Computer and Video Game Addiction—A Comparison between 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 compulsive use of
computer and video games that may interfere with daily life. It is not clear whether video game
playing meets diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV). Objectives: First objective is to review the literature on computer and video game
addiction over the topics of diagnosis, phenomenology, epidemiology, and treatment. Second
objective is to describe a brain imaging study measuring dopamine release during computer game
playing. Methods: Article search of 15 published articles between 2000 and 2009 in Medline and
PubMed on computer and video game addiction. Nine abstinent “ecstasy” users and 8 control
subjects were scanned at baseline and after performing on a motorbike riding computer game while
imaging dopamine release in vivo with [123I] IBZM and single photon emission computed
tomography (SPECT). Results: Psycho-physiological mechanisms underlying computer game
addiction are mainly stress coping mechanisms, emotional reactions, sensitization, and reward.
Computer game playing may lead to long-term changes in the reward circuitry that resemble the
effects of substance dependence. The brain imaging study showed that healthy control subjects had
reduced dopamine D2 receptor occupancy of 10.5% in the caudate after playing a motorbike riding
computer game compared with baseline levels of binding consistent with increased release and
binding to its receptors. Ex-chronic “ecstasy” users showed no change in levels of dopamine D2
receptor occupancy after playing this game. Conclusion: This evidence supports the notion that
psycho-stimulant users have decreased sensitivity to natural reward. Significance: Computer game
addicts or gamblers may show reduced dopamine response to stimuli associated with their addiction
presumably due to sensitization. Keywords addictionx, brain imaging, computer game playing,
dopamine, reward, video game playing INTRODUCTION Problem Definition Computer 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., Department of Medical Biophysics and
Nuclear Medicine, Hadassah Hospital, Ein Kerem, Jerusalem, Israel. E-mail:
[email protected] Users may play compulsively, isolating themselves from other forms of
social contact, and focus almost entirely on in-game achievements rather than broader life events.
Griffiths (1) has operationally defined addictive behavior as any behavior that features what he
believes are the six core components of addiction (i.e., salience, mood modification, tolerance,
withdrawal symptoms, conflict, and relapse). He further argued that video game addiction fulfils the
criterion of addiction by virtue of meeting these criteria. In his view, since many video game users
are excessive users and not addicts, video game addiction may be a medium for satisfaction of
arousal and reward (see section on mechanisms of reward). In addition to the neurochemical basis
for addiction, there are accompanied behavioral markers of dependence in adolescents such as
stealing, truancy, not doing homework, irritability if unable to play, etc. Finally, single case studies
have shown the video game addiction was used in order to compensate for deficiencies in one’s life
in areas such as interpersonal relationships, physical appearance, disability, coping, etc. Griffith (2)
argued that although there are educational, social, and therapeutic benefits to video games play,
taken in excess they could lead to addiction, playing 24 hours a day 7 days a week and in some cases
to a gambling problem. Finally, Griffiths (3) concluded that adverse effects of video game addiction
are relatively minor and temporary resolving spontaneously with decreased frequency of play or to
affect a small group of players. There is no evidence for genetic factors influencing video or
computer game addiction. Most studies describe a behavior that is independent of other psychiatric
disorders (e.g., not just secondary to another condition such as attention deficit hyperactivity
disorder [ADHD] or mania). There is a single study suggesting co-morbidity with depression (4) and
for comorbidity with ADHD (5) but there is no evidence for co-morbidity with substance use
disorder. On the spectrum of impulsivity and obsessive-compulsive behavior, there is some evidence
for impulsivity on the Barrat Impulsiveness scale (4), and excessive computer and video game playing
supports the notion of obsessive-compulsive behavior although formal assessment of obsessive-
compulsive behavior in these individuals has not been 268 Am J Drug Alcohol Abuse Downloaded
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COMPUTER/VIDEO GAME ADDICTION 269 done. According to Griffiths (6) case studies of individuals
who use the Internet excessively may also provide better evidence of whether Internet addiction
exists, because the data collected are much more detailed than data from surveys. Case studies can
highlight the role of context in distinguishing excessive gaming from addictive gaming and can
demonstrate that excessive gaming does not necessarily mean that a person is addicted. It is argued
that online gaming addiction should be characterized by the extent to which excessive gaming
impacts negatively on other areas of the gamers’ lives rather than the amount of time spent playing.
