Transdiagnostic Connectome-Based Prediction of Craving.

OBJECTIVE: Craving is a central construct in the study of motivation and human behavior and is also a clinical symptom of substance and non-substance-related addictive disorders. Thus, craving represents a target for transdiagnostic modeling. METHODS: The authors applied connectome-based predictive modeling (CPM) to functional connectivity data in a large (N=274) transdiagnostic sample of individuals with and without substance use-related conditions, to predict self-reported craving. Functional connectomes derived from three guided imagery conditions of personalized appetitive, stress, and neutral-relaxing experiences were used to predict craving rated before and after each imagery condition. The generalizability of the "craving network" was tested in an independent sample using functional connectomes derived from a cue-induced craving task collected before and after fasting to predict craving rated during fasting. RESULTS: CPM successfully predicted craving, thereby identifying a transdiagnostic "craving network." Anatomical localization of model contribution suggested that the strongest predictors of craving were regions of the salience, subcortical, and default mode networks. As external validation, in an independent sample, the "craving network" predicted food craving during fasting using data from a cue-induced craving task. CONCLUSIONS: These data provide a transdiagnostic perspective to a key phenomenological feature of addictive disorders-craving-and identify a common "craving network" across individuals with and without substance use-related disorders, thereby suggesting a neural signature for craving or urge for motivated behaviors.

Development, Content Validation, and Feasibility of Yoga Module for Smartphone Addiction.

Context: Mental health practitioners have postulated that smartphone addiction is a disorder characterized by maladaptive and problematic behavior, and treatment modalities are scarce. Yoga has been found to be a viable tool for addiction treatment and other psychiatric conditions, but no specific validated module is currently available for smartphone addiction. Objective: The study intended: (1) to develop a yoga-based intervention for smartphone addiction, based on the ancient literature of yoga and a modern literature review; (2) to validate the developed module with experts from different schools of yoga; and (3) to test the module's feasibility and efficacy for young adolescents, with the objective of creating biopsychosocial well-being. Design: The research team first conducted a search of traditional and contemporary literature, with the objective of developing the yoga program. That yoga program was then sent to yoga experts for content validation. A pilot study then tested the feasibility of using the developed module for individuals with internet and smartphone addiction. Setting: The study took place in Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) University, Bengaluru, India. Participants: For content validity, participants were 15 yoga experts who had >10 years of experience in treating mental health disorders. For feasibility in a pilot study, participants were 22 students from an engineering college in Bengaluru, South India. Outcome Measures: For content validity, the experts' opinions were rated using a content validation ratio (CVR) through Lawshe's formula. For the feasibility study, assessments were performed at baseline and post intervention. Data were collected to evaluate: (1) addiction level using the Smartphone Addiction Scale - Short Version (SAS-SV), (2) impulsiveness using the Barat Impulsive Scale (BIS); (3) sleep problems using the Pittsburgh Sleep Quality Index (PSQI), (4) mindfulness using the Mindful Attention Awareness Scale (MAAS), (4) self-regulation using the Short Self-Regulation Questionnaire (SSRQ); and general health using the General Health Questionnaire (GHQ-12). Results: In the final version of the module, 26 out of 35 items (74.28%) of the practices in the developed program were retained, together with the modifications suggested by the experts. The content validity index for the whole module, an average of all CVRs, was 0.74. The study found significant reductions in the most symptom scores after participants practiced the yoga module for six weeks. Conclusions: A yoga module for smartphone addiction was developed, validated, and checked for feasibility. The content validity of the module was found to be good. The module was found to potentially useful for reducing symptoms in individuals with smartphone addiction. Future studies should test the efficacy of the developed program through a randomized, controlled clinical trial.

Treatment effectiveness of a mindfulness-based inpatient group psychotherapy in adolescent substance use disorder - study protocol for a randomized controlled trial.

