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Considering adverse correlates of problematic use of internet use PUI , the present study evaluated an intervention aimed at PUI and several putative underpinnings. A randomized controlled trial study investigated the efficacy of emotional working memory training eWMT in improving impulsivity, risky decision-making, and cognitive emotion-regulation CER strategies among individuals with PUI in comparison with a placebo group. Twenty continuous sessions of eWMT significantly improved participants' impulsivity, risky decision-making, CER, internet use and PUI symptoms in the short term, compared to the placebo condition. These preliminary results suggest that eWMT may constitute a promising intervention for PUI and improving cognitive and emotional functioning, and larger, longer studies are warranted. PUI has been considered by some to be a behavioral addiction Griffiths, Nonetheless, PUI constitutes a major public health concern and has been the focus of large-scale initiatives and is relevant to multiple behaviors and stakeholders. One model of drug addiction proposes two systems involving emotion-based impulsive and cognitive-control-based reflective systems Bechara, Adolescents may thus exhibit relatively poorer cognitive emotion-regulation CER relative to adults. Taken together, prefrontal cortical function, which has been linked to impulsivity, risky decision-making, and CER, is typically immature during adolescence Steinberg, , and this may make adolescents vulnerable to PUI, particularly in the current digital-technology environment. Different subtypes of PIU have been proposed. According to Young , internet addiction could be classified into five categories: net compulsions e. However, this typology was criticized by Griffiths who suggested that these sub-types may involve addictions on the internet rather than addiction to it. According to Tiego et al. People with PUI may show cognitive impairments, especially in executive functioning Brand et al. Such executive dysfunction may be reflected in impulsivity Choi et al. Impulsivity has been implicated in addictive disorders and PUI Diotaiuti et al. Impulsivity may transcend behavioral and substance addictions Cao et al. High levels of impulsivity may promote risky or harmful behaviors, such as PUI Diotaiuti et al. Given these data, it is possible that PUI may be reduced by targeting interventions on functions of brain structures related to impulsivity, such as the prefrontal cortex. It has been hypothesized that individuals with PUI are more likely to engage in risk-taking processes that provide immediate gratification despite an increased risk of experiencing loss, and that these individuals give less attention to long-term consequences Brand et al. Over-reliance on reward systems and underuse of prefrontal control systems may underlie risky behaviors such as PUI in young adults Galvan, et al. Consequently, interventions for PUI may involve altering functioning of reward systems and the prefrontal cortex, in order to generate better self-control and reduce risk-taking behaviors Wu et al. Therefore, targeting risky decision-making might help reduce PUI symptomatology. CER involves a range of processes by which people may change the types and durations of emotions they experience. Accordingly, implementation of adaptive emotion regulation strategies instead of maladaptive ones may decrease PUI Moniri et al. Understanding and targeting common underlying mechanisms that may exist between impulsivity, risk-taking, and CER strategies may help alleviate symptoms of PUI. Based on this hypothetical mechanism and empirical data from people with gaming disorder Wu et al. Thus, reducing maladaptive CER strategies may promote use of adaptive strategies instead of the internet in a maladaptive way, reducing symptoms of PUI. Since PUI is not a recognized disorder in main nomenclature systems, there are no therapies or treatments with formal indications Griffiths, ; Musetti et al. Interventions for PUI may have the potential to improve cognitive and emotional control and reduce impulsivity and risk-taking. The main purpose of eWMT involves improving emotional dysfunctions and cognitive impairments i. Individuals are provided with emotional training by auditory and visual stimuli alongside cognitive training. Individuals determine whether faces they view on-screen are located in the same spatial locations as ones they saw previously or whether words with which they are presented are ones they encountered previously. To improve performance, a person should disregard affective content of faces and focus instead on the content of the words. The literature has demonstrated the effectiveness of eWMT in improving executive functions and emotional regulation in people with post-traumatic stress disorder PTSD Schweizer et al. The extant literature suggests that various interventions may reduce the negative outcomes related to PUI, including acceptance and commitment therapy Firouzkouhi Berenjabadi et al. These interventions generally require significant resources, such as a trained and licensed therapist. Computer-mediated cognitive training that can be completed at home may be useful for individuals with fewer resources. Therefore, we undertook such a study. Initial findings from the study under consideration elsewhere indicated that eWMT was efficacious in improving attention, working memory, and inhibitory control in patients with PUI. To our best knowledge, we are the first to examine the efficacy of eWMT on