It is also suggested that an activity cannot be described as an addiction if there are few (or no)
negative consequences in the player’s life even if the gamer is playing 14 hours a day (7). Currently,
it is not clear whether video game playing meets criteria for a syndrome, e.g., Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or ICD10 definition of a clinically
significant pattern (consistent cooccurrence and time course) of behavioral and psychological signs
and symptoms that cause distress or impairment. In 2007, the American Psychiatric Association
reviewed whether or not video game addiction should be added to the new DSM to be released in
2012. The conclusion was that there was not enough evidence to warrant the inclusion of computer
game addiction as a disorder. DIAGNOSIS AND PREVALENCE The diagnostic assessment of internet or
computer game dependency remains problematic. Different studies in different countries have used
different scales to assess prevalence of computer game addiction. A national Harris Poll survey of
1,178 U.S. youths ages 8–18 years found that 8.5% of computer gamers were pathological players
according to standards established for pathological gambling (Harris Interactive, 2007). Among 323
German children ranging in age from 11 to 14 years, 9.3% (N = 30) met criteria for dependency and
pathological gaming using DSM-IV and ICD-10 criteria (8). A second study of 7069 computer-game
players reported that 11.9% met three of the diagnostic criteria for addiction (9). Finally, among 221
computer game players, 6.3% have met ICD-10 criterion of addiction (10). Among 2327 Norwegian
youth, 2.7% (4.2% of the boys, 1.1% of the girls) fulfilled the criteria for pathological playing
following a “Diagnostic Questionnaire for Internet Addiction of Young;” 9.8% (14.5% of the boys, 5%
of the girls) were considered to be engaging in “at risk playing” (11). In the United Kingdom, a survey
of 387 adolescents (12–16 years of age) found that 20% met computer dependence using a scale
adapted from the DSM-III-R criteria for pathological gambling (12). A German National survey of
7000 gamers found that 12% met three of the criterion for internet addiction (9). Results of a
German nationwide survey of 44,610 male and female ninth-graders in 2007 and 2008 have shown
that 3% of the male and.3% of the female students were diagnosed as dependent on video games.
Video game dependency (VGD) was accompanied by increased levels of psychological and social
stress in the form of lower school achievement, increased truancy, reduced sleep time, limited
leisure activities, and increased thoughts of committing suicide. In addition, it becomes evident that
personal risk factors were crucial for VGD (13). Finally, a survey of 3,975 Turkish undergraduate
students found that the most preferred type of game was violent games; while preference for
strategy and fantasy role-play games has increased with age, preference for other games has
decreased (14). This review searched articles published between 2000 and 2009 in Medline and
PubMed using the key word computer and video game addiction over the topics of diagnosis,
phenomenology, epidemiology, and treatment. WHY DO PEOPLE BECOME ADDICTED TO COMPUTER
GAME PLAYING? Although repetition of favorite activities has a moderate effect upon computer
game addiction, flow experience, the emotional state embracing perceptional distortion and
enjoyment shows a strong impact on addiction in Taiwanese players (15). Responses of computer
game players in Taiwan have qualitatively reflected their psychological needs and motivations in
daily life, but also to the interplay of real self and virtual self, compensatory, or extensive satisfaction
for their needs and selfreflections (16). Social relationships and the specific time and flexibility
characteristics (“easy-in, easy-out”) in multiplayer browser games have been suggested as the main
cause for enjoyment in Germany (17). Game and internet addictions are also connected with
interpersonal relationship patterns (18). Competition, in contrast, seems to be less important for
browser gamers than for users of other game types. There is only weak evidence for the assumption
that aggressive behavior is associated with excessive gaming (9). Excessive computer game playing
could result in deficient visual-spatial ability (19). HEALTH HAZARDS The medical profession, for over
20 years, has voiced a number of concerns about video game playing. Back in the early 1980s,
rheumatologists described cases of “Pac 270 A. M. WEINSTEIN neuropathy (34). Recently, there is a
study describing ten patients who experienced epileptic seizures while playing the newest genre of
electronic games Massively Multiplayer Online Role-Playing Games (MMORPGs) (35). Patients were
predominantly young, male adults, and most of the events were generalized tonic-clonic seizures,
myoclonic seizures, and absences. The author suggested that while the prevalence of
MMORPGinduced seizures remains unknown, there should be an awareness of this special form of
reflex seizures in order to provide an appropriate health warning to MMORPG players. PREVENTION
AND TREATMENT There is preliminary evidence for success of an “initiated abstinence” 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 centers for video game
addiction. In 2009, ReSTART has set up a residential treatment center in Seattle, WA for pathological
internet use. There is little evidence for psychological or pharmacological treatment for video and
computer game addiction. A study using methylphenidate in 62 Korean children diagnosed with
ADHD and internet video game addiction was reported (2). After 8 weeks of treatment, measures of
internet use scores and internet usage times were significantly reduced, and these measures were
positively correlated with measures of attention. The authors suggest that internet video game
playing might be a means of self-medication for children with ADHD. In addition, they cautiously
suggest that Methylphenidate (MPH) might be evaluated as a potential treatment of Internet
addiction. In summary, there are very few clinical trials and no meta-analyses on treatment for
excessive computer game addiction. MOTORBIKE-RIDING COMPUTER GAME FOR QUANTIFYING
DOPAMINE RELEASE: RATIONALE AND AIMS OF THE STUDY Chronic use of psycho-stimulants such as
cocaine and methamphetamine results in long-term effects to the dopamine reward system. For
example, compared to healthy subjects, detoxified cocaine-dependent subjects exhibit reduced
striatal D2 receptor availability (37–39) and decreased drug-induced dopamine release (39, 40).
