Transcranial direct current stimulation for online gamers: A prospective single-arm feasibility study

Recent treatment and novel imaging studies evaluating treatment of internet gaming disorder: a narrative review

Internet Gaming Disorder (IGD) is an emerging public health concern; effective treatments are still under development. This mini-review focuses on summarizing the main scientific evidence from psychological, pharmacological, brain imaging, and emerging treatment approaches for IGD. We searched PubMed and Scopus databases using keywords related to IGD and treatment. Cognitive behavioral therapy (CBT) is the most extensively researched psychological treatment for IGD, supported by several randomized controlled trials (RCTs). Other promising approaches include mindfulness, relapse prevention, abstinence protocols, and family therapy. Pharmacological treatments like bupropion and escitalopram have shown benefits, especially when IGD is comorbid with conditions like major depressive disorder. However, the quality of evidence is moderate for psychological interventions but low to moderate for pharmacological approaches. Emerging treatments such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and electro-acupuncture have demonstrated efficacy in reducing IGD symptoms and modulating brain activity. Brain imaging techniques like functional magnetic resonance imaging (fMRI) have provided insights into the neural mechanisms underlying IGD and treatment effects, although these studies lack randomized controlled designs. While multimodal approaches show promise, larger, well-designed RCTs are needed to establish effective IGD treatments.

More grateful, less addicted! Understanding how gratitude affects online gaming addiction among Chinese college students: a three-wave multiple mediation model

BACKGROUND

Online game addiction has become a prominent public concern, particularly among emerging adults, warranting in-depth investigation. Despite prior cross-sectional research indicating a negative correlation between gratitude and online gaming addiction, a dearth of longitudinal research exists in this area. Furthermore, the underlying mechanisms that explain the link between gratitude and online gaming addiction remain poorly understood, highlighting a critical research gap in the field.

METHODS

To bridge this gap, our study adopted a three-wave longitudinal design and constructed a multiple mediation model. Over the course of one year, data was collected from a sample of Chinese undergraduates, with 319 students participating at Time 1, 305 at Time 2, and 292 at Time 3. Participants were administered online self-report surveys, enabling the acquisition of valuable data regarding their levels of gratitude, online game addiction, self-control, and loneliness.

RESULTS

The findings revealed a negative correlation between gratitude measured at Time 1 and online game addiction assessed at Time 3. Further analysis demonstrated that both self-control and loneliness played multiple mediating roles at Time 2 in the link between gratitude and online game addiction.

CONCLUSION

These research findings shed light on the underlying mechanisms between gratitude and online game addiction, which provide implications for developing interventions (e.g., interventions based on gratitude) for reducing young adults' online game addiction.

Novel approaches for treating Internet Gaming Disorder: A review of technology-based interventions

Internet Gaming Disorder (IGD) has become a significant issue in mental healthcare over the past decades as the number of people engaging in excessive and unhealthy gaming increases with each year. Despite its inclusion in the 5th Edition of Diagnostic Statistical Manual and the development of a number of treatment methods that have been designed and tested for IGD, treatment remains a challenge. This review attempts to give an overview of the current state of IGD and its treatment with a specific focus on the potential of technology-based solutions, such as web-based programs, mobile applications, and virtual reality. The review also highlights the need for additional work in the area of treatment development for IGD and the preliminary evidence for the usefulness and importance of technology-based treatment methods which offer unique advantages, such as accessibility, scalability, and cost-effectiveness, over other existing treatment options.

A Literature Review on the Efficacy and Related Neural Effects of Pharmacological and Psychosocial Treatments in Individuals With Internet Gaming Disorder

OBJECTIVE

Internet gaming disorder (IGD) has attracted considerable attention as a serious mental and public health issue worldwide. Currently, there are no established treatment guidelines for IGD. Herein, we review the latest findings on the efficacy and related neural effects of pharmacological and psychosocial treatments for individuals with IGD.

METHODS

A database search of relevant studies published between 2007 and 2020 was conducted using PubMed and Google Scholar. Twenty-seven studies were reviewed for current evidence related to the efficacy and neural effects of pharmacological and psychosocial IGD treatments.

