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Computer and Video Game Addiction—A

Comparison between Game Users and Non-Game
Users

Aviv Malkiel Weinstein

To cite this article: Aviv Malkiel Weinstein (2010) Computer and Video Game Addiction—A
Comparison between Game Users and Non-Game Users, The American Journal of Drug and
Alcohol Abuse, 36:5, 268-276, DOI: 10.3109/00952990.2010.491879

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The American Journal of Drug and Alcohol Abuse, 36:268–276, 2010
Copyright © Informa Healthcare USA, Inc.
ISSN: 0095-2990 print / 1097-9891 online
DOI: 10.3109/00952990.2010.491879
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 com-
pulsive use of computer and video games that may interfere with
daily life. It is not clear whether video game playing meets di-
agnostic 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. Meth-
ods: 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 ad-
diction 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 occu-
pancy of 10.5% in the caudate after playing a motorbike riding
computer game compared with baseline levels of binding consis-
tent with increased release and binding to its receptors. Ex-chronic
“ecstasy” users showed no change in levels of dopamine D2 recep-
tor occupancy after playing this game. Conclusion: This evidence
supports the notion that psycho-stimulant users have decreased
sensitivity to natural reward. Significance: Computer game ad-
dicts 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: avivweinstein@yahoo.com
268
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, tol-
erance, withdrawal symptoms, conflict, and relapse). He further
argued that video game addiction fulfils the criterion of addic-
tion 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 accompa-
nied 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 al-
though 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 tempo-
rary 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 hyper-
activity disorder [ADHD] or mania). There is a single study
suggesting co-morbidity with depression (4) and for comorbid-
ity 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 exces-
sive 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
 COMPUTER/VIDEO GAME ADDICTION
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 gam-
ing 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 con-
sequences 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 Man-
ual of Mental Disorders, Fourth Edition (DSM-IV) or ICD-
10 definition of a clinically significant pattern (consistent co-
occurrence 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 differ-
ent 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 es-
tablished 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 patholog-
ical 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 Ad-
diction 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). Re-
sults 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
269
video games. Video game dependency (VGD) was accompa-
nied 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 per-
sonal 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, phenomenol-
ogy, epidemiology, and treatment.
WHY DO PEOPLE BECOME ADDICTED TO COMPUTER
GAME PLAYING?
Although repetition of favorite activities has a moderate ef-
fect upon computer game addiction, flow experience, the emo-
tional state embracing perceptional distortion and enjoyment
shows a strong impact on addiction in Taiwanese players (15).
Responses of computer game players in Taiwan have qualita-
tively 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 self-
reflections (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 en-
joyment in Germany (17). Game and internet addictions are also
connected with interpersonal relationship patterns (18). Compe-
tition, 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 num-
ber of concerns about video game playing. Back in the early
1980s, rheumatologists described cases of “Pac-man’s Elbow”
and “Space Invaders’ Revenge” in which players have suffered
skin, joint, and muscle problems from repeated button hitting
and joystick pushing on the game machines (20). Early research
by Loftus and Loftus indicated that two-thirds of (arcade) video
game players examined complained of blisters, calluses, sore
tendons, and numbness of fingers, hands, and elbows directly as
a result of their playing. There have been a whole host of case
studies in the medical literature reporting some of the adverse
effects of playing video games (21, 22). These have included
auditory hallucinations (23), enuresis (24), encoprisis (25),
wrist pain (26), neck pain (27), elbow pain (27), tenosynovitis-
also called “nintendinitis” (28–31), hand-arm vibration syn-
drome (32), repetitive strain injuries (33), and peripheral
270 A. M. WEINSTEIN
neuropathy (34). Recently, there is a study describing ten pa-
tients who experienced epileptic seizures while playing the
newest genre of electronic games Massively Multiplayer Online
Role-Playing Games (MMORPGs) (35). Patients were predom-
inantly young, male adults, and most of the events were gener-
alized tonic-clonic seizures, myoclonic seizures, and absences.
The author suggested that while the prevalence of MMORPG-
induced seizures remains unknown, there should be an aware-
ness 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 ab-
stinence” 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 cen-
ters 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 phar-
macological 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 mea-
sures 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 sum-
mary, 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 ab-
stinent “ecstasy” users with a history of using sequential “ec-
stasy” doses had no reductions in striatal dopamine transporter
(DAT) binding (41). Since other stimulant drug abusing popu-
lations 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. Be-
cause some subjects were former chronic users of MDMA (“ec-
stasy”), 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 play-
ers 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 mea-
sure dopamine D2 receptor availability in human subjects using
dopamine competition with either [123 I] IBZM (a D2 receptor
antagonist radiotracer) in single photon emission computed to-
mography (SPECT) (42) or [11 C] raclopride in positron emission
tomography (PET). Either [123 I] IBZM or [11 C] raclopride bind-
ing is sensitive to endogenous DA concentration; this procedure
can also be used to measure relative changes in DA concentra-
tion 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), mon-
etary 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,
 COMPUTER/VIDEO GAME ADDICTION
TABLE 1.
List of drugs and alcohol use among ex-“ecstasy” users.
Drug Mean
Cigarettes (per day) 17
Alcohol units per week 2.95
Amphetamines: lifetime number of tablets 2.8
Cocaine: lifetime number of times used 25
L.S.D.: lifetime number of tablets 75
Marijuana: number of cigarettes per day 11.8
Inhalants 20.8
Opiates: number of times used 2.4
PCP 0 0
Magic mushrooms: lifetime number of use 9.4
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 com-
plete 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 [123 I] IBZM, followed
by constant infusion of 5–6 mCi of [123 I] 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 postin-
jection. We are not aware of any literature precedents for using
an altered [123 I] IBZM infusion protocol like ours. In healthy
volunteers who were injected with bolus [123 I] IBZM without
constant infusion, pseudo-equilibrium was achieved at 90 min
post-bolus injection of [123 I] IBZM, and it was maintained un-
til 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 re-
sults. 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.
271
SD Range
6.75 5–30
2.54 0–9
4 0–10
3.6 0–50
80 0–500
11 1–30
62 0–200
3 0–8
0
16 0–50
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 condi-
tions. Its accuracy is not known under the conditions of this
study, where infusion was stopped before the first scan. All im-
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
MarsBaR tool within SPM.
RESULTS
First, at baseline, there was no significant difference in D2
receptor occupancy, i.e., partition coefficient (V3”), in absti-
nent “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 cau-
date, 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 correla-
tion between performance measures (reaction time on the video
game) of all subjects and baseline measures of binding poten-
tials (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). 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
0.5
controls 0.4