Currently, there is evidence that abstinent “ecstasy” users with a history of using sequential
“ecstasy” doses had no reductions in striatal dopamine transporter (DAT) binding (41). Since other
stimulant drug abusing populations show evidence of diminished dopamine responsiveness we 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 other psycho-stimulants
such as cocaine and methamphetamine might result in long-term changes to the dopaminergic
reward system. The effects of “ecstasy”-induced alterations on the dopamine reward circuit (basal
ganglia-thalamo-cortical circuit) are potentially secondary to the neurotoxic effects of “ecstasy” on
5-HT signaling. We, therefore, decided to investigate dopamine release in the brain during playing of
a motorbike riding computer game. Because some subjects were former chronic users of MDMA
(“ecstasy”), we were also able to evaluate whether past chronic use of “ecstasy” had any long-term
effects on game performance, levels of dopamine receptor occupancy, or dopamine release in the
striatum during game playing. Unfortunately, our study did not include computer game players since
our grant was limited to investigate drug addiction. BEHAVIORALLY-INDUCED DOPAMINE-RELEASE IN
THE BRAIN’S REWARD SYSTEM The quantification of dopamine release in the human brain is now
possible due to brain imaging techniques that measure dopamine D2 receptor availability in human
subjects using dopamine competition with either [123I] IBZM (a D2 receptor antagonist radiotracer)
in single photon emission computed tomography (SPECT) (42) or [11C] raclopride in positron
emission tomography (PET). Either [123I] IBZM or [11C] raclopride binding is sensitive to
endogenous DA concentration; this procedure can also be used to measure relative changes in DA
concentration secondary to pharmacological or behavioral interventions. Playing a computer tank
riding game can release dopamine in vivo in the human brain comparable to the dopamine released
as a result of pharmacological challenge with amphetamines (43). Behavioral paradigms, such as
playing a video game (43), monetary reward tasks (44), and non-hedonic food motivation (45) also
release dopamine in brain meso-limbic reward centers. PROCEDURE Subjects Nine former “ecstasy”
users (mean age 25 years (SD = 3.5); 8 males, 1 female) verified abstinent up to 1.5 years (mean = 5
months, range 1–18 months) and eight control subjects (mean age 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 number of tablets in their lifetime was 428.5 (range 30–1500). They used “ecstasy” on average
for 12 years and 3 months (SD = .92). They reported on average 7 times of using “ecstasy” in a
month during their last year of use before treatment (SD = 3.3) and time since last use was on
average 5 months (range 1–18 months). A list of all substances used by ex-”ecstasy” users is
presented in Table 1. The former “ecstasy”-users, recruited from drug treatment centers. Control
subjects were recruited through advertisement in treatment centers and the hospital. They reported
no current or recent use of “ecstasy” or marijuana. Five of the ex-“ecstasy” patients were treated
with antidepressant medication (Sertraline, Am J Drug Alcohol Abuse Downloaded from
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COMPUTER/VIDEO GAME ADDICTION 271 TABLE 1. List of drugs and alcohol use among ex-“ecstasy”
users. Drug Mean SD Range Cigarettes (per day) 17 6.75 5–30 Alcohol units per week 2.95 2.54 0–9
Amphetamines: lifetime number of tablets 2.8 4 0–10 Cocaine: lifetime number of times used 25 3.6
0–50 L.S.D.: lifetime number of tablets 75 80 0–500 Marijuana: number of cigarettes per day 11.8 11
1–30 Inhalants 20.8 62 0–200 Opiates: number of times used 2.4 3 0–8 PCP 0 0 0 Magic mushrooms:
lifetime number of use 9.4 16 0–50 Venlafaxine, Fluoxetine, and Escitalopram) and six of them were
treated with relaxants (Clonazepam and Diazepam). They were scanned six months after treatment
when they were not taking medication. Behavioral Computerized Game Commercially available
motorbike-riding computerized video game by “motogp” ultimate racing technology
(www.THQ.Co.UK) using a joystick. The time it took to complete each track on the racing field was
recorded on the computer. Procedure Eligible subjects gave written informed consent and were
admitted to the hospital at 10 a.m. Starting at 10:30 a.m., they received a bolus injection of 5–6 mCi
of [123I] IBZM, followed by constant infusion of 5–6 mCi of [123I] IBZM (1.7–2 mCi/hr for three
hours while resting on a hospital bed. Due to problems with radiation safety in our brain imaging
facility, we were not able to continue with constant infusion beyond 3 hours postinjection. We are
not aware of any literature precedents for using an altered [123I] IBZM infusion protocol like ours. In
