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Official websites use. Share sensitive information only on official, secure websites. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Internationally there are few studies investigating effective treatments specifically designed for this condition. This study utilized a single group design with pretest, post-test and a three- and six-month follow-up, with measures of severity of GD and mood. The results show a statistically significant decrease in symptoms of GD after treatment. The decrease in symptoms of GD was maintained at the 3-months follow-up after treatment. Correspondingly we saw a decrease in both depression and anxiety that also was upheld 3 months after treatment. As GD is a new diagnostic concept more research is needed, also taking psychiatric comorbidity into consideration, to arrive at evidence-based conclusions regarding effective treatments. Considering the promising results in this small pilot study with large behavioral changes and reduced symptoms of GD, upheld at least 3 months after treatment, a larger randomized controlled study is warranted. Keywords: adolescents, young adults, adults, treatment, CBT, gaming disorder, pilot. Gaming disorder is manifested by impaired control over gaming, increasing priority given to gaming and continuation or escalation of gaming despite the occurrence of negative consequences. Proposed criteria for this diagnosis include preoccupation, withdrawal, tolerance, reduced control, giving up other activities, continuing despite problems, deception, gaming to escape negative moods and risking or having lost relationships or opportunities. The suggested threshold for diagnosis is to fulfil at least five of these nine criteria in a month period. As a consequence of being a newly defined disorder data on prevalence are scarce and inconsistent. Average worldwide prevalence of GD has been estimated at 1. There is evidence that GD often is accompanied by psychiatric comorbidity. There are further findings that GD is associated with poor psychosocial functioning and lower performance in the academic or working spheres 7—9. Reduced self-satisfaction outside of playing video games, feelings of loneliness 10—12 , negative affectivity and disinhibition 13 is also common. Whether these psychopathologies and impairments are risk factors for GD or consequences thereof, is not known and needs to be further studied longitudinally. Gaming disorder is more common among men 3 , 7 , 14 , 15 and among youth and young adults 3 , Low levels of family cohesion have been identified as a risk factor for GD in young adults and there is also a higher probability in this group of being unmarried, unemployed, having high levels of depression and anxiety 16—18 , and a higher risk for suicide attempts 18 compared to individuals without GD. Several studies have shown that it is common among those with GD to use gaming to escape from negative emotions 18— Cognitive behavioral therapy has been suggested as the most effective treatment for GD but has mostly been tested in a young population There is also a scarcity of peer reviewed clinical treatment studies that include follow-up data to conclude if treatment gains are upheld over time In an early CBT study that included adults, decreased symptoms of IA was found and sustained at the six-month follow-up 27 , No control group was included. Further, the Short-term treatment of internet and computer game addiction STICA was tested in young adults and improvements in symptoms related to IA was found compared to waitlist controls Moreover, a multimodal treatment with CBT elements was tested in 40 adults and the severity of GD was decreased Only three studies had a follow up period of three or six months 29 , 30 , Globally, more treatment research on GD is needed. It is therefore important to develop treatment manuals designed for this group of patients and evaluate their effects. This pilot study aimed to evaluate the effects and feasibility of a recently developed CBT treatment manual designed specifically for the treatment of GD. We first hypothesize that a week CBT treatment will reduce symptoms of GD in a clinical population of young adults and adults fulfilling criteria for GD. We also hypothesize that a reduction of GD symptoms will be accompanied by a reduced amount of hours spent gaming each week. Our secondary hypothesis is that there will be a concurrent decrease in symptoms of psychiatric comorbidity such as depression and anxiety. We also have a third explorative hypothesis that the participants will experience an increased quality of life and have fewer symptoms of procrastination after treatment. This is a single group pilot study with pretest, post-test and a three-month follow-up. The clinic is the largest of its kind in Sweden offering specialized care for patients with gambling and gaming disorder. Patients were referred to the clinic either via self-referral or by other healthcare facilities. The participants were consecutively recruited from the treatment-seeking population at the clinic. The initial assessment was conducted either as a videoconference or on site and included an anamnestic interview, a semi-structured diagnostic interview regarding symptoms of GD, screening for other psychiatric disorders, assessment of health, lifestyle, and psychosocial resources. After this assessment, made by a psychologist, a social worker or a nurse, participants were offered to enter the treatment program. All participants signed a consent form. Participants were excluded if they had somatic or psychiatric conditions that contraindicated treatment or severely hindered treatment participation e. The study was approved by the regional ethics committee of the University of Gothenburg and complied with the guidelines of the