RESULTS

Pharmacological studies suggest that bupropion may play a significant role in IGD. Additionally, nuclear imaging studies on IGD have demonstrated functional impairment of the dopamine system, providing a neurobiological basis for the efficacy of dopamineenhancing drugs. Among the various psychosocial interventions, current evidence suggests that cognitive behavioral therapy may be an effective intervention for IGD. Cognitive behavioral therapy and bupropion were found to influence resting-state functional connectivity within the cortico-subcortical circuit and default mode network, suggesting a possible neural mechanism. Innovative approaches, including virtual reality treatment, residential camps, voluntary abstinence, and transcranial direct current stimulation, have shown promising results. However, methodological limitations, such as the absence of proper controls, small sample sizes, short duration, inconsistency of inclusion criteria across studies, and self-report measures of outcome, hamper conclusions regarding the efficacy of treatments.

CONCLUSION

Ongoing basic research and clinical trials overcoming these limitations could add to the existing knowledge on IGD and contribute to the development of evidence-based treatments.

Universal Transcranial Direct Current Stimulation (tDCS) Headset for targeting the bilateral Dorsolateral Prefrontal Cortex: Towards facilitating broader adoption

Electrode position affects the brain current flow intensity and distribution induced by transcranial direct current stimulation (tDCS). The dorsolateral pre-frontal cortex (DLPFC) is a common target in neuropsychology and neuropsychiatry applications. A positioning scheme and subsequently a headgear has previously been developed to target the DLPFC automatically - devoid of any scalp ruler or neuronavigation method. This approach minimizes the time cost for pre-treatment measurements without compromising targeting accuracy and induced electric field focality. The goal of this study was to further develop this headgear to facilitate broader adoption while maintaining its core design elements intact. Briefly, we developed the headset to accommodate all adult head sizes (52-62 cm) rather than having multiple sizes, to have increased robustness, enhanced visual aesthetics, and have improved usability.We recruited 8 subjects and tested the accuracy of electrode placement on various head sizes. We also tested usability with the System Usability Scale (SUS) and asked the subjects to rate visual appeal. Our study demonstrated that the newly developed headset had greater usability and was more visually appealing than its predecessor without compromising targeting accuracy.Clinical Relevance- This study introduces a headset for routine tDCS administration targeting bilateral DLPFC. The headset is highly usable, robust, and is expected to facilitate home and high-volume use.

Managing Problematic Usage of the Internet and Related Disorders in an Era of Diagnostic Transition: An Updated Review

INTRODUCTION

Problematic Usage of the Internet (PUI) refers to a broad and likely heterogeneous group of Internet-related conditions associated with behavioural disturbances and functional impairment.

METHODS

Within PUI several conditions have been reported, including Gaming Disorder, Shopping Addiction, Cyberchondria, Gambling Disorder, Cyberpornography Addiction and Cyberbullying. While increasing reports in the field try to define the epidemiologic and clinical boundaries of these conditions, the rapid and continuous evolution of Internet related behaviours as well as their problematic/pathological expressions are often difficult to diagnose, assess, approach with treatment interventions and follow-up.

RESULTS

In addition, some of the PUI-related conditions show characteristics of addiction to the Internet as a preferential tool to engage in specific behaviours, while some others exclusively manifest on the Internet, making it necessary to find distinct assessment and treatment pathways.

CONCLUSION

The inclusion of Internet Gaming Disorder in Section III by the DSM-5 and the recognition of Gaming Disorder by the ICD-11 opened the way for a systematic clinical investigation of this and other PUI-related conditions, particularly in terms of preventive and therapeutic strategies. The present article is aimed at offering an updated clinical overview on the main expressions of PUI, focussing on the latest acquisitions in this evolving field.