BACKGROUND: Current treatments for adolescents with substance use disorder (SUD) have had only limited success. In recent years, research has underlined the role of self-regulatory processes and impulsivity in the development and maintenance of SUD in adolescents. Mindfulness has gained much attention due to its capacity to influence self-regulatory processes, particularly in adult populations. Initial studies have shown the potential of mindfulness-based approaches in younger SUD patients. The aim of the present clinical trial is to evaluate the added treatment effect of a mindfulness-based group psychotherapy ("Mind it!") for adolescents with SUD in comparison to the current standard treatment. Moreover, we seek to explore the feasibility of the intervention and possible mediators of treatment effects. METHODS/DESIGN: There will be N = 340 participants aged between 13 and 19 years who are receiving child or adolescent psychiatric or psychotherapeutic inpatient or day treatment targeting their SUD and who have reported substance use 30 days before detoxification and do not show acute psychotic or suicidal symptoms at baseline. The study is a prospective randomized controlled multi-center trial in which patients are assessed: (1) after completing a prior detoxification phase (t0), (2) at 4 weeks (t1), (3) at 8 weeks (t2), and (4) at 6 months after t2 (t3). Participants in the intervention group will receive mindfulness-based group psychotherapy in addition to their existing treatment regime. The primary outcome is substance use in the past 30 days at follow-up based on the Timeline Followback self-report. Secondary outcomes include craving, severity of dependence, and abstinence motivation. Mindfulness, impulsivity, and emotion regulation will be analyzed as possible mediators of treatment effects. DISCUSSION: This trial is expected to provide evidence of the added effect of a novel, safe, and feasible treatment option for adolescents with SUD. TRIAL REGISTRATION: German Register of Clinical Studies, DRKS00014041 . Registered on 17 April 2018.

Automatic detection advantage of network information among Internet addicts: behavioral and ERP evidence.

Converging evidence has proved the attentional bias of Internet addicts (IAs) on network information. However, previous studies have neither explained how characteristics of network information are detected by IAs with priority nor proved whether this advantage is in line with the unconscious and automatic process. To answer the two questions, this study aims to investigate whether IAs prioritize automatic detection of network information from the behavior and cognitive neuroscience aspects. 15 severe IAs and 15 matching healthy controls were selected using Internet Addiction Test (IAT). Dot-probe task with mask was used in the behavioral experiment, while deviant-standard reverse oddball paradigm was used in the event-related potential (ERP) experiment to induce mismatch negativity (MMN). In the dot-probe task, when the probe location appeared on the Internet-related picture's position, the IAs had significantly shorter reaction time than do the controls; in the ERP experiment, when Internet-related picture appeared, MMN was significantly induced in the IAs relative to the controls. Both experiments show that IAs can automatically detect network information.

An Observational Study of Treatment Seeking Users of Natural Opiates from India.

BACKGROUND: The type of opioid used influences the severity and complications experienced. Natural opiates (opium and poppy husk) use is a socio-culturally accepted phenomenon reported in India. However, studies on their profile, quality of life, and addiction severity are limited. OBJECTIVES: The objective of this cross-sectional, observational study was to assess the socio-demographic profile, clinical profile, addiction severity, and quality of life of treatment-seeking natural opiate users. METHOD: Hundred subjects aged 18-65 years using opium or poppy husk seeking outpatient treatment at a tertiary addiction treatment center in India were interviewed to collect information on their socio-demography, natural opiate, and other substance use. Additionally, their addiction severity and quality of life were assessed using Addiction Severity Index-Lite and WHO Quality of Life-Bref instrument, respectively. RESULTS: All subjects were male with a mean age of 44.6 (±11.0) years. Majority (97%) used poppy husk daily orally. Curiosity/experimentation (63%) was the most common reason for starting opiate use. The past month rates of tobacco, alcohol, cannabis, and sedative-hypnotics use was 58%, 33%, 3%, and 12%, respectively. Only 4% injected any opioid. Inability to afford opiates (72%) was the most common reason for seeking treatment. Rates of medical, familial, social, psychological, and legal complications were low, while the WHOQOL-BREF scores fell between 40 and 50 across various domains. Conclusions/Importance: Natural opiate users may constitute distinct subgroup of opioid users with fewer/no complications despite long duration of uninterrupted use. These findings would be important in planning management strategies for people dependent on natural opiates.

A novel approach of substitution therapy with inhalation of essential oil for the reduction of inhalant craving: A double-blinded randomized controlled trial.