Declaration of Helsinki Dnr: There exists no gold-standard treatment of behavioral addictions. The treatment has been developed at the clinic and consists of CBT-techniques such as stimulus control, cognitive restructuring and relapse prevention commonly known from other treatment programs for GD 24 , 32 , addictive behaviors 25 , 26 , 32 , 35—38 and substance use disorders 39—41 including behavioral self-control training In addition, elements from motivational interviewing MI 43 are used, especially in the initial stages of treatment to strengthen the motives for behavioral change, as this method has been shown to be effective in supporting other types of behavioral change 44 , Motivational interviewing does probably not have a significant effect as a standalone intervention Additional support regarding psychosocial resources or health and lifestyle factors were offered if such a need was identified. The added support consisted of a few optional sessions described more in detail below , in addition to the CBT-treatment. Starting at the first session, and continuing throughout the treatment, patients were also encouraged to keep track of their gaming activity via a weekly gaming diary. Phase 1 : In the initial phase individual goals for the treatment are formulated. Goals are formulated both regarding gaming activity what amount and type of gaming activity the patient wants to retain at end of treatment and other changes the patient wants to make during treatment for example to increase weekly exercise or to increase social activities outside gaming. Self-monitoring of gaming is introduced. Phase 2 : Sessions follow with a focus on learning new skills to control gaming activity and to initiate other activities. The patients learn to identify their individual triggers for gaming, and strategies for stimulus control are implemented for example uninstalling programs, moving the computer to another room, or blocking internet access for parts of the day. Much attention is also devoted to the introduction of new activities behavioral activation , chosen individually to match the interests and goals of each patient, to fill some of the time otherwise devoted to gaming. Techniques for handling difficult feelings and unhelpful thoughts related to gaming are also introduced and practiced, as well as time-management and problem-solving skills. Phase 3 : At the final stages a plan is formulated to maintain the changes made during treatment and how to get back on track if a relapse occurs. A summary is made of the most helpful techniques learned during treatment, the patients identify situations where they expect it would be especially difficult to maintain their changes and formulate strategies to tackle this both proactive to stay on track and reactive to get back on track if they relapse. Follow up : After treatment is completed, the patients are contacted by phone for a follow-up after three and six months. As part of the follow-up the patients also fill out self-report questionnaires. If needed, two booster sessions are offered to analyze problematic situations that have occurred and to revise the relapse prevention plan. Optional modules : In addition to the above-mentioned sessions, there are also optional modules. Based on the intake assessment an individual plan for optional modules is made. An individual patient can take part in none, some, or all of these. This has been added as familial conflicts about gaming and lack of consensus about treatment goals might hinder change 47 , and conversely that higher levels of family cohesion seem to be a protective factor against GD 16 , b 1—3 additional sessions for support regarding psychosocial resources, for example to establish contact with other societal support systems, c 1—3 additional sessions for support regarding health and lifestyle factors, for example to initiate physical exercise or to cut down on alcohol use, d 1 additional session for support on how to plan and conduct home-work assignments throughout treatment. However, our manual also differs in many ways from other treatments for behavioral addictions and specifically gaming disorder. One essential difference is that the manual, unlike many other approaches, is specifically developed for gaming disorder. The intervention has been developed with a population with considerable psychiatric co-morbidity in mind. Handouts for patients have been made as simple as possible and a flexible system with additional sessions to meet individual needs has been designed. We also include family sessions to help the family support the patient and offer support to activate a professional network around the patient. The GAIT was our main outcome measure. It consists of 17 questions regarding gaming that cover all the DSM-5 diagnostic criteria for Internet gaming disorder. The questions concern all digital games including games on computer, mobiles or TV, both gaming with others and alone We used a timeline follow back measure as our second main outcome measure. This type of measure was originally developed to track alcohol-consumption 49 but has been adapted for this study to track behaviors relevant to GD. The GD-TLFB is a diary where frequency and duration of weekly gaming can be tracked as well as other time spent online and time spent on screen-free activities. The gaming diary serves as a valuable complement to the symptom measures. Although the aim of treatment is to alleviate the negative consequences of gaming the symptoms and not time spent gaming per se , still, decreasing time spent gaming is a necessary step to reach that goal. Aside from being used as an outcome measure, the gaming diary also serves as an important clinical tool for self-monitoring. PHQ-9 is developed according to the diagnostic criteria in DSM-4 and the total score can be used to assess