healthy volunteers who were injected with bolus [123I] IBZM without constant infusion, pseudo-
equilibrium was achieved at 90 min post-bolus injection of [123I] IBZM, and it was maintained until
the end of the SPECT session at 3 hours postinjection (46). In our study, due to the termination of
constant infusion after 3 hours, there is a possibility of a higher rate of washout of the tracer from
the plasma, which might have affected the results. However, there is evidence that postinfusion
equilibrium is maintained, and the washout rate of the tracer from the plasma may have been
minimal, and it may have not affected our results (47). After a baseline SPECT scan, they returned to
their room and played the motorbike-riding computer game for 40 minutes. After game playing,
they had a second SPECT scan, followed after 15 minutes of rest by a third SPECT scan. Image
Analysis A measure of dopamine receptor occupancy obtained without plasma measurements is the
specific to nonspecific equilibrium partition 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 striatum and occipital cortex, respectively (42). This calculation has been
shown to give accurate values of V3” under equilibrium conditions. Its accuracy is not known under
the conditions of this study, where infusion was stopped before the first scan. All images 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 the MarsBaR tool
within SPM. RESULTS First, at baseline, there was no significant difference in D2 receptor occupancy,
i.e., partition coefficient (V3”), in abstinent “ecstasy” users compared with control subjects (.71 and
.86, respectively). Second, during performance of the video game, there was a 10.5% reduction,
compared to baseline, in the partition coefficient (V3”) in control subjects in the caudate, consistent
with increased dopamine release and binding to the D2 receptors. In control subjects, there were
lower rates of binding potential after motorbike riding game compared with baseline (scan 1 versus
scan 2) in the right caudate t (1,7) = 2.56; p < .05. There was no reduction in the abstinent “ecstasy”
users after performance of the video game in all parts of the striatum. Third, D2 receptor levels have
not returned to baseline after the third scan in control subjects consistently with results reported by
a previous study (22). Fourth, there was significant correlation between performance measures
(reaction time on the video game) of all subjects and baseline measures of binding potentials (scan
1) in the right caudate (r = .70; p < .001), left caudate (r = .67; p < .01), right putamen (r = .68; p <
.01), and left putamen (r = .72; p < .001). Fin 272 A. M. WEINSTEIN Right caudate 0 0.1 0.2 0.3 0.4 0.5
0.6 0.7 0.8 scan1 scan2 scan3 V3" controls patients Left caudate 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 scan1
scan2 scan3 V3" controls patients Right putamen 0 0.2 0.4 0.6 0.8 1 1.2 scan1 scan2 scan3 V3"
controls patients Left putamen 0 0.2 0.4 0.6 0.8 1 scan1 scan2 scan3 V3" controls patients 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 the motorbike video game. Figure 1 shows measures of partition coefficient (V3”)
in control subjects and abstinent “ecstasy” patients in the caudate and putamen divided by laterality
in all scans (1, 2, and 3). Table 2 shows average V3” measures and standard deviations in the caudate
putamen in control subjects and ex-“ecstasy” users in all scans. DISCUSSION Control subjects had
significant 10.5% reduction in binding potential measure in the caudate after performance
compared with their baseline measure, consistent with the results reported by a previous study (43)
that showed 13% reduction of binding potential in the ventral striatum after video game
performance. This is comparable to measures of dopamine release produced by amphetamine (49)
or methylphenidate (50, 51). This Am J Drug Alcohol Abuse Downloaded from
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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 Control subjects mean .64 .53 .44 mean .75 .65 .56 SD .29 .26 .17 SD
.36 .29 .23 Ex-“ecstasy” subjects mean .53 .50 .48 mean .61 .59 .54 SD .24 .13 .19 SD .16 .22 .20 Left
putamen Scan 1 Scan 2 Scan 3 Right putamen Scan 1 Scan 2 Scan 3 Control subjects mean .95 .88 .71
mean 1.10 1.00 .84 SD .40 .36 .30 SD .44 .36 .28 Ex-“ecstasy” subjects mean .80 .79 .78 mean .91 .92
.84 SD .26 .17 .29 SD .25 .20 .26 finding implies that video game playing is capable of significant
dopamine release that is comparable to the effects of psychostimulant drugs on the brain. It is
plausible that individuals who are addicted to video-game playing derive much pleasure from playing
these games due to extensive dopamine release. In contrast, former “ecstasy” users showed little
change in D2 binding potential in the caudate/putamen in response to video game performance.