impulsivity, risk-taking, CER strategies and internet-use behaviors among young adults with PUI. It was hypothesized that in comparison with a placebo group, eWMT would decrease internet use H1 and reduce symptoms of PUI H2 , impulsivity H3 , risk-taking H4 , and employment of maladaptive CER strategies and increase employment of adaptive strategies H5. The study focuses on the effectiveness of eWMT on the cognitive impairments and emotional dysfunctions of individuals with PUI. The first paper of this study was published on the journal of Addictive Behaviors Shahrajabian et al, focusing on inhibition, attention, and working memory. Consequently, the total sample size was calculated to be Moreover, by considering attrition, 40 subjects were recruited and randomly assigned into two groups. Study participants with IAT scores below 80 were excluded. Young proposed a cut-off of 50, and 80 was selected to recruit individuals with more severe PUI. The IAT consists of 20 items related to online internet use, including psychological dependence, compulsive use, withdrawal, PUI-related issues at school or work, sleep problems, family problems, and time management issues. Two clinical psychologists evaluated the remaining participants to confirm PUI symptoms, ensure no other comorbid disorders were present participants with mild to severe depression or anxiety disorders were excluded , and assess their readiness for the study. No psychotropic medication was administered to participants, and their vision was normal or corrected to normal. Sixty-three participants were excluded 21 excluded because of co-occurring disorders, 42 as they did not meet the inclusion criteria. Forty individuals met the criteria for inclusion in the study. Of these, 36 individuals completed the sessions, post-test, and follow-up. Therefore, the final sample included 36 participants. The participant selection and study procedure processes are shown in Fig. Citation: Journal of Behavioral Addictions 12, 3; The study's aims were explained to participants. Participants provided written informed consent. A question was also asked of all participants regarding their most frequent online activity. The placebo and treatment groups did not differ on demographic characteristics, PUI severity, and implementation conditions number of sessions and duration of each session. The study was single-blind and randomized. The research team was aware of the participants' training groups, and participants were unaware of differences among groups. Overall, participants were assessed at three stages: the pre-intervention period T0 , post-intervention period T1 , and three-month follow-up period T2. Thus, the experimental design consisted of three phases: pretest, intervention, and posttest. Before starting the intervention, three participants two in the intervention group and one in the placebo group discontinued attending the intervention without declaring a reason for the cancellation see Fig. Therefore, 36 individuals completed the study. For the intervention phase, the eWMT group received training while the placebo group received placebo training detailed below. Before session ten, two additional patients in the intervention group and two individuals in the placebo group declined to participate further, reporting that the words used in the emotional work memory training program made them reluctant to continue. Some patients were also removed due to irregular attendance at training sessions. After three months, all participants were asked to complete measures for a third time for the follow-up phase. The dual n-back exercise is one to strengthen active memory. These stimuli are presented in a random order, either individually or simultaneously. The negative valence of words e. In this task, participants received two kinds of feedback. For auditory targets, a disturbing sound was heard if the target was missed, and a pleasant sound if it was correctly determined. Upon accurately identifying visuospatial targets, a green happy emoji was presented, while a red sad emoji was presented upon missing them. The procedure is described in Fig. Overview of affective dual n-back task Schweizer et al. Placebo training. Participants in this group were shown two panels with geometrical shapes on a screen. On the top panel, there were three shapes that individuals were asked to note by clicking on the mouse. The panels also contained five to 13 distractor shapes. The quantity of distractors included with the targets was random i. Scores above 37 indicate pathological internet use. The Cronbach alpha reliability coefficient of the scale was 0. Individuals were asked to sequentially press a button to inflate a series of 30 balloons that were presented on their screen. There are two types of points on the screen, one temporary and one permanent. Every time the balloon was pumped, 50 points were added to the person's impermanent score. Then, a new balloon was substituted and the amount of points acquired from inflating the balloon was added to the constant score. Balloons could explode or expand. A bigger balloon was related to a greater possibility of bursting and a larger virtual reward. After each balloon burst or reward was collected, the individual's exposure to that balloon finished and a new balloon appeared until all 30 balloons had been presented. Here, participants received another 50 points which were added to the temporary score each time they inflated the balloon. Individuals were instructed to increase their virtual reward in the task. The balloons burst at unspecified points. People with