Inhalants, which are neurotoxic central nervous system (CNS) suppressants, are frequently abused by young adults. Unlike other CNS depressants, including alcohol and opiates, no treatment is currently approved for inhalant dependence. In this report, a novel approach of substitution treatment for inhalant addiction was explored in a double-blinded, randomized, controlled crossover design to examine the effects of inhalation of essential oil and perfume on the reduction of cue-induced craving for inhalant in thirty-four Thai males with inhalant dependence. The craving response was measured by the modified version of Penn Alcohol Craving Score for Inhalants (PACS-inhalants). The participants (mean age ± SE = 27.9 ± 1.4) in this trial had used inhalant for 5.8 ± 1.1 years. Cravings could be induced in all participants by visual cues as assessed by ^50% increases in inhalant craving levels. Generalized estimating equations showed a significant suppressant effect of essential oil, but not perfume, on the craving response as compared with baseline cue-induced craving. Moreover, essential oil, but not perfume, had significant effects on physiological responses including decreasing pulse rate. It is concluded that inhaling essential oil as a substitution treatment for inhalant may be used as part of treatment programs for reducing inhalant craving.

Physical Therapy.

Physical therapy has the evidence-based science knowledge to address a wide range of physical and psychological problems of addiction. Neuromodulation techniques are becoming more and more important in the treatment of addiction. Here, the efficacy of different neuromodulation techniques in addiction, such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), is critically evaluated. Other physical therapy methods including Biofeedback, Physical Activity and Acupuncture are also presented.

Traditional Chinese Medicine (TCM) Therapy.

Traditional Chinese Medicine(TCM) has been utilized in China for more than 2,000 years, and it has been practiced in treatment of substance addiction and non-substance addictions. TCM have efficacy in the rehabilitation of abnormal physical problems induced by chronic drug use, including improving immune function, increasing working memory, and protecting against neurological disorders. Given that TCM is potentially effective in the prevention of relapse, it has been suggested that TCM may be the ideal choice in the future for the treatment of opiate addiction. This review examines the significance of effective Chinese herbs and prescriptions for Drug Addiction, Alcohol addiction and food addiction.

Nutrition Support Therapy.

In most addictions, serious nutritional deficiencies of major proteins, fats, vitamins and minerals exist which prevent their capability to digest carbohydrates efficiently. This review aims to point out some treatment approaches in nutrition management for alcohol addiction, drug addiction, food addiction, Internet addiction and sex addiction, according to existing literatures.

Recreational stimulants, herbal, and spice cannabis: The core psychobiological processes that underlie their damaging effects.

AIMS: Recreational drugs are taken for their positive mood effects, yet their regular usage damages well-being. The psychobiological mechanisms underlying these damaging effects will be debated. METHODS: The empirical literature on recreational cannabinoids and stimulant drugs is reviewed. A theoretical explanation for how they cause similar types of damage is outlined. RESULTS: All psychoactive drugs cause moods and psychological states to fluctuate. The acute mood gains underlie their recreational usage, while the mood deficits on withdrawal explain their addictiveness. Cyclical mood changes are found with every central nervous system stimulant and also occur with cannabis. These mood state changes provide a surface index for more profound psychobiological fluctuations. Homeostatic balance is altered, with repetitive disturbances of the hypothalamic-pituitary-adrenal axis, and disrupted cortisol-neurohormonal secretions. Hence, these drugs cause increased stress, disturbed sleep, neurocognitive impairments, altered brain activity, and psychiatric vulnerability. Equivalent deficits occur with novel psychoactive stimulants such as mephedrone and artificial "spice" cannabinoids. These psychobiological fluctuations underlie drug dependency and make cessation difficult. Psychobiological stability and homeostatic balance are optimally restored by quitting psychoactive drugs. CONCLUSIONS: Recreational stimulants such as cocaine or MDMA (3.4-methylenedioxymethamphetamine) and sedative drugs such as cannabis damage human homeostasis and well-being through similar core psychobiological mechanisms.

[Food addiction: Definition, measurement and limits of the concept, associated factors, therapeutic and clinical implications]. / L'addiction à l'alimentation : définition, mesure et limites du concept, facteurs associés et implications cliniques et thérapeutiques.