This finding implies low brain dopamine response to natural reward presumably due to previous
sensitization to stimulant drugs that release a great amount of dopamine in their brain over time.
The finding of correlation between reaction time measurements and the baseline scan V3” for both
cohorts merits further consideration. Our findings suggest that there was no effect of game playing
on changes in V3” in ex-“ecstasy” users, even though their reaction times like comparison subject
reaction times were correlated with baseline scan V3”. These findings taken altogether may imply at
least a partial dissociation between 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,” which may have affected measures of binding potential especially in the case of
marijuana. Secondly, most ex-“ecstasy” users have been treated with Selective Serotonin Reuptake
Inhibitors (SSRIs) or relaxant medication (benzodiazepines), and these medications 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, but that would only mean that their
dopamine receptor occupancy should 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 affected the
results, but there is no evidence for any menstrual-cycledependent variation in D2 receptor density
detectable with single PET [11C] Raclopride (53). Fifthly, the second and third scans were not
performed under ideal conditions of equilibrium, and this may have affected the results due to
higher rates of washout. Finally, this is a small sample even for a brain imaging study due to strict
selection criteria. OVERALL DISCUSSION Computer or video game addiction, which is excessive or
compulsive use of computer and video games with resulting adverse consequences, is not clinically
defined as a part of behavioral addictions in DSM-IV. There is no official diagnosis or definition of the
disorder in any official diagnostic system. There were several studies investigating the prevalence of
this disorder; however, they used different scales adapted from the DSM-III-R criteria for
pathological gambling or other addictions to create diagnostic questionnaires. People like computer
game playing and become addicted to it due to repetition of favorable activities or emotional
experiences, experiences of fulfillment, social relationship, and flexibility, while the aspects of
competition and aggression have been discounted. Three different mechanisms have been
suggested as driving excessive computer gaming, although there have been very few psycho-
physiological investigations of these underlying mechanisms. First, it has been suggested that
computer games are inadequate means of coping with frustration, stress, and fears Am J Drug
Alcohol Abuse Downloaded from informahealthcare.com by Simon Fraser University on 04/04/11
For personal use only. 274 A. M. WEINSTEIN (5). The excessive usage of computer and video games
is seen as a rewarding behavior which can, due to learning mechanisms, become a prominent and
inadequate strategy for 11 to 14 year old children to cope with negative emotions like frustration,
uneasiness, and fears. Like substance abuse or addiction, excessive computer and video game
players use their excessive rewarding behavior specifically as an inadequate stress coping strategy. It
is also known that computer game addiction decreased the quality of interpersonal relationships and
the amount of social anxiety increased as the amount of time spent playing online games increased
(54). Secondly, and consistent with the stress-coping explanation, it has been suggested that in-
game reinforcement and skill significantly influence a number of affective measures, most notably
excitement, arousal, and frustration (55). Thirdly, excessive computer game playing may be
maintained through effects on reward and sensitization (56), similar to the longterm changes in the
brain reward circuitry thought to maintain substance dependence. Electroencephalographic
recordings in computer game players have shown increased emotional processing of computer-
related cues in parietal brain regions in pathologically excessive players compared with casual
players. Furthermore, when participants with online game addiction were presented with gaming
pictures and mosaic control pictures while undergoing functional magnetic resonance imaging
(fMRI), they have shown activation of the brain’s craving areas including the right orbito-frontal
cortex, right nucleus accumbens, bilateral anterior cingulate and medial frontal cortex, right dorso-
lateral prefrontal cortex, and right caudate nucleus (57). Thus, the results suggest that the gaming
urge/craving in online gaming addiction and craving in substance dependence might share the same
neurobiological mechanism. Finally, in an functional Magnetic Resonance Imaging (fMRI) study
contrasting a space-infringement game with a control task, males showed greater activation and
functional connectivity compared to females in the meso-cortico-limbic system (58). These findings
may be attributable to higher motivational states in males, as well as gender differences in reward
prediction, learning reward values, and cognitive state during computer video game playing. These
gender differences may help explain why males are more attracted to, and more likely to become
“hooked” on video games. The reward and sensitization explanation is consistent with growing
evidence that computer game playing addiction, similar to other behavioral addictions like
compulsive gambling, overeating, sex, and shopping, leads to long-term changes in the reward
circuitry that resemble the effects of substance dependence. Advanced brain imaging techniques
using the dopamine-competition paradigm can quantify dopamine release as result of computer
game playing. So far, playing computer games in healthy volunteers has shown dopamine release in
the striatum to a similar extent as pharmacological challenge, whereas we have shown that former
chronic users of “ecstasy” released very little dopamine after performance of a computer game. We
speculate that, similar to psycho-stimulant abusers, individuals diagnosed with behavioral addictions
such as gambling and computer game addiction would show reduced dopamine release after
performance of video games or gambling presumably due to sensitization. Future research could
investigate these individuals and could give a psycho-biological explanation to this emerging object
of scientific research. ACKNOWLEDGMENT We would like to thank Shaul Schreiber, Isachar Herman,
Omri Frisch, and Eitan Ekstein for providing access to their patients. We would like to thank the staff
at the Departments of Nuclear Medicine at Sourasky Medical Center and Hadassah Hospital,
particularly Einat Even-Sapir, Mazal Greemland, Hedva Lerman, Yodphat Krausz, and Boris Bakunin.
