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COMPUTER/VIDEO GAME ADDICTION 269
done. According to Griffiths (6) case studies of individuals who video games. Video game dependency (VGD) was accompa-
use the Internet excessively may also provide better evidence of nied by increased levels of psychological and social stress in the
whether Internet addiction exists, because the data collected are form of lower school achievement, increased truancy, reduced
much more detailed than data from surveys. Case studies can sleep time, limited leisure activities, and increased thoughts of
highlight the role of context in distinguishing excessive gam- committing suicide. In addition, it becomes evident that per-
ing from addictive gaming and can demonstrate that excessive sonal risk factors were crucial for VGD (13). Finally, a survey
gaming does not necessarily mean that a person is addicted. It of 3,975 Turkish undergraduate students found that the most
is argued that online gaming addiction should be characterized preferred type of game was violent games; while preference for
by the extent to which excessive gaming impacts negatively on strategy and fantasy role-play games has increased with age,
other areas of the gamers’ lives rather than the amount of time preference for other games has decreased (14).
spent playing. It is also suggested that an activity cannot be This review searched articles published between 2000 and
described as an addiction if there are few (or no) negative con- 2009 in Medline and PubMed using the key word computer and
sequences in the player’s life even if the gamer is playing 14 video game addiction over the topics of diagnosis, phenomenol-
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neuropathy (34). Recently, there is a study describing ten pa- potentially secondary to the neurotoxic effects of “ecstasy” on
tients who experienced epileptic seizures while playing the 5-HT signaling.
newest genre of electronic games Massively Multiplayer Online We, therefore, decided to investigate dopamine release in the
Role-Playing Games (MMORPGs) (35). Patients were predom- brain during playing of a motorbike riding computer game. Be-
inantly young, male adults, and most of the events were gener- cause some subjects were former chronic users of MDMA (“ec-
alized tonic-clonic seizures, myoclonic seizures, and absences. stasy”), we were also able to evaluate whether past chronic use
The author suggested that while the prevalence of MMORPG- of “ecstasy” had any long-term effects on game performance,
induced seizures remains unknown, there should be an aware- levels of dopamine receptor occupancy, or dopamine release in
ness of this special form of reflex seizures in order to provide the striatum during game playing.
an appropriate health warning to MMORPG players. Unfortunately, our study did not include computer game play-
ers since our grant was limited to investigate drug addiction.
sures were positively correlated with measures of attention. The Playing a computer tank riding game can release dopamine in
authors suggest that internet video game playing might be a vivo in the human brain comparable to the dopamine released as
means of self-medication for children with ADHD. In addition, a result of pharmacological challenge with amphetamines (43).
they cautiously suggest that Methylphenidate (MPH) might be Behavioral paradigms, such as playing a video game (43), mon-
evaluated as a potential treatment of Internet addiction. In sum- etary reward tasks (44), and non-hedonic food motivation (45)
mary, there are very few clinical trials and no meta-analyses on also release dopamine in brain meso-limbic reward centers.
treatment for excessive computer game addiction.
PROCEDURE
MOTORBIKE-RIDING COMPUTER GAME FOR Subjects
QUANTIFYING DOPAMINE RELEASE: RATIONALE AND Nine former “ecstasy” users (mean age 25 years (SD = 3.5);
AIMS OF THE STUDY 8 males, 1 female) verified abstinent up to 1.5 years (mean = 5
Chronic use of psycho-stimulants such as cocaine and months, range 1–18 months) and eight control subjects (mean
methamphetamine results in long-term effects to the dopamine age 35.75 years(SD = 6.5); 7 males, 1 female). Former “ecstasy”
reward system. For example, compared to healthy subjects, users had less education (12 (.9) years) than control subjects
detoxified cocaine-dependent subjects exhibit reduced striatal (13.75 (1.6) years). Ex-“ecstasy” users used on average 220
D2 receptor availability (37–39) and decreased drug-induced “ecstasy” tablets (range 30–600) in their life, and total number
dopamine release (39, 40). Currently, there is evidence that ab- of tablets in their lifetime was 428.5 (range 30–1500). They
stinent “ecstasy” users with a history of using sequential “ec- used “ecstasy” on average for 12 years and 3 months (SD =
stasy” doses had no reductions in striatal dopamine transporter .92). They reported on average 7 times of using “ecstasy” in a
(DAT) binding (41). Since other stimulant drug abusing popu- month during their last year of use before treatment (SD = 3.3)
lations show evidence of diminished dopamine responsiveness and time since last use was on average 5 months (range 1–18
we have decided to test whether this observation extends to months). A list of all substances used by ex-”ecstasy” users is
“ecstasy” abusers in response to a non-drug reward/challenge. presented in Table 1.