Addictions, which are characterized by the inability to control a behavior despite existence of physical or psychological consequences, have biological, psychological and social determinants. Although the possibility of developing an addiction to some psychoactive substances (e.g. alcohol, tobacco, cannabis) and to gambling (i.e., gambling disorder) is now well demonstrated, the possibility to develop a non-drug addiction (i.e., behavioral addiction) to certain behaviors which provide pleasure (e.g. eating, having sex, buying things) is still in debate. The concept of food addiction, which refers to people who exhibit substance dependence criteria in relation to some high-fat and high-sugar foods, was recently proposed by applying substance dependence DSM criteria to eating behavior. To assess food addiction, the Yale Food Addiction Scale is now the only self-administered questionnaire (diagnosis and estimate of the number of symptoms of food addiction). Prevalence for food addiction is higher in overweight and obese patients, and in patients with certain psychopathological characteristics (i.e., depression, Attention Deficit Hyperactivity Disorder, high impulsivity), in patients who are single and in patients with neurobiological alterations in the reward system. However, it is still unclear whether food addiction is necessary associated with subsequent increase in body weight and/or obesity. An increasing number of studies demonstrated that drug addiction and food addiction shares some similar clinical, neurobiological and psychopathological and sociocultural risk factors. To test the pertinence to include food addiction as an addiction, it would be interesting to conduct future studies in patients who may experience harms related to their food addiction, including not only patients with obesity, but also patients with metabolic syndrome, type 2 diabetes, hypertension, dyslipidemia, atherosclerosis, stroke, or coronary heart disease. Food addiction is a clinical and multidimensional concept which requires integrated care with psychotherapy, pharmacological and social lines of approach. This concept has also practical implications in terms of prevention and public health (e.g., prevention, brief interventions, possible law enforcement regarding some kinds of food which could present some addictive properties).

The Role of Habits in Massive Multiplayer Online Role-Playing Game Usage: Predicting Excessive and Problematic Gaming Through Players' Sensitivity to Situational Cues.

We examined the effect of habitual regulation of massive multiplayer online role-playing game (MMORPG) playing on the problematic (addictive) usage and excessiveness of gaming (time that user spent playing weekly, per session, and in relation to his other leisure activities). We developed the approach to assess the strength of habitual regulation that was based on sensitivity to situational cues. We defined cues as real-life or in-game conditions (e.g., work to be done, activities with friends or family, need to relax, new game expansion) that usually promote gaming (proplay cues) or prevent it (contraplay cues). Using a sample of 377 MMORPG players, we analyzed relationships between variables through partial least squares path modeling. We found that proplay cues sensitivity significantly positively affected the excessiveness of gaming (playing time) as well as the occurrence of problematic usage symptoms. Conversely, contraplay cues sensitivity functioned as a protective factor from these conditions; significant negative effects were found for playing time and problematic usage. Playing time was confirmed to be a mediating variable, affected by cues sensitivity and at the same time affecting problematic usage symptoms. We obtained moderately strong coefficients of determination for both endogenous variables (R(2) = 0.28 for playing time; R(2) = 0.31 for problematic usage) suggesting that the proposed variables possess good explanatory power. Based on our results, we argue that the strength of habitual regulation within MMORPG usage has both positive and negative effects on excessive and problematic usage, which is a new and important finding within the area of Internet gaming addiction.

Attentional bias and executive control in treatment-seeking substance-dependent adolescents: A cross-sectional and follow-up study.

BACKGROUND: Research in adults shows that substance dependent individuals demonstrate attentional bias (AB) for substance-related stimuli. This study investigated the role of AB in adolescents diagnosed with alcohol, cannabis, amphetamine or GHB dependency on entering therapy and six months later, and the role of executive control (EC) as a moderator of the relationship between problem severity and AB. METHODS: Seventy-eight young substance-dependent (SD) patients (mean age=19.5), and 64 healthy controls (HC; mean age=19.0) were tested. Thirty-eight SD patients took part at 6-month follow-up (FU). AB was indexed by a visual probe task, EC by the attention network task, problem severity by the short alcohol (or drug) use disorder identification test and the severity of dependence questionnaire. RESULTS: SD patients demonstrated an AB for substance stimuli presented for 500 ms and 1250 ms, with the latter related to severity of dependence. There was a nonsignificant tendency indicating that EC was higher in HC than SD participants, but EC did not moderate the relationship between AB and dependency. Substance use, dependency, EC and AB remained unchanged in the 6 month FU period. CONCLUSIONS: Young SD patients showed a stronger relatively early as well as maintained AB toward substance cues. A stronger maintained attention was related to higher severity of dependence. Further, there were some indications that EC might play a role in adolescent substance use. The finding that at FU AB and problem severity were not decreased, and EC was not increased underlines the persistent character of addiction.