V3"
patients 0.3
0.2
0.1
0
scan1 scan2 scan3

Right putamen
1.2
1
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).

in performance (reaction-time) between the two groups on the DISCUSSION

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.
Control subjects had significant 10.5% reduction in bind-
ing potential measure in the caudate after performance com-
pared 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 perfor-
mance. This is comparable to measures of dopamine release pro-
duced by amphetamine (49) or methylphenidate (50, 51). This
 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 .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
Control .95 .88 .71 mean 1.10 1.00 .84
subjects
mean
SD .40 .36 .30 SD .44 .36 .28
Ex-“ecstasy” .80 .79 .78 mean .91 .92 .84
subjects
mean
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 psycho-
stimulant 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 con-
trast, former “ecstasy” users showed little change in D2 binding
potential in the caudate/putamen in response to video game per-
formance. 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 measure-
ments 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 be-
tween 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-cycle-
dependent variation in D2 receptor density detectable with single
PET [11 C] 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 be-
havioral 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 addic-
tions 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 mech-
anisms. First, it has been suggested that computer games are
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
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, un-
easiness, 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 long-
term changes in the brain reward circuitry thought to maintain
substance dependence. Electroencephalographic recordings in
computer game players have shown increased emotional pro-
cessing of computer-related cues in parietal brain regions in
pathologically excessive players compared with casual play-
ers. Furthermore, when participants with online game addiction
were presented with gaming pictures and mosaic control pic-
tures 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 accum-
bens, 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 moti-
vational 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, sim-
ilar 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 re-
lease as result of computer game playing. So far, playing com-
puter games in healthy volunteers has shown dopamine release
in the striatum to a similar extent as pharmacological chal-
lenge, 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 gam-
bling 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 dis-
cussions 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 Col-
lege 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 Anti-
Drug 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.
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