severity of depressive symptoms. Based on the total score the level of severity is classified as none 0—4 , mild 5—9 , moderate 10—14 , moderately severe 15—19 or severe 20—27 depression. PHQ-9 has been shown to have high validity in detecting severity of depression The total score is 21, and the scores indicate minimal 0—4 , mild 5—9 , moderate 10—14 or severe 15—21 anxiety It is divided into six different life areas that are rated individually regarding perceived importance and satisfaction. The maximum score is 96 with higher scores indicating higher levels of quality of life, and scores below 52 being associated with clinical samples It consists of 12 items rated on a 1—5 point Likert scale with higher scores indicating higher levels of procrastination We also collected demographic data about the participants including age, sex, educational level, living situation and current occupation. It consists of 10 items divided into three areas: alcohol consumption, symptoms of dependence and negative consequences of alcohol consumption. The maximum score is 40, with a cut-off score of 6 for women and 8 for men indicating hazardous or harmful drinking The questions are categorized in three areas, drug use, dependence symptoms and negative consequences of drug use. DUDIT scores of 1 or more for women and 3 or more for men indicate problematic drug use Out of the 28 participants 12 were treated individually and the rest in group format. In the analyses, irrespective of having received the treatment via group or individual sessions, data from all participants have been included. The primary outcome variables were symptoms of GD measured by the GAIT and the four measures included in the gaming diary. The gaming diary consisted of nine repeated measures from the start of treatment to the last session of treatment. Mixed effects models were used as they handle missing data and correlation between repeated measurements better than a classical repeated measures ANOVA 56 , Further, as the mixed model uses all available data points it is possible to do an intention-to-treat analysis, including all participants in the analysis. For the primary outcome measure GAIT, a basic model with a fixed slope for time was created. Time was coded as 0—3 with 0 being baseline and 3 being 3-month follow-up. To account for possible non-linear effects a quadratic effect of time x time was tested, found non-significant and was therefore discarded. A random intercept and random slope for time was tested but did not improve the model according to a likelihood ratio test and were thus discarded. Model building was approached in the same way for the secondary outcome PHQ-9, and time was similarly coded here. The quadratic effect of time x time was non-significant and discarded. A diagonal covariance pattern was used for the repeated measures as the model did not otherwise converge. Unstructured covariance type was used for the random effects. For the GAD-7 time was similarly coded. The quadratic term of time x time was non-significant and discarded. The random intercept and random slope for time did not improve model fit according to a likelihood ratio test and were discarded. For the BBQ time was coded 0—2, with 0 being baseline, and 2 being three-month follow-up. When the random intercept and random slope for time was added the model failed to converge, and the model with random intercept were not an improvement according to a likelihood ratio test. The random effects were thus discarded. For the PPS time was similarly coded. When the random intercept and random slope for time was added the model failed to converge. A model with diagonal covariance pattern and random intercept did converge and was a better model according to a likelihood ratio test. The means and standard deviations for these participants are however presented for descriptive purposes. Time was coded as 0—8 with 0 being diary entry pre-treatment and 8 the final entry during treatment. A quadratic fixed effect of time x time was tested to account for possible non-linearity. The quadratic effect of time x time was non-significant and was discarded. For non-gaming screen time, time was coded similarly. The quadratic effect was non-significant and discarded. For non-screen leisure time, time was coded in the same way. Estimated means of variables were calculated for all time points in the mixed-models that yielded significant effects. Estimated means of non-significant models are not reported. Confidence intervals of within group effect sizes were calculated using Pearson correlations of observed values between baseline and the final time-point. There were 28 participants included in this study, with an average age of Of these, there was only one woman 3. In the sample, The majority Of the participants, Regarding alcohol and illicit drugs, See Table 2 for a full list of subject demographics. One individual can have several diagnoses. The model estimates for the primary outcome of GD symptoms measured by the GAIT can be found in Table 3 along with confidence intervals, p -value and effect size. The model intercept of This means that symptoms of GD decreased over time. This is illustrated in Figure 1 , where model estimated means are plotted over time and compared to observed means with standard deviations. The observed mean for the limited number of 6-months follow-ups is also presented in Figure 1 for descriptive purposes. Model estimates of gaming behaviors, including confidence intervals, p -values and effect sizes. Observed means from baseline to 6-month follow-up, and estimated means from baseline to 3-months follow-up for the GAIT. In Table 3 the model estimates together with p -values, confidence intervals and effect sizes for the various measures of gaming behavior derived from the gaming diary are reported. Participants