Neuromodulatory Effect of Transcranial Direct Current Stimulation on Resting-State EEG Activity in Internet Gaming Disorder: A Randomized, Double-Blind, Sham-Controlled Parallel Group Trial

Transcranial direct current stimulation (tDCS) has been used as an adjunct therapy for psychiatric disorders; however, little is known about the underlying neurophysiological effects of tDCS in Internet gaming disorder (IGD). We investigated the effects of tDCS on cortical activity using resting-state electroencephalography (EEG) in patients with IGD. This randomized, double-blind, sham-controlled parallel group study of tDCS (ClinicalTrials.gov NCT03347643) included 31 IGD patients. Participants received 10 sessions (2 sessions per day for 5 consecutive days) of active repetitive tDCS (2 mA for 20 min per session) or sham stimulation. Anode/cathode electrodes were placed over the left and right dorsolateral prefrontal cortex, respectively. In total, 26 participants (active group n = 14; sham group n = 12) completed the trial. Resting-state EEG spectral activity (absolute power) and functional connectivity (coherence) were used to assess the effects of tDCS on cortical activity before stimulation and 1 month after the intervention. Active stimulation of tDCS suppressed increase of intra-hemispheric beta coherence after 1 month, which was observed in the sham group. The 1-month follow-up assessment revealed that absolute gamma power in the left parietal region was decreased in the active group relative to the sham group. Our findings suggest that repetitive tDCS stabilizes fast-wave activity in IGD.

Are Malaysian Youths Overdependent on the Internet?: A Narrative Review

Overdependence on the internet is a grave concern that has enveloped Malaysian youths which could lead to a variety of sequelae. This narrative review aims to determine the definition of internet overdependence and its associated factors, as well as the potential preventive and treatment strategies for internet overdependence. From the literature, internet overdependence is regarded as a 3-factor model encompassing salience, self-control failure, and serious consequences. Sociodemographic factors such as age, gender, and ethnicity, as well as psychosocial factors such as depression, anxiety, stress, and loneliness, were found to be associated with internet overdependence among Malaysian youths. A multimodal treatment approach is recommended by the implementation of various types of treatments, integrating disciplines such as pharmacology, psychotherapy, and family counseling. Despite various terminologies being used and unclear conceptualization of its nomenclature, overdependence on the internet is prevalent among youths in Malaysia. Future research should go toward establishing a clear definition of its terminology and attaining more robust evidence on treatment strategies.

Efficacy of single-session transcranial direct current stimulation on addiction-related inhibitory control and craving: a randomized trial in males with Internet gaming disorder

BACKGROUND

Transcranial direct current stimulation (tDCS) of the dorsolateral prefrontal cortex (dlPFC) may reduce substance use and other addictive behaviours. However, the cognitive mechanisms that underpin such effects remain unclear. Impaired inhibitory control linked to hypoactivation of the prefrontal cortex may allow craving-related motivations to lead to compulsive addictive behaviours. However, very few studies have examined whether increasing the activation of the dlPFC via anodal tDCS could enhance inhibitory control over addiction-related distractors. The current study aimed to enrich empirical evidence related to this issue.

METHODS

Thirty-three males with Internet gaming disorder underwent active (1.5 mA for 20 minutes) and sham tDCS 1 week apart, in randomized order. We assessed inhibitory control over gaming-related distractors and craving pre- and post-stimulation.

RESULTS

Relative to sham treatment, active tDCS reduced interference from gaming-related (versus non-gaming) distractors and attenuated background craving, but did not affect cue-induced craving.

LIMITATIONS

This study was limited by its relatively small sample size and the fact that it lacked assessments of tDCS effects on addictive behaviour. Future tDCS studies with multiple sessions in larger samples are warranted to examine the effects on addictive behaviours of alterations in addiction-related inhibitory control.

CONCLUSION

These findings demonstrate that stimulation of the dlPFC influences inhibitory control over addiction-related cues and addiction-related motivation. This is the first empirical study to suggest that enhanced inhibitory control may be a cognitive mechanism underlying the effects of tDCS on addictions like Internet gaming disorder. Our finding of attenuated background craving replicated previous tDCS studies. Intriguingly, our finding of distinct tDCS effects on 2 forms of craving suggests that they may have disparate underlying mechanisms or differential sensitivity to tDCS.

CLINICAL TRIALS #

NCT03352973.