["What I don't Appreciate in Real Life": Online Role Playing Game Addiction of an Adolescent--Case Study]. / ¼Was ich am richtigen Leben nicht so schätze« Online-Rollenspielsucht eines Jugendlichen--Fallstudie.

The present article aims to provide an insight into the life story of a computer-game addicted adolescent. Here, the relationship between the symptom game addiction, the family as a reference framework, the game's characteristics, as well as the subjective emotional state of the adolescent are of particular interest. An emphasis is also laid on the psychodynamically approached question of the impact of infantile and current relationship experiences (both within a family environment as well as with peers) on personal development. Last, still within a psychodynamic framework, we hope to provide a better understanding of the role of online computer-game addiction in the process of experiences potentially dominated by conflicts.

An Evaluation of the Italian Version of the Yale Food Addiction Scale in Obese Adult Inpatients Engaged in a 1-Month-Weight-Loss Treatment.

Addiction is a compulsive need for and use of a specific substance leading to a habit, tolerance, and psychophysiological symptoms. Excessive food consumption is similar to that of substance addiction. Some individuals who have trouble losing weight display addictive eating symptoms. To investigate food addiction in a sample of obese adults referred to hospital for a 1-month-weight-loss treatment. The Italian version of the Yale Food Addiction Scale (YFAS-16) was used as a screening tool in 88 obese inpatients. The construct validity of the YFAS-16 was assessed by testing its correlations with measures of binge eating (Binge Eating Scale), impulsiveness (Barratt Impulsiveness Scale), and emotional dysregulation (Difficulties in Emotion Regulation Scale). 34.1% of our sample was diagnosed with YFAS food addiction. Such diagnosis was also supported by strong associations between FA and psychological and behavioral features, typically descriptive of classic addiction. Patients who endorsed the YFAS-16 criteria for food addiction (FA) had significantly higher binge eating levels, greater emotional dysregulation, and nonacceptance of negative feelings; they lacked goal-oriented behavior, had little impulse control, had difficulty in emotion recognition, and attentional impulsivity; and they were unable to concentrate and lacked inhibitory control behavior, unlike participants who did not meet the FA criteria. Further research is needed to support the reliability of the YFAS-16. This measure has the potential to be applied in epidemiological research, estimating the prevalence of FA within the Italian population and to assess new treatments' efficacy for obese patients with food addiction symptoms seeking weight-loss treatments.

[Spirituality in schizophrenic diseases]. / Spiritualität bei schizophrenen Erkrankungen.

OBJECTIVE: The aim of this study was to investigate different dimensions of religiosity and spirituality among schizophrenic inpatients (F 2x) compared to addiction patients (F 10.2, F 19.2) and to healthy controls. In addition the dimensions of religious and spiritual well-being were examined and related to different parameters of mental illness. METHOD: The group of schizophrenic patients (n = 39) was compared to a group of addiction patients (n = 33) and a healthy control group (n = 38) by means of the multidimensional inventory for religious/spiritual well-being (MI-RSWB). Additionally, dimensions of RSWB were related to the Beck depression inventory (BDI) and the brief symptom inventory (BSI) in the group of schizophrenic patients. RESULTS: The group of schizophrenic patients did not differ from the addiction patients or from the healthy controls in the RSWB dimensions, except for the hope transcendent sub-dimension. Furthermore, dimensions of RSWB turned out to be negatively correlated with the severity of psychiatric symptoms (BDI and BSI). CONCLUSION: As assumed a positive relationship between RSWB and subjective well-being can be confirmed also for the group of schizophrenic patients. Existentially oriented dimensions such as hope and forgiveness might be specifically relevant for the group of schizophrenics.

Physiological arousal deficits in addicted gamers differ based on preferred game genre.