were gaming at a model estimated average of This means they were reduced linearly from a model estimated average of The model estimated an average of See Table 4 for observed means and standard deviations, and model estimated means for the measures in the gaming diary. Means, standard deviations and model estimated means for all timepoints in the gaming diary. The model estimated mean at baseline was Observed means and standard deviations as well as model estimated means can be found in Table 6. Observed means for the limited number of 6-month follow-ups are for descriptive purposes also presented in Table 6. Model estimates of non-gaming behaviors secondary outcomes, including confidence intervals, p -values and effect sizes. Means, standard deviations, and model estimated means for non-gaming behavior secondary outcomes. The data are presented over time as means with standard deviations. This was an uncontrolled pilot study intended to evaluate the feasibility of a newly developed manualized CBT treatment for patients diagnosed with GD. The 28 participants included in the study were followed from baseline to 3-months post treatment. We investigated symptoms of GD, sociodemographic factors, alcohol and drug use, depression and anxiety, quality of life and procrastination. We notice both differences and similarities regarding sociodemographic characteristics when comparing the patients in our study with populations in earlier studies. However, both the age range and the high education level seen in our study is similar to other IA-studies with adult patients 26 , In our study, only one woman chose to participate. The prevalence of GD is estimated to be 2. However, the proportion of women in our study and other treatment studies for GD 23 , 24 are still much lower than could be expected based on prevalence. In this aspect, GD differs from other psychiatric conditions where women usually are overrepresented as treatment-seekers Still, we believe it is important to continue including women in future treatment studies, and also make active efforts to reach more women with GD. The association between GD and substance use has been investigated, but findings so far are mixed. Other studies have for example shown a positive correlation between severity of GD and frequency of substance use 63— On the other hand, it has also been reported that a heavy investment in gaming may lead to a reduction in alcohol use 67 or that no association between alcohol and gaming disorder could be detected Considering the findings that some treatment seekers with GD also have a problematic intake of alcohol or other drugs, together with the mixed research findings so far regarding associations between GD and substance use, we believe that it is important to regularly screen for possible co-morbidities with SUD in future treatment studies. Thereby, we can increase our knowledge on how substance use and SUD might affect treatment results, and if changes regarding gaming also are associated with changes in substance use. Time spent gaming after treatment was on average We want to emphasize that the aim of the treatment was not total abstinence from gaming or other internet activities but simply to gain control over gaming habits. With the gaming diary we also wanted to measure changes in non-gaming screen time, to make sure that time spent gaming not only transitioned into other types of screen-time. Instead, the gaming diary showed that the decrease in time spent gaming also was accompanied by a small decrease in other types of screen time. The patients also more than doubled their amount of screen-free leisure time. It is difficult to compare results from different studies as there are no gold-standard instruments for measuring GD, and many different instruments have been used in previous studies With this caveat in mind, we observe that in our study, as well as in earlier studies regarding adults with IA 26 , 28 and GD 23 , 24 , we see substantial changes in symptoms after treatment compared to baseline. This also holds for changes in hours spent online in our as well as in other studies 26 , Our secondary measures focused on anxiety, depression, quality of life, and procrastination. For these variables we saw changes in the expected direction, although the change in quality of life did not reach statistical significance. We argue that all these aspects are important to take into account when evaluating treatments for GD. By measuring for example quality of life we address a broader definition of health than simply the absence of symptoms, and capture additional aspects highly relevant to GD. Lower quality of life has been shown to be associated to GD, and also differentiating highly engaged gamers from those with problematic gaming 70 , The complex interplay between these factors is also illustrated by findings that levels of anxiety and depression mediate the relationship between GD and quality of life We also saw a significant reduction of symptoms of procrastination, measured by the PPS 53 after treatment, although the levels were still high. The decision to include strategies to identify and handle procrastination in our manual was based both on clinical observations, and earlier findings that symptoms of procrastination was associated with clinical severity of internet gaming disorder Similarly, in a prevention program for adolescents with at risk for GD, a reduction of symptoms of GD was accompanied by a decrease in procrastination The association between procrastination and GD is further supported by findings that lower levels of procrastination predict spontaneous remission of GD Based on this we suggest that procrastination could be a relevant factor to take into consideration in treatment strategies for GD. Our study had some clear limitations but also strengths. There