Effects of transcranial direct current stimulation on addictive behavior and brain glucose metabolism in problematic online gamers

BACKGROUND AND AIMS

Some online gamers may encounter difficulties in controlling their gaming behavior. Previous studies have demonstrated beneficial effects of transcranial direct current stimulation (tDCS) on various kinds of addiction. This study investigated the effects of tDCS on addictive behavior and regional cerebral metabolic rate of glucose (rCMRglu) in problematic online gamers.

METHODS

Problematic online gamers were randomized and received 12 sessions of either active (n = 13) or sham tDCS (n = 13) to the dorsolateral prefrontal cortex over 4 weeks (anode F3/cathode F4, 2 mA for 30 min, 3 sessions per week). Participants underwent brain 18F-fluoro-2-deoxyglucose positron emission tomography scans and completed questionnaires including the Internet Addiction Test (IAT), Brief Self-Control Scale (BSCS), and Behavioral Inhibition System/Behavioral Activation System scales (BIS/BAS) at the baseline and 4-week follow-up.

RESULTS

Significant decreases in time spent on gaming (P = 0.005), BIS (P = 0.03), BAS-fun seeking (P = 0.04), and BAS-reward responsiveness (P = 0.01), and increases in BSCS (P = 0.03) were found in the active tDCS group, while decreases in IAT were shown in both groups (P < 0.001). Group-by-time interaction effects were not significant for these measures. Increases in BSCS scores were correlated with decreases in IAT scores in the active group (β = -0.85, P < 0.001). rCMRglu in the left putamen, pallidum, and insula was increased in the active group compared to the sham group (P for interaction < 0.001).

DISCUSSION AND CONCLUSIONS

tDCS may be beneficial for problematic online gaming potentially through changes in self-control, motivation, and striatal/insular metabolism. Further larger studies with longer follow-up period are warranted to confirm our findings.

BOLD activity during emotion reappraisal positively correlates with dietary self-control success

We combined established emotion regulation and dietary choice tasks with fMRI to investigate behavioral and neural associations in self-regulation across the two domains in human participants. We found that increased BOLD activity during the successful reappraisal of positive and negative emotional stimuli was associated with dietary self-control success. This cross-task correlation was present in medial and lateral prefrontal cortex as well as the striatum. In contrast, BOLD activity during the food choice task was not associated with self-reported emotion regulation efficacy. These results suggest that neural processes utilized during the reappraisal of emotional stimuli may also facilitate dietary choices that override palatability in favor of healthfulness. In summary, our findings indicate that the neural systems supporting emotion reappraisal can generalize to other behavioral contexts that require reevaluation of rewarding stimuli and outcomes to promote choices that conform with the current goal.

A role for the right dorsolateral prefrontal cortex in enhancing regulation of both craving and negative emotions in internet gaming disorder: A randomized trial

Reward-seeking and relief from negative emotions are two central motivational drives underlying addictions. Impaired executive control over craving and negative emotions contributes to compulsive addictive behaviors. Neuroimaging evidence has implicated the prefrontal cortex (PFC) in regulating craving or emotions. This study aims at examining whether anodal transcranial direct current stimulation (tDCS) over a specific region of the PFC would enhance both regulation processes. Thirty-three men with internet gaming disorder received active (1.5 mA for 20 minutes) and sham tDCS over the right dorsolateral PFC (dlPFC) one week apart in a randomized order. During each stimulation session, participants regulated craving for gaming during a regulation of craving (ROC) task and negative emotions during an emotion regulation (ER) task using cognitive reappraisal. Subjective ratings of craving and negative emotions and skin conductance responses (SCRs) were recorded. For both craving and negative emotions, tDCS of the right dlPFC facilitated downregulation and upregulation: active relative to sham tDCS decreased ratings (ROC: 95% CI of difference -1.38 to -0.56, p < 0.001; ER: -1.65 to -0.70, p < 0.001) and/or SCRs (ROC: -1.99 to -0.41 μs, p = 0.004) for downregulation, and increased ratings (ROC: 0.24 to 0.82, p = 0.001; ER: 0.26 to 0.72, p < 0.001) for upregulation. These findings provide the first experimental evidence confirming that tDCS of the right dlPFC enhances both craving- and negative-emotion-regulation. This suggests a promising approach for concurrently enhancing executive control over two central motivational drives underlying addictions.