high risk-taking tended to inflate each balloon more to gain more points by assuming the risk of the balloon exploding. The BART score was computed by the subject's overall score this score is inversely related to a high-risk decision-making style and the number of times balloons burst this score is directly related to a high-risk decision-making style. The 11th version of the BIS includes 30 questions and can be separated to 3 subscales, including non-planning, motor, and, attentional to indicate total impulsiveness scores. All items were summed, with greater scores reflecting higher impulsivity Patton et al. Javid et al. The instrument includes 18 questions to examine maladaptive i. The Cronbach's alpha in the current study was 0. Before analysis, basic assumptions of mixed-design ANOVAs including no significant outliers in any cell of the design checked by box plot; normality checked using the Shapiro-Wilk normality test; homogeneity of variances assessed using the Levene's test; sphericity checked using the Mauchly's test; homogeneity of covariance tested by Box's M were checked and met. Therefore, data from 36 participants 18 in each group remained for the final analysis. Analyses were performed on individuals in both groups that had completed measurements at T0 baseline , T1 post-intervention , and T2 three-month follow-up. The analysis considered differences between T0 vs. T1 and T0 vs. To examine if trajectories of outcome variables in the intervention and placebo groups differed between individuals, a series of mixed models was applied with internet use, PUI, CERS, impulsivity and risky decision-making scores as the dependent factors and group intervention and placebo , time T0-T2 , and the interaction between time and group as independent factors fixed effects. The ethics committee of Kharazmi University IR. All subjects were informed about the study and all provided informed consent. Table 1 illustrates the demographic characteristics of the samples. As evident in Table 1 , demographic variables did not differ between the two groups. These differences require further investigation because they did not show which group differed from the other group in terms of the interest variables. Further results are summarized in Table 3. Al within-subject effects i. Moreover, the effect of the interaction of two independent variables group and the number of measurements at pre-test T0 , post-test T1 and follow-up T2 were significant. Regarding between-subject factors, the effects of group i. Daily internet use in the intervention group was reduced from 7. In addition, regarding PUI scores, the scores in the intervention group were reduced from To explore trajectories of outcome variables in the intervention and placebo groups, paired-samples t -tests were conducted in the two groups from T0 to T1 and T0 to T2 for all outcome variables Table 4. The paired-samples t -tests revealed significant changes in all outcome variables in the intervention group from T0 baseline to T1 post treatment and T2 three-month follow-up , but not in the placebo group. Paired-samples t -tests in intervention group and placebo group for trajectories of outcome variables. Finally, to explore the superiority of the intervention group compared to the placebo group, direct pairwise comparisons independent t -tests between groups at each time T0, T1, T2 were made Table 5. Independent-samples t -tests of intervention group compared to placebo group in relation to variables of interest. As shown in Table 5 , at baseline T0 there were no significant differences between the intervention group and the placebo group. However, in the post-intervention period T1 and three-month follow-up period T2 , the treatment intervention group was superior to the placebo group in all outcomes. In sum, the findings indicated the superiority of the eWMT intervention to the placebo throughout the study. Considering the multiple facets of PUI, which may include cognitive, emotional and behavioral aspects, multidimensional interventional approaches may be needed. In the present study, by using eWMT, we sought to alter emotional regulation, cognitive functioning, and linked domains of impulsivity and risky decision-making, and to reduce problematic behaviors. Previously, we have found efficacy for eWMT on attention, working memory, and inhibitory control in patients with PIU published elsewhere. Here we examined potential effects of eWMT on impulsivity, risky decision-making, and use of maladaptive and adaptive CER strategies. Internet use also decreased. In addition, the results indicated a significant decrease in the levels of impulsivity, risk-taking and the use of MCERS. Schweizer et al. The results indicated that eWMT was linked to increases in cognitive control and usage of adaptive emotion-regulation strategies. As discussed in the introduction, people with PUI often display poor cognitive and emotional control. Therefore, considering the results of Schweizer et al. In order to measure emotional changes, we, like Schweizer et al. However, no prior research had examined the effectiveness of eWMT in reducing symptoms of PUI prior to our study reported here and elsewhere. The effects of eWMT on cognitive and emotional symptoms in a range of psychological disorders have been demonstrated by Beloe and Derakshan , Du Toit et al. According to the present findings, combined with previous research, deficits in cognitive control and working memory are closely related to poor emotional regulation and psychiatric symptomology Schweizer et al. When working memory is