Fineberg NA 1,2,3 Zsolt Demetrovics - PowerPoint Presentation

1. Fineberg NA1,2,3Zsolt Demetrovics4COST Action 16207 1.Hertfordshire Partnership University NHS Foundation Trust, Rosanne House, Welwyn Garden City, UK2. University of Hertfordshire, College Lane, Hatfield, UK3. Cambridge University School of Clinical Medicine, Cambridge, UK4. ELTE Eötvös Loránd University, Budapest, HungaryAdvancing Research Into Problematic Use Of The Internet – Toward Horizon Europe European Commission, Brussels, March 25, 2019

2. Declaration of interestsIn the past several years I have received Personal fees from Sun, Abbott, Lundbeck, Taylor and Francis, Oxford University PressPersonal fees and non-financial support from Otsuka-Lundbeck, the MHRA, the BAP, the RANZCP and Wiley Grants and non-financial support from the EU, ECNP, ShireNon-financial support from the WHO, CINP, International Forum of Mood and Anxiety Disorders, International College of Obsessive Compulsive Spectrum Disorders and RCPsychGrants and non-financial support from the NIHR, MRC and WellcomeDavid Baldwin 2

3. AIMSFrom a public and clinical health research perspective, review Emerging conceptualizations of PUI - phenomenology neuropsychological models and markers comorbiditycost and burdeninterventionsEU COST Action 16207 (EU-PUI), advancing understanding of the psycho-biological basis of different forms of PUI, the societal cost and burden and implications for interventionKey future research and policy directions

4. Problematic Use of the Internet (PUI) Umbrella term defining a wide range of problematic online behaviours - gaming, viewing pornography, buying, gambling, streaming, social media….Growing concern about the public health and societal costs of PUI across the lifespan, including in vulnerable children and young people WHO ICD-11 recognises gaming, gambling, compulsive sexual behaviour disorders as mental disorders based on clinical evidence & public health needs There remains a critical scarcity of reliable information on:clinical parametersgeographical differences (E Asia)comorbiditiesbrain-based biologysocio-health-economic impactevidence-based treatments   Fineberg NA et al, 2018, Manifesto for a European Research Network into Problematic Usage of the Internet , Eur Neuropsychopharmacol. 28(11), 1232-1246 PUI AS BEHAVIOURAL ADDICTION?

5. ADDICTION: CORE ASPECTSMultifaceted construct, incorporating impaired control (unsuccessful attempts to reduce intake), craving (strong preoccupations or motivational drives leading to behavioural engagement), impairment (neglect of other areas of life leading to occupational, relational and other problems), risky/harmful use (persisting intake despite awareness of damaging psychological or physiological effects or other negative consequences), physiological features (tolerance, withdrawal). DSM-5, American Psychiatric Association 2013

6. PUI and Addiction Gaming, porn, buying, gambling, social media, streaming..impaired control (unsuccessful attempts to reduce intake), craving (strong preoccupations or motivational drives leading to behavioural engagement), impairment (neglect of other areas of life leading to occupational, relational and other problems), risky/harmful use (persisting intake despite awareness of damaging psychological or physiological effects or other negative consequences), ? physiological features (tolerance, withdrawal) Less clear whether, apart from gambling, other forms of PUI meet psycho-physiological criteria relating to addiction

7. InternetProblematicProblematic Internet UseNon-problematic useSocial mediaGamingPornographyShoppingGamblingStreaming

8. Gaming Disorder11th revision of the International Classification of Diseases (ICD-11) (WHO 2018)GD is characterized by Impaired control over gaming, increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities, continuation or escalation of gaming despite the occurrence of negative consequences . The behavior pattern is of sufficient severity to cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.The pattern of gaming behaviour may be continuous or episodic and recurrent. The gaming behaviour and other features are normally evident over a period of at least 12 months, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.