We hypothesized that chronic use of “ecstasy,” similar to other The former “ecstasy”-users, recruited from drug treatment
psycho-stimulants such as cocaine and methamphetamine might centers. Control subjects were recruited through advertisement
result in long-term changes to the dopaminergic reward system. in treatment centers and the hospital. They reported no current
The effects of “ecstasy”-induced alterations on the dopamine or recent use of “ecstasy” or marijuana. Five of the ex-“ecstasy”
reward circuit (basal ganglia-thalamo-cortical circuit) are patients were treated with antidepressant medication (Sertraline,
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
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Venlafaxine, Fluoxetine, and Escitalopram) and six of them were Image Analysis
treated with relaxants (Clonazepam and Diazepam). They were A measure of dopamine receptor occupancy obtained without
scanned six months after treatment when they were not taking plasma measurements is the specific to nonspecific equilibrium
medication. 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
Behavioral Computerized Game and occipital cortex, respectively (42). This calculation has been
Commercially available motorbike-riding computerized shown to give accurate values of V3 ” under equilibrium condi-
video game by “motogp” ultimate racing technology tions. Its accuracy is not known under the conditions of this
For personal use only.
(www.THQ.Co.UK) using a joystick. The time it took to com- study, where infusion was stopped before the first scan. All im-
plete each track on the racing field was recorded on the computer. ages were registered and normalized to an IBZM template (48)
using the preprocessing tools of Statistical Parametric Mapping
(SPM). The image comparisons were then performed using the
Procedure MarsBaR tool within SPM.
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 [123 I] IBZM, followed RESULTS
by constant infusion of 5–6 mCi of [123 I] IBZM (1.7–2 mCi/hr First, at baseline, there was no significant difference in D2
for three hours while resting on a hospital bed. Due to problems receptor occupancy, i.e., partition coefficient (V3”), in absti-
with radiation safety in our brain imaging facility, we were not nent “ecstasy” users compared with control subjects (.71 and
able to continue with constant infusion beyond 3 hours postin- .86, respectively). Second, during performance of the video
jection. We are not aware of any literature precedents for using game, there was a 10.5% reduction, compared to baseline, in
an altered [123 I] IBZM infusion protocol like ours. In healthy the partition coefficient (V3”) in control subjects in the cau-
volunteers who were injected with bolus [123 I] IBZM without date, consistent with increased dopamine release and binding to
constant infusion, pseudo-equilibrium was achieved at 90 min the D2 receptors. In control subjects, there were lower rates of
post-bolus injection of [123 I] IBZM, and it was maintained un- binding potential after motorbike riding game compared with
til the end of the SPECT session at 3 hours postinjection (46). baseline (scan 1 versus scan 2) in the right caudate t (1,7) = 2.56;
In our study, due to the termination of constant infusion after p < .05. There was no reduction in the abstinent “ecstasy” users
3 hours, there is a possibility of a higher rate of washout of after performance of the video game in all parts of the striatum.
the tracer from the plasma, which might have affected the re- Third, D2 receptor levels have not returned to baseline after the
sults. However, there is evidence that postinfusion equilibrium third scan in control subjects consistently with results reported
is maintained, and the washout rate of the tracer from the plasma by a previous study (22). Fourth, there was significant correla-
may have been minimal, and it may have not affected our results tion between performance measures (reaction time on the video
(47). After a baseline SPECT scan, they returned to their room game) of all subjects and baseline measures of binding poten-
and played the motorbike-riding computer game for 40 minutes. tials (scan 1) in the right caudate (r = .70; p < .001), left caudate
After game playing, they had a second SPECT scan, followed (r = .67; p < .01), right putamen (r = .68; p < .01), and left
after 15 minutes of rest by a third SPECT scan. putamen (r = .72; p < .001). Finally, there was no difference
272 A. M. WEINSTEIN
Right caudate
0.8
0.7
0.6
0.5
controls
V3"
0.4
patients
0.3
0.2
0.1
0
scan1 scan2 scan3
Left caudate
0.7
0.6
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0.5
controls 0.4
V3"
patients 0.3
0.2
0.1
0
scan1 scan2 scan3
Right putamen
1.2
1
For personal use only.
0.8
controls
V3"
0.6
patients
0.4
0.2
0
scan1 scan2 scan3
Left putamen
1
0.8
controls 0.6
V3"
patients 0.4
0.2
0
scan1 scan2 scan3
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).