impaired, cognitive functions may be impaired, which can affect education, employment, and other aspects of daily life Zhou et al. As a result of ineffective cognitive strategies to deal with problems of daily life Engel, , PUI may occur Park et al. Neurobiological studies implicate the prefrontal cortex and hippocampus in PUI, with lower levels of activation in the prefrontal cortex reported Brand et al. Prefrontal cortical dysfunction has also been related to disorders involving emotional dysregulation Brand et al. Thus, cognitive eWMT may speculatively improve functioning of the prefrontal cortex and thus related domains and disorders Schweizer et al. The effects of eWMT may include the development of new skills and reorganization of emotional strategies that promote changes in cognitive, emotional and behavioral domains. The efficacy of eWMT in the present study may involve simultaneous focus on cognitive, emotional and behavioral domains, and this possibility should be tested in future studies. Using eWMT during continuous sessions appears to improve emotional working memory Schweizer et al. Speculatively, eWMT may operate through involvement of the ventrolateral prefrontal cortex, which contributes to inhibition, and this possibility should be directly investigated in future studies. The present study's results may be partly explained by the developmental plasticity of neural substrates engaged in controlling emotions. Consistent with the results of Schweizer et al. Both impulsivity and compulsivity may contribute to poor recovery and relapse Lee et al. Impulsivity may involve poor response inhibition or inhibitory control Choi, et al. Over-reliance on reward systems and underuse of prefrontal control systems may underlie risky decision-making in individuals with PUI Galvan et al. Since eWMT sessions led to increased emotional working memory capacity Schweizer et al. Possible mechanisms for reductions in internet use and PUI severity warrant additional direct examination. The effects of eWMT may rely upon the development of new skills and the reorganization of emotional strategies. Prefrontal cortical dysfunction has been linked to impaired emotion regulation, poor working memory and PUI Brand et al. As the neural foundations of emotional working memory and emotion regulation both involve the dorsolateral prefrontal cortex, anterior cingulate cortex and hippocampus, improving working memory may improve emotion regulation strategies Schweizer et al. The results of the present study and previous research indicate that eWMT improves emotional control Schweizer et al. These results resonate with prior ones. For example, Schweitzer et al. Also, Schweizer et al. Furthermore, Schweizer et al. Individuals with PUI may surf the internet to deal with negative emotions as a maladaptive coping strategy Elhai et al. During eWMT, the capacity of emotional working memory is strengthened by emotional stimuli presented to the participants during the sessions, leading to decreases in the use of maladaptive emotion-regulation strategies Schweizer et al. According to the literature and the results of the present study, impulsivity, risky decision-making, and CERS are factors involved in PUI and may have common underlying mechanisms that may lead to functional improvement through eWMT. Based on changes in impulsivity, risky decision-making, and CERS at the post-test stage, eWMT may lead to sustained improvement of cognitive and emotional control over time, although longer studies are needed. The study design highlights the feasibility of running digital interventions for PUI. These kinds of interventions are not expensive and easily accessible as they do not need professional healthcare personnel working with individuals with PUI. Further studies are needed to examine if eWMT is beneficial in these settings and for other conditions. Future studies may investigate the efficacy of eWMT on other mental disorders or in other settings for example, in primary healthcare clinics or hospitals. While we examined the efficacy of eWMT on reducing impulsivity, risky decision-making, CERS, internet use, and symptoms of PUI, future research may focus on other domains for example, decision-making involving tolerance for ambiguity. Study limitations should be noted. Additionally, participants conducted training at home which made it difficult to standardize the training environment. Another limitation was related to the eWMT program. Another limitation was the homogeneity of the participant pool e. Future studies should examine other groups. Similarly, PUI is heterogeneous. While participants reported different types of internet use e. The IAT was in part used for inclusion purposes, and other more current and arguably less criticized measures exist. Further, high severity of PUI was needed for inclusion, and the extent to which findings extend to less severely affected individuals warrants additional study. Training-related changes in CER and impulsivity were examined via self-report measures, which are vulnerable to demand effects. PUI is a heterogenous entity, and future studies should examine specific forms. Given the limitations mentioned, future studies are needed to determine if it would be of benefit to develop and streamline eWMT software developed specifically for PUI. While the chosen dependent variables impulsivity, risk-taking, emotional regulation strategies, internet use and symptoms of PUI are important in the context of PUI, there are no definite measures to determine the success of an intervention. As an example, while impulsivity