are a number of limitations in the dataset from this study: the sample size is small, there are missing data, there is no pre-treatment measurement for the primary outcome and a number of secondary outcomes, and repeated measurements have been given at variable time points i. The choice to collect the gaming diary more seldom than every week was made to minimize missing data. Still, a substantial amount of data was missing. In the coming randomized controlled trial RCT we will amend this by focusing more on collecting diaries on even fewer occasions during treatment, thereby being able to focus more on making sure that diaries on these chosen weeks will be registered. The use of weekly diaries will still be part of the treatment, but our experiences so far indicate that, for a considerable part of the intended study population, remembering or wanting to complete these daily or weekly throughout the whole treatment period poses a challenge. Even though statistical methods maximum likelihood estimation have been employed to reduce the problem of missing data, the results of this pilot study should be interpreted with care. The single group design also limits the conclusions. There is a lack of treatment options and insufficient evidence regarding effective treatment of GD. This is the first treatment manual for GD, developed and studied in Sweden, closely evaluated with standardized measures and one of the few treatments so far developed specifically for GD. Moreover, our study participants have undergone a careful diagnostic assessment. This study is also highly clinically relevant as the participants are treatment seeking patients in regular care. This is a strength since follow-up data after treatment is scarce 3 , Findings about the stability of GD over time are somewhat mixed. From studies to date it seems that a proportion of people with GD spontaneously recover 76 but a sizable amount remains that still fulfil the diagnosis at least one year later or more 66 , We also consider it a strength that we offer a flexible treatment, with additional sessions to add if needed. A vast majority were men, not seldom isolated using the game to escape from negative thoughts and emotions. Our CBT treatment, specifically designed to treat patients with GD, showed promising results with reduced symptoms of GD, upheld at least 3-months after treatment, accompanied by decreased time spent gaming almost equivalent to a normal work week. We further observed that the treatment was feasible to deliver as most patients stayed in treatment, and that the treatment was possible to implement as a part of regular care at the treatment center. In conclusion, there is insufficient evidence regarding effective treatments for GD. Based on our promising preliminary pilot findings, we will conduct a RCT. For the upcoming RCT the manual will be shortened, giving increased possibilities to add sessions based on individual needs. We believe there is a need for a flexible treatment specifically designed for individuals with GD with considerable psychiatric comorbidity, to help them improve their quality of life and regain control over their gaming. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The studies involving human participants were reviewed and approved by Swedish Ethical Review Authority. AH had the main responsibility of the writing of the manuscript also contributed with specific knowledge in gaming addicted patients and the main idea for the manuscript. MM made all the statistical analyses and responsible for the result section. EA was responsible for the informed consent form to collect and keep track of the data and Method section. AS was a senior researcher of the work and the Principal investigator for this research, and supervised the writing of the whole manuscript throughout the research process. All authors contributed to the article and approved the submitted version. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. They also thank all the staff involved at the Clinic for gambling addiction and screen health. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Front Psychiatry. Pilot data findings from the Gothenburg treatment for gaming disorder: a cognitive behavioral treatment manual Annika Hofstedt Annika Hofstedt 1 Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Find articles by Annika Hofstedt. Find articles by Mikael Mide. Find articles by Elin Arvidson. Find articles by Sofia Ljung. Find articles by Jessica Mattiasson. Find articles by Amanda Lindskog. Received Feb 9; Accepted May 8; Collection date Content of the CBT-treatment for gaming disorder together with measure points. Additional session for support regarding psychosocial resources Additional session for support regarding health and lifestyle factors 1 session with support on how to work with home-work assignments. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Diagnostic assessment of Internet Gaming Disorder according to DSM-5 Anamnestic information Assessment of other psychiatric conditions Assessment of psychosocial resources Assessment of health and lifestyle factors. Motivational interviewing Goal setting Introduction of self-monitoring strategies. Learning new skills to gain control over the gaming activity and to initiate alternate activities. Psychoeducation Identification of individual triggers for gaming Time-management Stimulus control Behavioral activation Using skills from gaming to reach treatment goals Strategies to identify and handle feelings Strategies to identify and handle unhelpful thoughts Problem solving. Evaluation of treatment Individual plan to maintain changes and to handle relapses. Follow-up on how changes have been maintained If needed: 2 booster sessions to revise the relapse prevention plan.

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