9. But - not all forms of PUI resemble addictionNot all forms of PUI are functionally impairing e.g. ‘hazardous gambling’ Online shopping, porn viewing resemble impulse-control or sexual disorders Repeatedly checking e-mails, digital hoarding resemble OCD or OCRDs Excessive social media may reflect avoidance - social anxiety disorder, ASD ‘Cyberchondria’ (online searching for health-related info) involves - intolerance of uncertainty driving compulsive reassurance seeking, - is amplified by the ambiguity of Internet health information, - increases anxiety, by discovering new triggers for health-related worry, reinforcing further compulsive checking. Phenotypic similarities to behavioural addictions for some forms of PUI For others, similarities with social anxiety, impulse-control and OCRDs Certain Internet functions may actively reinforce PUI

10. The endophenotype model in psychiatryNeurocognitionBrain abnormalitiesAetiologyGeneticEnvironmentalEndophenotypicmarkers“measurable components unseen by the unaided eye along the pathway between disease and distal genotype”Gottesman & Gould 2003Expressed behaviour

11. Top down controlBottom up drive

12. Update Overview on Brain Imaging Studies of Internet Gaming DisorderWeinstein A. Front Psychiatry 2017 Systematic review; 76 studies (23 resting state, 18 functional connectivity, 27 activation, 8 pharmacology).GD participants showed imaging changes in brain regions involved in decision-making, behavioural inhibition and emotional regulation lower GMD - anterior cingulate, supplementary motor area, cerebellum, insula, inferior temporal gyrusLower WMD - inferior frontal gyrus, insula, amygdala, anterior cingulate.(Weinstein et al, Neurosci Biobehav Reviews, 2017)Caution; changes may reflect predisposing factors rather than effects of GD.

13. Candidate Neurocognitive Models for PUIIncreased attentional bias to salient cues Impulsive choice behaviour Motor disinhibition Disadvantageous decision making (delay discounting)Faulty reversal learning Inflexible attentional set-shiftingBias toward habit and away from goal-directed acts Various of these domains affected in candidate behavioural addictions e.g. gambling, binge eating, hair pulling and skin picking disorders. Also affected in impulse control disorders and OCD.Neurocognitive function in PUI little studied……….impulsivecompulsive

14. Cognition in PUI: Meta-analysis of 40 studiesIoannidis K et al., Br J Psychiatry. 2019 Feb 20:1-8. Systematic literature review of peer-reviewed case-controlled studies comparing cognition in PUI (broadly defined) to healthy controls. Findings subjected to meta-analysis where >= 4 publications existed for a cognitive domain of interest. 2922 participants across 40 studies. PUI was associated with impairment in inhibitory control (Stroop task Hedge’s g=0.53 ±0.18 [SE], Stop-signal task g=0.42±0.12, Go/No-Go task g=0.51±0.17) decision-making (g=0.49±0.11) working memory (g=0.40±0.17)Whether or not gaming was the predominant online behaviour did not significantly moderate the cognitive effects.Nor did age, gender, geographical area of reporting or the presence of co-morbidities* Impulsivity & executive dysfunction differentiate PUI, broadly defined.

15. Impact of Comorbid Impulsive/Compulsive Disorders on PUIChamberlain S et al., 2018, J Behav Addict. 7(2):269-275123 adults aged 18-29 years recruited using media adverts.Detailed psychiatric assessment, including interviews, questionnaires and neuropsychological testing. Participants classified into three groups: - PUI with no comorbid impulsive/compulsive disorders (n=18) - PUI with >=one comorbid impulsive/compulsive disorder (n=37) - Healthy controls (n=67) The 3 groups did not differ on age, gender, levels of education, nicotine consumption or alcohol use. Quality of life was significantly impaired in PUI irrespective of whether or not individuals had comorbid impulsive/compulsive disorders (large effect size). Impaired response inhibition and decision-making were only identified in PUI with impulsive/compulsive comorbidities (medium effect sizes).

16. Cost And Burden Of PUI – Public Health Uncertainties Global societal risk of PUI growing as Internet exposure increasesPUI often starts in childhood/adolescence and increases over time. Reported PUI prevalence ranges from 1% - 36.7%!Social, cultural and demographic differences in Internet access, use, behaviours and attitudesDiffering instruments and thresholds across studies. Scarcity of reliable primary data means the full impact of PUI in specific juridisdictions is poorly understood.Public health burden of PUI includes associated comorbidities, which magnify as PUI becomes more severe and chronic.Also, the indirect costs associated with the burden of care and lost occupational income carried by the family.

17. Cost And Burden Of PUI – At The Citizen Level PUI is associated with relationship difficulties, academic and employment underperformance, financial problems:In children and adolescents, functional impairment (reduced grades, disrupted schooling or university education, onset of psychopathological symptoms) found to follow prolonged excessive use of video games. Meta-analysis of 120,000, 6 -19year olds (Carter et al 2016) found those with bedtime access to a media device were more likely to report poor sleep, not enough sleep, and daytime sleepiness (even with access only).UK study of 10,904, 14 year olds (Kelly et al 2019) found gender – moderated associations between social media use & depressive symptoms.Video-streaming is a leading PUI domain in university students (Van Ameringen et al 2017), emphasising potential for socially acceptable forms of online behaviour to be associated with adverse health in the young.