may be a good predictor of PUI, it may not be treatable with an intervention, possibly limiting the validity of impulsivity as an outcome variable. Similarly, risky decision-making is not a usual measure of therapeutic success. Nonetheless, it has been argued that approaches aiming to investigate efficacy of interventions consider the use of such experimental medicine measures Beckenstrom et al. Considering these factors, the positive results of the study may be limited in determining the success of the intervention, in turn potentially limiting the transferability of findings to other contexts. As most data were collected via self-report scales, biased or distorted responses were possible. Additional behavioral assessments would be beneficial and were excluded due to subject burden. Temporal duration is another potential limitation. While a shorter duration may be beneficial, it may limit durability, although this possibility is speculative. Furthermore, multiple psychological factors e. The study was of relatively short duration. As long-term effects of the training were not assessed, it is not clear how long improvement lasts. In the current study, the primary goal was to evaluate the effectiveness of a low-cost intervention for PUI among Iranian young adults. Participation in eWMT sessions were linked to significant improvements in executive functions and symptoms of PUI compared to a placebo group. EWMT appears to be a promising technique for reducing the symptoms of PUI and improving individuals' impulsivity, decision-making and emotional functioning. SJEC: study design, data collection, writing, editing, data interperation; FS: study design, data collection, writing, editing, data interperation; JH: study design, supervision, formal data analysis: MP: supervision, editing: DK: editing: FH: preliminary data analysis. The authors report no conflict of interest with respect to the content of this manuscript. Potenza is an associate editor of the Journal of Behavioral Addictions. The data supporting this study's findings are available on request from the corresponding author. Alavi , S. 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Journal of Behavioral Addictions. The effects of emotional working memory training on internet use, impulsivity, risky decision-making, and cognitive emotion regulation strategies in young adults with problematic use of the internet: A preliminary randomized controlled trial study into possible mechanisms. Marc N. Potenza Marc N. Daria J. Kuss Daria J. Open access. Download PDF. Check for updates. Introduction Considering adverse correlates of problematic use of internet use PUI , the present study evaluated an intervention aimed at PUI and several putative underpinnings. Methods A randomized controlled trial study investigated the efficacy of emotional working memory training eWMT in improving impulsivity, risky decision-making, and cognitive emotion-regulation CER strategies among individuals with PUI in comparison with a placebo group. Results Twenty continuous sessions of eWMT significantly improved participants' impulsivity, risky decision-making, CER, internet use and PUI symptoms in the short term, compared to the placebo condition. Discussion These preliminary results suggest that eWMT may constitute a promising intervention for PUI and improving cognitive and emotional functioning, and larger, longer studies are warranted. Abstract Introduction Considering adverse correlates of problematic use of internet use PUI , the present study evaluated an intervention aimed at PUI and several putative underpinnings. Underlying mechanisms Understanding and targeting common underlying mechanisms that may exist between impulsivity, risk-taking, and CER strategies may help alleviate symptoms of PUI. Emotional working memory training Since PUI is not a recognized disorder in main nomenclature systems, there are no therapies or treatments with formal indications Griffiths, ; Musetti et al. The current study The extant literature suggests that various interventions may reduce the negative outcomes related to PUI, including acceptance and commitment therapy Firouzkouhi Berenjabadi et al. Consort flow diagrams of study development Citation: Journal of Behavioral Addictions 12, 3; Results Demographic characteristics Table 1 illustrates the demographic characteristics of the samples. Table 1. Table 2. Table 3. Table 4. T1 T0 vs. T2 T0 vs. Table 5. Discussion Considering the multiple facets of PUI, which may include cognitive, emotional and behavioral aspects, multidimensional interventional approaches may be needed. Practical implications The study design highlights the feasibility of running digital interventions for PUI. Limitations Study limitations should be noted. Conclusion In the current study, the primary goal was to evaluate the effectiveness of a low-cost intervention for PUI among Iranian young adults. Funding sources No financial support was received for this study. Conflict of interest The authors report no conflict of interest with respect to the content of this manuscript. Data sharing The data supporting this study's findings are available on request from the corresponding author. Export References. F 1, Cohen's d.
Introduction: Substance abuse is one of the health, medical, and social problems in today's world that affects more or less all societies.
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3 Research Center of Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, IR Iran. 4 Department of Psychiatry.
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