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 .64 .53 .44 mean .75 .65 .56
subjects
mean
SD .29 .26 .17 SD .36 .29 .23
Ex-“ecstasy” .53 .50 .48 mean .61 .59 .54
subjects
mean
SD .24 .13 .19 SD .16 .22 .20
Left putamen Scan 1 Scan 2 Scan 3 Right putamen Scan 1 Scan 2 Scan 3
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finding implies that video game playing is capable of significant availability measures decline about 6.6% every 10 years) (52).
dopamine release that is comparable to the effects of psycho- Fourthly, since there was only one female subject in each group,
For personal use only.
stimulant drugs on the brain. It is plausible that individuals who and they were both pre-menopausal, this may have affected
are addicted to video-game playing derive much pleasure from the results, but there is no evidence for any menstrual-cycle-
playing these games due to extensive dopamine release. In con- dependent variation in D2 receptor density detectable with single
trast, former “ecstasy” users showed little change in D2 binding PET [11 C] Raclopride (53). Fifthly, the second and third scans
potential in the caudate/putamen in response to video game per- were not performed under ideal conditions of equilibrium, and
formance. This finding implies low brain dopamine response this may have affected the results due to higher rates of washout.
to natural reward presumably due to previous sensitization to Finally, this is a small sample even for a brain imaging study
stimulant drugs that release a great amount of dopamine in their due to strict selection criteria.
brain over time.
The finding of correlation between reaction time measure-
ments and the baseline scan V3” for both cohorts merits further OVERALL DISCUSSION
consideration. Our findings suggest that there was no effect of Computer or video game addiction, which is excessive or
game playing on changes in V3” in ex-“ecstasy” users, even compulsive use of computer and video games with resulting
though their reaction times like comparison subject reaction adverse consequences, is not clinically defined as a part of be-
times were correlated with baseline scan V3”. These findings havioral addictions in DSM-IV. There is no official diagnosis
taken altogether may imply at least a partial dissociation be- or definition of the disorder in any official diagnostic system.
tween the reward and motor system consequences of “ecstasy” There were several studies investigating the prevalence of this
use. disorder; however, they used different scales adapted from the
There are several limitations to our study. First, our ex- DSM-III-R criteria for pathological gambling or other addic-
“ecstasy” patients have used other drugs than “ecstasy,” which tions to create diagnostic questionnaires. People like computer
may have affected measures of binding potential especially game playing and become addicted to it due to repetition of
in the case of marijuana. Secondly, most ex-“ecstasy” users favorable activities or emotional experiences, experiences of
have been treated with Selective Serotonin Reuptake Inhibitors fulfillment, social relationship, and flexibility, while the aspects
(SSRIs) or relaxant medication (benzodiazepines), and these of competition and aggression have been discounted.
medications are known to interact with the dopamine system, Three different mechanisms have been suggested as driving
although they were not medicated during scanning. Thirdly, excessive computer gaming, although there have been very few
the ex-“ecstasy” users were younger than control subjects, but psycho-physiological investigations of these underlying mech-
that would only mean that their dopamine receptor occupancy anisms. First, it has been suggested that computer games are
should be higher than control subjects (dopamine transporter inadequate means of coping with frustration, stress, and fears
274 A. M. WEINSTEIN
(5). The excessive usage of computer and video games is seen as abusers, individuals diagnosed with behavioral addictions such
a rewarding behavior which can, due to learning mechanisms, as gambling and computer game addiction would show reduced
become a prominent and inadequate strategy for 11 to 14 year dopamine release after performance of video games or gam-
old children to cope with negative emotions like frustration, un- bling presumably due to sensitization. Future research could
easiness, and fears. Like substance abuse or addiction, excessive investigate these individuals and could give a psycho-biological
computer and video game players use their excessive rewarding explanation to this emerging object of scientific research.
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 ACKNOWLEDGMENT
increased as the amount of time spent playing online games We would like to thank Shaul Schreiber, Isachar Herman,
increased (54). Secondly, and consistent with the stress-coping Omri Frisch, and Eitan Ekstein for providing access to their
explanation, it has been suggested that in-game reinforcement patients. We would like to thank the staff at the Departments of
and skill significantly influence a number of affective measures, Nuclear Medicine at Sourasky Medical Center and Hadassah
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most notably excitement, arousal, and frustration (55). Thirdly, Hospital, particularly Einat Even-Sapir, Mazal Greemland,
excessive computer game playing may be maintained through Hedva Lerman, Yodphat Krausz, and Boris Bakunin. We would
effects on reward and sensitization (56), similar to the long- also like to thank David Nutt and Paul Grasby for early dis-
term changes in the brain reward circuitry thought to maintain cussions and initiation of the study, John Seibyl for advice
substance dependence. Electroencephalographic recordings in concerning imaging, Nanette Freedman and Elisheva Deutz for
computer game players have shown increased emotional pro- image analysis, and Marko Leyton and Mike Morgan for useful
cessing of computer-related cues in parietal brain regions in comments on the manuscript. Preliminary results of this study
pathologically excessive players compared with casual play- were presented at the College of Problems of Drug Dependence
ers. Furthermore, when participants with online game addiction annual meeting, Orlando, FL, June 2005 and the European Col-
were presented with gaming pictures and mosaic control pic- lege of Neuropsychopharmacology annual meeting in Vienna,
tures while undergoing functional magnetic resonance imaging Austria, October 2007.
(fMRI), they have shown activation of the brain’s craving areas
For personal use only.
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