18. PUI – Now A Cause For Clinical ConcernEpidemiological data reported an association between rates of social media and smartphone use, depression and suicide in a large sample of young people (Twenge et al 2017).Systematic review of publications (2011 – 2015) found a specific association between self-harm/suicidal behaviour and Internet addiction, high levels of Internet use and websites with self-harm or suicide content (Marchant et al 2017). Meta-analysis of 23 cross-sectional studies (n = 270,596) and 2 prospective studies (n = 1,180) provides evidence that PUI is associated with increased suicidality even after adjusting for potential confounding variables including depression (Cheng et al J Clin Psychiatry 2018)Though the direction of causality remains unclear, PUI is reported to associate with comorbid substance addictions, depression, anxiety disorders, OCD and ADHD as well as general executive dysfunction. Growing reports of treatment-seeking cases of PUI with functional impairment, not limited to East Asia and in cases without major comorbidity, indicating PUI does present as the primary issue for intervention.

19. Interventional Strategies – Psychological No treatments are currently approved for PUICognitive behaviour therapy (CBT) has a larger evidence base than other psychological therapies Motivational interviewing, group counselling, self-help approaches (encouraging abstinence, coping with high-risk triggers, modifying lifestyle to reinforce healthier behaviours) may have some valueMajor methodological issues, including (but not limited to) small study samples, lack of randomisation or appropriate control conditions, inconsistent diagnostic definitions and symptom severity measurement,limited information on adherence to treatment.Zajac et al Psychol Addict Behav, 2017King et al Clinical Psychology Review 2017

20. Interventional strategies – pharmacological, somaticAppropriately controlled pharmacological treatment trials for PUI are absent and only a few case reports are availableReview of evidence-based treatments for similar disorders may be informative. Medications showing efficacy in OCD (SRIs) and hair pulling disorder (glutamate modulators e.g. N-acetyl cysteine, opioid antagonists e.g. naltrexone) could be considered. Alternative techniques for neuro-stimulation, such as transcranial direct current stimulation or theta burst stimulation, are also being studied in PUI with some evidence of benefit (Jeong et al Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation 2017) Once the entity of PUI is better delineated, controlled trials of such agents could be conducted with greater confidence.

21. EUROPEAN NETWORK FOR PROBLEMATIC USE OF THE INTERNET (EU-PUI) www.cost.eu/COST_Actions/ca/CA16207Multidisciplinary expertise (animal and human neuroscience, genetics, clinicians, bio & information-technology industry, health economists, policy makers, service planners, patients & carers)Advance understanding of the psycho-biological basis of different forms of PUI and the societal cost and burdenSpearhead development of treatment and prevention programmes39 countries 146 members

22. Manifesto for a European Research Network into Problematic Usage of the InternetKey Research QuestionsReliable consensus-driven definitions of the problems & establishment of reliable diagnosesInstruments to measure severity across different forms of PUI, age groups, cultures that are sensitive to changeLong-term studies to understand the clinical course and impacts of PUI on health and wellbeing Identify those most vulnerable e.g. via genetics, personality types, social groups or types of online exposureBiomarkers/digital markers to improve early detection and interventionDiscover and develop interventions (prevention, treatment) Fineberg NA et al Eur Neuropsychopharmacol, Nov;28(11):1232-1246.

23. Manifesto for a European Research Network into Problematic Usage of the InternetKey Research QuestionsReliable consensus-driven definitions of the problems & establishment of reliable diagnosesInstruments to measure severity across different forms of PUI, age groups, cultures that are sensitive to changeLong-term studies to understand the clinical courses and impacts of PUI on health and wellbeing Identify those most vulnerable e.g. via genetics, personality types, social groups or types of online exposureBiomarkers/digital markers to improve early detection and interventionDiscover and develop interventions (prevention, treatment) Fineberg NA et al Eur Neuropsychopharmacol, Nov;28(11):1232-1246.