We would also like to thank David Nutt and Paul Grasby for early discussions and initiation of the
study, John Seibyl for advice concerning imaging, Nanette Freedman and Elisheva Deutz for image
analysis, and Marko Leyton and Mike Morgan for useful comments on the manuscript. Preliminary
results of this study were presented at the College of Problems of Drug Dependence annual meeting,
Orlando, FL, June 2005 and the European College of Neuropsychopharmacology annual meeting in
Vienna, Austria, October 2007. Declaration of Interest The reported research was funded by a grant
from the “Adams Trust” in Tel Aviv University and a grant from the Israeli AntiDrug Authority. Dr.
Weinstein is now supported by the Israeli Anti-Drug Authority and the National Institute for
Psychobiology in Israel. The authors report no conflict of interest. The authors alone are responsible
for the content and writing of this paper. REFERENCES 1. Griffiths MD. A “components” model of
addiction within a biopsychosocial framework. Journal of Substance Use 2005; 10:191–197. 2.
Griffiths MD. Videogame addiction: further thoughts and observations. Int J Ment Health Addiction
2008; 6:182–185. 3. Griffiths MD. Videogame addiction: Fact or fiction? In Willoughby T, Wood E,
(Eds.). Children’s Learning in a Digital World. Oxford: Blackwell Publishing, 2007; pp. 85–103. 4. te
Wildt BT, Putzig I, Zedler M, Ohlmeier MD. Internet dependency as a symptom of depressive mood
disorders. Psychiatr Prax 2007; 34(Suppl 3):S318–322. (in German) 5. Han D, Lee Y, Na C, Ahn J,
Chung U, Daniels M, Haws C, Renshaw P. The effect of methylphenidate on Internet video game play
in children with attention-deficit/hyperactivity disorder. Compr Psychiatry 2009; 50(3):251–256. 6.
Griffiths MD. Does Internet and computer “addiction” exist? Some case study evidence.
Cyberpsychol and Behav 2000; 3(2):211–218. 7. Griffiths MD. The role of context in online gaming
excess and addiction: Some case study evidence. Int J Ment Health Addiction 2010; 8:119– 125. Am J
Drug Alcohol Abuse Downloaded from informahealthcare.com by Simon Fraser University on
04/04/11 For personal use only. COMPUTER/VIDEO GAME ADDICTION 275 8. Grusser SM,
Thalemann R, Albrecht U, Thalemann CN. Excessive computer usage in adolescents—Results of a
psychometric evaluation. Wien Klin Wochenschr 2005; 117(5–6):188–195. (in German) 9. Grusser
SM, Thalemann R, Griffiths MD. Excessive computer game playing: evidence for addiction and
aggression? Cyberpsycho Behav 2007; 10(2):290–292. 10. Woelfling K, Thalemann R, Grusser SM.
Computer game addiction: A psychopathological symptom complex in adolescence. Psychiat Prax
2008; 35(5):226–232. (in German) 11. Johansson A, Gotestam KG. Problems with computer games
without mon- ¨ etary reward: similarity to pathological gambling. Psychol Rep 2005; 95(2):641–650.
12. Griffiths MD, Hunt N. Dependence on computer games by adolescents. Psychol Rep 1998;
82(2):475–480. 13. Rehbein F, Kleimann M, Moßle T. Prevalence and Risk Factors of Video ¨ Game
Dependency in Adolescence: Results of a German Nationwide Survey. Cyberpsychology, Behavior,
and Social Networking. [ePub ahead of print] doi:10.1089/cpb.2009.0227. 14. Tahiroglu AY, Celik GG,
Uzel M, Ozcan N, Avci A. Internet use among Turkish adolescents. Cyberpsychol Behav 2008;
11(5):537–543. 15. Chou TJ, Ting CC. The role of flow experience in cyber-game addiction.