PET Hypometabolism of the Prefrontal-Cingulate Cortices in Internet Gaming Disorder

Recently, excessive and uncontrolled use of online games has been recognized as a public concern. Although previous neuroimaging studies have reported structural and functional brain deficits in Internet gaming disorder (IGD), very few studies have investigated the regional cerebral metabolic rate of glucose (rCMRglu). This study investigated the differences in rCMRglu between individuals with IGD and healthy controls using 18F-fluoro-2-deoxyglucose positron emission tomography (18F-FDG PET). A total of 23 adults with IGD and 23 controls underwent brain 18F-FDG PET scans and completed self-report questionnaires. A whole-brain voxel-wise analysis of rCMRglu was conducted and associations between rCMRglu and severity of IGD were assessed. The IGD group showed higher impulsivity (p = 0.04) and lower self-control (p = 0.002) than the control group. In addition, the IGD group had lower FDG uptake in the left medial orbitofrontal gyrus, left middle cingulate cortex, left superior frontal gyrus, and right anterior cingulate cortex (p < 0.001). A significant negative association was found between the rCMRglu in the right anterior cingulate cortex and the number of fulfilled diagnostic criteria for IGD (β = -0.50, p = 0.02). Our results suggest that IGD may be associated with deficits of glucose metabolism in the prefrontal-cingulate cortices.

Treatments of internet gaming disorder: a systematic review of the evidence

Introduction: The American Psychiatric Association included Internet gaming disorder (IGD) in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders, and the World Health Organization included gaming disorder in the 11th revision of the International Classification of Diseases. These recent updates suggest significant concern related to the harms of excessive gaming.Areas covered: This systematic review provides an updated summary of the scientific literature on treatments for IGD. Inclusion criteria were that studies: 1) evaluate the effectiveness of an intervention for IGD or excessive gaming; 2) use an experimental design (i.e. multi-armed [randomized or nonrandomized] or pretest-posttest); 3) include at least 10 participants per group; and 4) include an outcome measure of IGD symptoms or gaming duration. The review identified 22 studies evaluating treatments for IGD: 8 evaluating medication, 7 evaluating cognitive behavioral psychotherapy, and 7 evaluating other interventions and psychosocial treatments.Expert opinion: Even with the recent uptick in publication of such clinical trials, methodological flaws prevent strong conclusions about the efficacy of any treatment for IGD. Additional well-designed clinical trials using common metrics for assessing IGD symptoms are needed to advance the field.

Review: Non-Invasive Brain Stimulation in Behavioral Addictions: Insights from Direct Comparisons With Substance Use Disorders

BACKGROUND AND OBJECTIVES

Treatment models developed for substance use disorders (SUDs) are often applied to behavioral addictions (BAs), even though the correspondence between these forms of addiction is unclear. This is also the case for noninvasive brain stimulation (NIBS) techniques being investigated as potential treatment interventions for SUDs and BAs.

OBJECTIVES

to contribute to the development of more effective NIBS protocols for BAs.

METHODS

Two literature searches using PubMed and Google Scholar were conducted identifying a total of 35 studies. The first search identified 25 studies examining the cognitive and neurophysiological overlap between BAs and SUDs. The second search yielded 10 studies examining the effects of NIBS in BAs.

RESULTS

Impulsivity and cravings show behavioral and neurophysiologic overlaps between BAs and SUDs, however, other outcomes like working-memory abilities or striatal connectivity, differ between BAs and SUDs. The most-employed NIBS target in BAs was dorsolateral prefrontal cortex (DLPFC), which was associated with a decrease in cravings, and less frequently with a reduction of addiction severity.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Direct comparisons between BAs and SUDs revealed discrepancies between behavioral and neurophysiological outcomes, but overall, common and distinctive characteristics underlying each disorder. The lack of complete overlap between BAs and SUDs suggests that investigating the cognitive and neurophysiological features of BAs to create individual NIBS protocols that target risk-factors associated specifically with BAs, might be more effective than transferring protocols from SUDs to BAs. Individualizing NIBS protocols to target specific risk-factors associated with each BA might help to improve treatment interventions for BAs. (Am J Addict 2019;00:1-23).