24. Future Directions for Horizon Europe A longitudinal and cross-cultural approach to psychological and neurobiological processes in interaction with the developing brain and mind underlying the development and maintenance of Internet-use disorders Online and in person analysis of clinical and digital phenotypes, cognitive endophenotypes, brain imaging changes, genetics and epigenetics in different aged cohorts of young people at risk for PUI, followed for up to 5 years. 2. Analyze interactionsStudies should address interactions between trait and state variables.3. Specify types of Internet-use disordersStudies should distinguish between Gaming, Gambling, Pornography-use, Shopping, Streaming, Communication

25. We need research to tell us more about the extent of PUI, BUT Known harms include the development of mental disorders.Young people are particularly vulnerable, as disruption to cognitive, academic and social development affects long-term trajectories. Early intervention holds promise for reducing health and social burden.Industries (gaming, media etc) pursuing economic gains from online products and services need to lead and collaborate on consumer protection early identification of problems interventions Public engagement (including young people) is key to generate meaningful research questions develop rational, balanced and viable public health policieshttps://www.parliament.uk/business/committees/committees-a-z/commons-select/digital-culture-media-and-sport-committee/inquiries/parliament-2017/immersive-technologies/

26. Visit us at http://www.internetandme.eu/ Follow us on Net&Me COST Action Ca16207@ Net&Me

27. Events run by COST Action 16207, 2018/19Online Masterclass on Behavioural Addictions 29th March 2018 Hooked on WIFI 10th October 2018International Training school and conference on PUI14th – 16th January 2019Recordings of all these events may be freely viewed at www.InternetandMe.eu

28. Publications arising from the Action, 2017-19Banyai, F., Griffiths, M. D., Kiraly, O., & Demetrovics, Z. (2018). The Psychology of E-sports: A Systematic Literature Review. doi: 10.1007/s10899-018-9763-1Bányai, F., Zsila, Á., Demetrovics, Z., & Király, O. (2017). A problémás videojáték-használat újabb elméleti és gyakorlati megközelítései. INFORMÁCIÓS TÁRSADALOM: TÁRSADALOMTUDOMÁNYI FOLYÓIRAT, 18(1), 93-106.Chamberlain SR et al J The impact of comorbid impulsive/compulsive disorders in problematic Internet use. Behav Addict. 2018 Jun 1;7(2):269-275.Fineberg NA, Demetrovics Z, Stein DJ, Ioannidis K, Potenza MN), Grünblatt E, Brand M, Billieux J, Carmi L, King DL, Grant JE , Yücel M, Dell’Osso B, Rumpf HJ, Hall N, Hollander E, Goudriaan AE, Menchon J, Zohar J, Burkauskas J, Martinotti G , Van Ameringen M , Corazza O, Pallanti S, COST Action Network and Chamberlain SR. Manifesto for a European Research Network into Problematic Usage of the Internet. Eur Neuropsychopharmacol. Volume 28, Issue 11, November 2018, Pages 1232-1246Fineberg NA, Apergis-Schoute AM, Vaghi MM, Banca P, Gillan CM, Voon V, Chamberlain SR, Cinosi E, Reid J, Shahper S, Bullmore ET, Sahakian BJ, Robbins TW. Mapping Compulsivity in the DSM-5 Obsessive Compulsive and Related Disorders: Cognitive Domains, Neural Circuitry, and Treatment. Int J Neuropsychopharmacol. 2018 Jan 1;21(1):42-58. doi: 10.1093/ijnp/pyx088.Ioannidis K, et al. Problematic internet use as an age-related multifaceted problem: Evidence from a two-site survey. Addict Behav. 2018 Jun;81:157-166.Ioannidis K, Hook R, Goudriaan AE, Vlies S, Fineberg NA, Grant JE, Chamberlain SR. Cognitive deficits in problematic internet use: meta-analysis of 40 studies. Br J Psychiatry. 2019 Feb 20:1-8.King, D. L. & Gaming Industry Response Consortium. (2018). Comment on the global gaming industry’s statement on ICD-11 gaming disorder: A corporate strategy to disregard harm and deflect social responsibility? Addiction. DOI: 10.1111/add.14388.