Cyberpsychol Behav 2003; 6(6):663–675. 16. Wan CS, Chiou WB. Why are adolescents addicted to
online gaming? An interview study in Taiwan. Cyberpsychol Behav 2006; 9(6):762–766. 17. Klimmt C,
Schmid H, Orthmann J. Exploring the enjoyment of playing browser games. Cyberpsychol Behav
2009; 12(2):231–234. 18. Lee M, Ko Y, Song H, Kwon K, Lee H, Nam M, Jung I. Characteristics of
Internet use in relation to game genre in Korean adolescents. Cyberpsychol Behav 2007; 10(2):278–
285. 19. Sun DL, Ma N, Bao M, Chen XC, Zhang DR. Computer games: A doubleedged sword?
Cyberpsychol Behav 2008; 11(5):545–548. 20. Loftus GA, Loftus EF. Mind at Play: The Psychology of
Video Games. New York: Basic Books, 1983. 21. Griffiths M, Wood RTA. Risk factors in adolescence:
the case of gambling, videogame playing and the Internet. J Gambling Studies 2000; 16(2–3):199–
225. 22. Griffiths MD, Meredith A. Videogame Addiction and its treatment. J Contemp Psychother
2009; 39:247–253. 23. Spence SA. Nintendo hallucinations: A new phenomenological entity. Irish
Journal of Psychological Medicine 1993; 10:98–99. 24. Schink JC. Nintendo enuresis. American
Journal of Diseases in Children 1991; 145:1094. 25. Corkery JC. Nintendo power. American Journal of
Diseases in Children, 1990; 144:959. 26. McCowan TC. Space Invaders wrist. New England Journal of
Medicine 1981; 304:1368. 27. Miller DLG. Nintendo neck. Canadian Medical Association Journal
1991;145:1202. 28. Reinstein L. de Quervain’s stenosing tenosynovitis in a video games player.
Archives of Physical and Medical Rehabilitation 1983; 64:434–435. 29. Brasington R. Nintendinitis.
New England Journal of Medicine 1990; 322:1473–1474. 30. Casanova J, Casanova J. Nintendinitis.
Journal of Hand Surgery 1991; 16:181. 31. Siegal IM. Nintendonitis. Orthopedics 1991; 14:745. 32.
Cleary AG, Mckendrick H., Sills JA. Hand-arm vibration syndrome may be associated with prolonged
use of vibrating computer games. British Medical Journal 2002; 324:301. 33. Mirman MJ, Bonian VG.
“Mouse elbow:” A new repetitive stress injury. The Journal of the American Osteopathic Association
1992; 92: 701. 34. Friedland RP, St John, JN. Video-game palsy: Distalulnar neuropathy in a video
game enthusiast. New England Journal of Medicine 1984; 311: 58–59. 35. Chuang YC. Massively
multiplayer online role-playing game-induced seizures: A neglected health problem in Internet
addiction. Cyberpsychol Behav 2006; 9(4):451–456. 36. Kalke J, Raschke P. Learning by doing:
‘initiated abstinence,’ a schoolbased programme for the prevention of addiction. Results of an
evaluation study. Eur Addict Res 2004; 10(2):88–94. 37. Volkow ND, Fowler JS, Wolf AP, Schlyer D,
Shiue CY, Alpert R. Effects of chronic cocaine abuse on postsynaptic dopamine receptors. Am J
Psychiatry 1990; 147:719–724. 38. Volkow ND, Fowler JS, Wang GJ, Hitzemann R, Logan J, Schyler DJ.
Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in
cocaine abusers. Synapse1993; 14:169– 177. 39. Volkow ND, Wang GJ, Fowler, JS, Logan J, Gatley SJ,
Hitzemann R. Decreased striatal dopaminergic responsiveness in detoxified cocainedependent
subjects. Nature 1997; 386:830–833. 40. Martinez D, Broft A, Foltin RW, Slifstein M, Hwang D-R,
Huang Y, Perez A, Frankel WG, Cooper T, Kleber HD, Fischman MW, Laruelle M. Cocaine dependence
and D2 receptor availability in the functional subdivisions of the striatum: Relationship with cocaine-
seeking behavior. Neuropsychopharmacology 2004; 29:1190–1202. 41. McCann UD, Szabo Z,
Vranesic M, Palermo M, Mathews WB, Ravert HT, Dannals RF, Ricaurte GA. Positron emission
tomographic studies of brain dopamine and serotonin transporters in abstinent (+/−)3,4-
methylenedioxymethamphetamine (“ecstasy”) users: relationship to cognitive performance.
