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Cognitive behavioral therapy appeared to be an effective treatment for patients with gaming disorder, according to a randomized control trial.

In a group of 143 young men, 69.4% of patients who completed a 15-week cognitive behavioral therapy program specifically designed for internet and computer game addiction achieved remission, whereas just 23.9% of patients assigned to a wait-list control group did, reported Klaus Wölfling, PhD, of Johannes Gutenberg-University Mainz in Germany, and colleagues.

Specifically, the active group showed improved self-reported components of gaming disorder, including internet addiction symptoms (effect size 1.19), time spent online (effect size 0.88), and psychosocial functioning (effect size 0.64), they wrote in .

"I think the behavior patients are suffering [from is] severe enough to result in significant impacts in personal, social, family, and educational areas of function," Wölfling said in an . "In this kind of view, I think there has to be treatment for patients and we want to deliver."

Gaming disorder is a relatively new phenomenon categorized under the broader form of internet addiction, which also includes gambling and excessive shopping or pornography. The World Health Organization as an official condition in a 2018 draft version of the 11th edition of the International Classification of Diseases (ICD), which was confirmed by a vote earlier this year. The update, which goes into effect in 2022, characterizes the disorder as prioritizing gaming to other activities despite negative consequences.

There is some debate over its official classification and some clinicians believe that gaming disorders are actually byproducts of underlying conditions like social anxiety, said Alok Kanojia, MD, of Harvard Medical School in Boston, who was not involved in this study.

Kanojia said in his clinical experience working with patients with gaming disorder, he combines aspects of behavioral as well as psychodynamic and group therapy. But because patients with the disorder are heterogeneous and may have a number of underlying different disorders, it is difficult to design an all-encompassing therapy.

"One person plays because they feel isolated and have social anxiety and find a sense of social community," Kanojia told 番茄社区app. "That kind of person requires a different kind of treatment than a person, for example, who is hyper-competitive and feels a sense of power, control, and agency they don't feel in real life."

Wölfling said in the interview that the treatment used in this trial combined aspects of substance use and behavioral therapies. The first phase focused on psychoeducation and developing agreed-upon therapy goals; the second taught patients to use the internet in healthy ways; and the final termination phase concentrated on relapse prevention techniques.

Kanojia said although this manualized protocol appears to have reduced the effects of video game addiction, it's important not to over-interpret the findings since the follow-up in this study was short (6 months), the sample size was relatively small, and no women were included.

For this trial, Wölfling and his team enrolled men at four outpatient clinics in Germany and Austria who had internet addiction diagnosed through self-reported and clinically-confirmed scores on the Assessment of Internet and Computer Game Addiction (AICA). Scores of 13 or more on this scale are classified as addictive behavior and in this study, remission was considered a score lower than 7.

The 72 patients randomly assigned to the behavioral therapy arm underwent 15 group and as many as eight 2-week individual sessions. They were similar to the 71 patients in the control group demographically and medically and the group's mean age was about 26. Most had an advanced education and the unemployment rate was high at 18.9%, the authors reported.

Overall, the drop-out rate in the trial was "considerable," with a dozen patients leaving the trial midway through and an additional 12 dropping out in the termination phase, the authors reported. As a result, the strength of the findings after a six month follow-up assessment "cannot be interpreted," they noted.

"We found many of the patients to be ambivalent toward engaging in and completing treatment," they wrote. "This resistance indicates a core characteristic of [internet addiction]-affected patients."

Despite the high discontinuation rate, the effect sizes of treatment were even greater in an analysis excluding patients who dropped out when examining self-reported AICA scores (2.57), time spent gaming on weekdays (1.05), response at weekends (1.47), and depression (1.10), Wölfling and his team reported.

Notably, more than half of men included in the study (52.4%) were found to have at least one other mental disorder -- the majority of which were depressive disorders -- assessed through the Structured Clinical Interview for DSM-IV (SCID). Also, 14.7% were on psychotropic medication at the time of the trial. Over the course of the study, 14 adverse events and eight serious adverse events occurred, two of which were considered to be related to treatment, they added.

"We found that several patients became depressed over the course of the trial, and a few needed to be transferred to inpatient psychotherapy," the authors noted. "This finding concurs with our clinical experience that, in some cases, reduction of the addictive online behavior may also destabilize emotional self regulation."

Researchers said that because they weren't able to recruit a large enough sample size, the findings presented here may have overestimated the effect of cognitive behavioral therapy. Since all subjects in the trial were men without psychological conditions like major depression, the results are not generalizable to women, or patients with comorbid conditions, they added. Finally, self-reports were used to assess the effect of therapy, which is subject to bias.

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