29. Király O, Bőthe B, Ramos-Diaz J, Rahimi-Movaghar A, Lukavska K, Hrabec O, Miovsky M, Billieux J, Deleuze J, Nuyens F, Karila L, Griffiths MD, Nagygyörgy K, Urbán R, Potenza MN, King DL, Rumpf HJ, Carragher N, Demetrovics Z. Ten-Item Internet Gaming Disorder Test (IGDT-10): Measurement invariance and cross-cultural validation across seven language-based samples. Psychol Addict Behav. 2019 Feb;33(1):91-103.Laconi, S., Urbán, U., Kaliszewska-Czeremska, K., Kuss, D. J., Gnisci, A., Sergi, I., Barke, A., Jeromin, F., Groth, J., Gamez-Guadix, M., Ozcan, N. K., Siomos, K., Floros, G. D., Griffiths, M. D., Demetrovics, Z. Király, O. (2019). Psychometric evaluation of the nine-item Problematic Internet Use Questionnaire (PIUQ- 9) in nine European samples of internet users. Frontiers in Psychiatry, [in press]M. Pentek, T. Wijeratne, M. Jakovljevic, G. Kockaya, L-F Pau (Eds) , Accelerated Globalization and its Impact to the World’s Health Care Achievement, Frontiers Research Topics J., https://www.frontiersin.org/research-topics/9540/accelerated-globalization-and-its-impact-to-the-worldshealth- care-achievement , 2019Rumpf HJ, Achab S, Billieux J, Bowden-Jones H, Carragher N, Demetrovics Z, Higuchi S, King DL, Mann K, Potenza M, Saunders JB, Abbott M, Ambekar A, Aricak OT, Assanangkornchai S, Bahar N, Borges G, Brand M, Chan EM, Chung T, Derevensky J, Kashef AE, Farrell M, Fineberg NA, Gandin C, Gentile DA, Griffiths MD, Goudriaan AE, Grall-Bronnec M, Hao W, Hodgins DC, Ip P, Király O, Lee HK, Kuss D, Lemmens JS, Long J, Lopez-Fernandez O, Mihara S, Petry NM, Pontes HM, Rahimi-Movaghar A, Rehbein F, Rehm J, Scafato E, Sharma M, Spritzer D, Stein DJ, Tam P, Weinstein A, Wittchen HU, Wölfling K, Zullino D, Poznyak V. Including gaming disorder in the ICD-11: The need to do so from a clinical and public health perspective. J Behav Addict. 2018 Jul 16:1-6. doi: 10.1556/2006.7.2018.59Rumpf HJ et al Including gaming disorder in the ICD-11: The need to do so from a clinical and public health perspective. J Behav Addiction 2018 Jul 16:1-6.Stein, D. J., Billieux, J., Bowden-Jones, H., Grant, J. E., Fineberg, N., Higuchi, S., . . . Potenza, M. N. (2018). Balancing validity, utility and public health considerations in disorders due to addictive behaviours. World psychiatry: official journal of the World Psychiatric Association (WPA), 17(3), 363-364.Stein DJ, Billieux J, Bowden-Jones H, Grant JE, Fineberg N, Higuchi S, Hao W, Mann K, Matsunaga H, Potenza MN, Rumpf HM, Veale D, Ray R, Saunders JB, Reed GM, Poznyak V. Balancing validity, utility and public health considerations in disorders due to addictive behaviours. World Psychiatry. 2018 Oct;17(3):363-364. doi: 10.1002/wps.20570.Tomczyk, Ł., & Selmanagic-Lizde, E. (2018). Fear of Missing Out (FOMO) among youth in Bosnia and Herzegovina—Scale and selected mechanisms. Children and Youth Services Review, 88, 541-549.

30. Upcoming Events WPA World Congress of Psychiatry, Lisbon, Portugal https://2019.wcp-congress.com Behavioural Addiction: A Research And Clinical UpdateUpdate on Obsessive Compulsive Disorders Lisbon Addictions 2019, Portugal http://www.lisbonaddictions.eu Problematic Usage of Internet: From assessment to interventionBehavioural Addictions Trends in Neurosciences, XVIII Congress, Palanga, Lithuania.Emerging behavioural addictions. May 3rd 2019. PUI Information Day, Macedonia – Date to Be confirmedPUI: 2nd International Training School – March 2020, Budapest, Hungary

31. Conclusions Important work is being done but there is a need for a better understanding of PUI, in this changing environment, to promote individual, familial and public health. Recognition of PUI as a clear and growing risk to the health and wellbeing of a vulnerable group of individuals, e.g. through the Gaming Disorder diagnosis in ICD-11.Investment is needed in networked research into various forms of PUI at a European level (Horizon Europe).Informed Policies for prevention and early intervention, likely to involve negotiations with the gaming industry inter alia (addiction potential of games, age limits, preventive elements e.g. limit hours of play or include warning signs).

32. THANK YOU!Do visit us at http://www.internetandme.eu/