BACKGROUND/AIMS: There has been significant discussion surrounding the psychopathology of excessive gaming and whether it constitutes an addiction. The current study investigated physiological and subjective levels of arousal in gamers of two genres and the relationship between sensation seeking and gaming addiction. METHODS: Heart rate (HR), blood pressure (BP) and skin conductance were recorded at baseline, during gaming for 15 min and after gaming in 30 massively multiplayer online role-playing game (MMORPG) and 30 first-person shooter (FPS) male gamers. Gamers were identified as addicted using the Addiction-Engagement Questionnaire. Sensation seeking was measured using the Arnett Inventory of Sensation Seeking. RESULTS: Addicted MMORPG gamers (n=16) displayed significant decreases in cardiovascular activity during gaming compared to baseline and showed significant increases after gaming. Addicted FPS gamers (n=13) had significant increases in BP during gaming which decreased significantly after gaming. In comparison, non-addicted MMORPG gamers (n=14) had significant decreases in HR during gaming, whereas BP in non-addicted MMORPG and FPS gamers (n=17) increased during gaming and after gaming. There were no significant relationships between sensation seeking and addiction. CONCLUSION: There are physiological arousal deficits in addicted gamers, and these patterns differ according to the genre of game played.

Cue-elicited anxiety and craving for food using virtual reality scenarios.

Cue exposure therapy has been reported to be an effective intervention for reducing binge eating behavior in patients with eating disorders and obesity. However, in vivo food exposure conducted in the therapist's office presents logistical problems and lacks ecological validity. This study proposes the use of virtual reality technology as an alternative to in vivo exposure, and assesses the ability of different virtual environments to elicit anxiety and craving for food in a non-clinical sample. The results show that exposure to virtual environments provokes changes in reported craving for food. High-calorie food cues are the ones that elicit the highest increases in craving.

Cannabis intoxication inhibits avoidance action tendencies: a field study in the Amsterdam coffee shops.

RATIONALE: Experimental laboratory studies suggest that the approach bias (relatively fast approach responses) toward substance-related materials plays an important role in problematic substance use. How this bias is moderated by intention to use versus recent use remains unknown. Moreover, the relationship between approach bias and other motivational processes (satiation and craving) and executive functioning remains unclear. OBJECTIVES: The aim of this study was to investigate the cannabis approach bias before and after cannabis use in real-life setting (Amsterdam coffee shops) and to assess the relationship between approach bias, craving, satiation, cannabis use, and response inhibition. METHODS: Cannabis, tobacco, and neutral approach and avoidance action tendencies were measured with the Approach Avoidance Task and compared between 42 heavy cannabis users with the intention to use and 45 heavy cannabis users shortly after cannabis use. The classical Stroop was used to measure response inhibition. Multiple regression analyses were conducted to investigate relationships between approach bias, satiation, craving, cannabis use, and response inhibition. RESULTS: In contrast to the hypotheses, heavy cannabis users with the intention to use did not show a cannabis approach bias, whereas intoxicated cannabis users did show an approach bias regardless of image category. This could be attributed to a general slowing of avoidance action tendencies. Moreover, craving was negatively associated with the approach bias, and no relationships were observed between the cannabis approach bias, satiation, prior cannabis use, and response inhibition. CONCLUSION: Cannabis intoxication in a real-life setting inhibited general avoidance. Expression of the cannabis approach bias appeared not to be modulated by satiation or response inhibition.

Self-concept deficits in massively multiplayer online role-playing games addiction.

BACKGROUND: Previous studies on Internet addiction point towards a particular constellation of personality traits and deficits in social competence of players addicted to massively multiplayer online role-playing games (MMORPGs), which are hypothesized to result from impairments in self-concept. The aim of this study was to examine differences in self-concept and degree of avatar identification in World of Warcraft addicted, non-addicted and naive (nonexperienced) participants. METHODS: Participants (n = 45) completed interviews and self-report questionnaires on social, emotional and physical aspects of self-concept. Attributes of participants' 'actual self', 'ideal self' and their avatar were assessed using the Giessen test. The extent of avatar identification was examined by assessing differences between 'ideal self' and avatar evaluations. RESULTS: In contrast to nonaddicted and naive participants, addicted players showed a more negative body appraisal and lower self-esteem as well as lower permeability, social response, general mood and social potency on the Giessen test subscales. They further showed significantly lower discrepancies between 'ideal self' and avatar ratings on nearly all Giessen test subscales. DISCUSSION: The results point towards impairments in self-concept and a higher degree in avatar identification in addicted MMORPG players compared to the remaining participants. These results could have important implications for the treatment of addicted MMORPG players.