Few studies have looked at the effects of MMORPG. Kim evaluated online game addiction using a modified ver-sion of Young’s Internet Addiction Scale and observed a positive correlation between online game addiction and aggression and narcissistic personality traits, and a nega-tive correlation between online game addiction and self-control [15]. In an exploratory study, Hussain examined the gender swapping phenomenon [16] and in a qualita-tive analysis using 71 online interviews, showed how

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gamers used MMORPG to alleviate negative feelings, providing detailed descriptions of personal problems that arise due to playing MMORPG in a third of sub-jects [17]. In another exploratory study, Longman sepa-rated 206 international participants into 2 groups according to time spent playing MMORPG per week, and observed that the high use group presented low levels of offline social support and high levels of nega-tive psychological symptoms [18]. Another approach focused on the relationship between addiction and ava-tar, the game character [14]. In this international study, 15.4% of gamers were female and nearly 40% of 548 MMORPG players considered themselves addicted.

Moreover, Mentzoni et al. observed that problematic use of video games was associated with lower scores for life satisfaction and high levels of anxiety and depression [19].

Video games are a highly attractive leisure activity, and can even be used in medical applications (pain, muscular rehabilitation, cognitive stimulation, etc.) [20], but they can also cause adverse effects such as addic-tion. To address this growing phenomenon, the govern-ment of South Korea, a pioneering country for MMORPG development, has just decided to introduce a

Video games are a highly attractive leisure activity, and can even be used in medical applications (pain, muscular rehabilitation, cognitive stimulation, etc.) [20], but they can also cause adverse effects such as addic-tion. To address this growing phenomenon, the govern-ment of South Korea, a pioneering country for MMORPG development, has just decided to introduce a