Psychopharmacology (Berl) 2008; 200(3):439– 450. 42. Laruelle M, Abi-Dargham A, van Dyck CH,
Rosenblatt W, Zea-Ponce Y, Zoghbi SS, Baldwin RM, Charney DS, Hoffer PB, Kung HF, Innis RB. SPECT
imaging of striatal dopamine release after amphetamine challenge. J Nuc Med 1995; 36:1182–1190.
43. Koepp MJ, Gunn RN, Lawrence AD, Cunningham VJ, Dagher A, Jones T, Brooks DJ, Bench CJ,
Grasby PM. Evidence for striatal dopamine release during a video game. Nature 1998; 393:266–268.
44. Zald DH, Boileau I, El-Dearedy W, Gunn R, McGlone F, Dichter GS, Dagher A. Dopamine
transmission in the human striatum during monetary reward tasks. J Neuroscience 2004;
24(17):4105– 4112. 45. Volkow ND, Wang G-J, Fowler JS, Logan J, Jayne M, Franchesi D, Wong C,
Gatley SJ, Gifford AN, Ding Y-S, Pappas N. “Nonhedonic” food motivation in humans involves
dopamine in the dorsal striatum and methylphenidate amplifies this effect. Synapse 2002; 44:175–
180. 46. Catafau AM, Bullich S, Danus M, Penengo MM, Cot A, Abanades S, ´ Farre M, Pav ´ ´ıa J, Ros
D. Test-retest variability and reliability of 123IIBZM SPECT measurement of striatal dopamine D2
receptor availability in healthy volunteers and influence of iterative reconstruction algorithms.
Synapse 2008; 62(1):62–69. 47. Seibyl JP, Zea-Ponce Y, Brenner L, Baldwin RM, Krystal JH, Offord SJ,
Machoviak S, Charney DS, Hoffer PB, Innis RB. Continuous intravenous infusion of Iodine-123-IBZM
for SPECT determination of human brain dopamine receptor occupancy by antipsychotic agent RWJ-
37796. J Nuc Med 1996; 37:11–15. 48. Buchert R, Berding G, Wilke F, Martin B, von Borczyskowski D,
Mester J, Brenner W, Clausen M. IBZM tool: A fully automated expert system for the evaluation of
IBZM SPECT studies. Euro J Nuc Med Mol Imaging 2006; 33(9):1073–1083. 49. Farde L, Nordstrom,
AL, Wiesel FA, Pauli S, Halldin C, Sedvall G. Positron ¨ emission tomography analysis of central D1
and D2 dopamine receptor occupancy in patients treated with classical neuroleptics and clozapine.
Arch Gen Psychiat 1992; 49:538–544. 50. Volkow ND, Wang GJ, Fowler JS, Logan J, Schlyer D,
Hitzemann R, Lieberman J, Angrist B, Pappas N, MacGregor R, et al. Imaging endogenous dopamine
competition with [11 C] raclopride in the human brain. Synapse 1994; 16:255–262. Am J Drug
Alcohol Abuse Downloaded from informahealthcare.com by Simon Fraser University on 04/04/11
For personal use only. 276 A. M. WEINSTEIN 51. Booij J, Korn P, Linszen DH, van Royen EA.
Assessment of endogenous dopamine release by methylphenidate challenge using iodine-123
iodobenzamide single-photon emission tomography. Euro J Nuc Med 1997; 24(6):674–677. 52.
Volkow ND, Ding YS, Fowler JS, Wang GJ, Logan J, Gatley SJ, Hitzemann R, Smith G, Fields SD, Gur R.
Dopamine transporters decrease with age. J Nuc Med 1996; 37(4):554–559. 53. Nordstrom A-L,
Olsson H, Halldin C, A PET study of D2 dopamine receptor density at different phases of the
menstrual cycle. Psychiat Res (Neuroimaging) 1998; 83:1–6. 54. Lo SK, Wang CC, Fang W. Physical
interpersonal relationships and social anxiety among online game players.Cyberpsychol Behav 2005;
8(1):15–20. 55. Chumbley J, Griffiths M. Affect and the computer game player: The effect of gender,
personality, and game reinforcement structure on affective responses to computer game-play.
Cyberpsychol Behav 2006; 9(3):308–316. 56. Thalemann R, Wolfling K, Grusser SM. Specific cue
reactivity on computer game-related cues in excessive gamers. Behav Neurosci 2007; 121(3):614–
618. 57. Ko CH, Liu GC, Hsiao S, Yen JY, Yang MJ, Lin WC, Yen CF, Chen CS. Brain activities associated
with gaming urge of online gaming addiction. J Psychiatr Res 2009; 43(7):739–747. 58. Hoeft F,
Watson CL, Kesler SR, Bettinger KE, Reiss AL. Gender differences in the mesocorticolimbic system