Addictive Behaviors 64 (2017) 357–362

Contents lists available at ScienceDirect

Addictive Behaviors

journal homepage: www.elsevier.com/locate/addictbeh

Treatment with the Self-Discovery Camp (SDiC) improves Internet

gaming disorder
Hiroshi Sakuma ⁎, Satoko Mihara, Hideki Nakayama, Kumiko Miura, Takashi Kitayuguchi, Masaki Maezono,
Takuma Hashimoto, Susumu Higuchi
National Hospital Organization Kurihama Medical and Addiction Center, 5-3-1 Nobi, Yokosuka, Kanagawa 2390841, Japan

H I G H L I G H T S

• We devised a therapeutic residential camp for Internet gaming disorder.

• This Self-Discovery Camp led to decreased gaming time at a 3-month follow-up.
• Problem recognition and self-efficacy scores similarly increased after the camp.
• Onset age of Internet gaming disorder and problem recognition were correlated.

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Internet gaming disorder (IGD) is a novel behavioral addiction that influences the physical, mental,
Received 8 June 2015 and social aspects of health due to excessive Internet gaming. One type of intensive treatment for IGD is the ther-
Received in revised form 3 June 2016 apeutic residential camp (TRC), which comprises many types of therapies, including psychotherapy,
Accepted 9 June 2016 psychoeducational therapy, and cognitive behavioral therapy. The TRC was developed in South Korea and has
Available online 10 June 2016
been administered to many patients with IGD; however, its efficacy in other countries remains unknown. We in-
vestigated the efficacy of the Self-Discovery Camp (SDiC), a Japanese version of a TRC, and the correlations be-
Keywords:
Behavioral addiction
tween individual characteristics and outcome measures.
Onset Methods: We recruited 10 patients with IGD (all male, mean age = 16.2 years, diagnosed using the DSM-5) to
Internet spend 8 nights and 9 days at the SDiC. We measured gaming time as well as self-efficacy (using the Stages of
Cognitive behavioral therapy Change Readiness and Treatment Eagerness Scale, a measure of therapeutic motivation and problem recogni-
Video game tion).
Results: Total gaming time was significantly lower 3 months after the SDiC. Problem recognition and self-efficacy
towards positive change also improved. Furthermore, there was a correlation between age of onset and problem
recognition score.
Conclusions: Our results demonstrate the effectiveness of the SDiC for IGD, especially regarding gaming time and
self-efficacy. Additionally, age of onset may be a useful predictor of IGD prognosis. Further studies with larger
sample sizes and control groups, and that target long-term outcomes, are needed to extend our understanding
of SDiC efficacy.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Internet gaming disorder (IGD) is a behavioral addiction character-
ized by compulsive overuse of and dependence on various types of on-
line gaming, such as massively multiplayer online role-playing games
(MMORPGs) and first-person shooting games. Demographic research
Abbreviations: SDiC, Self-Discovery Camp; IGD, Internet gaming disorder; TRC,
therapeutic residential camp.
⁎ Corresponding author.
E-mail address: YRS02723@nifty.com (H. Sakuma).
has shown that only a small proportion of heavy gamers are likely to de-
velop IGD (Baggio et al., 2016; Mentzoni et al., 2011). Patients with IGD
immerse themselves in online games and present difficulties in physi-
cal, mental, and social aspects of health (American Psychiatric
Association, 2013; Kim et al., 2016). Recently, IGD has gained promi-
nence alongside the development of information technologies and In-
ternet services (Griffiths, Kuss, & King, 2012).
IGD is characterized not only by compulsive overuse, but also by
similarities with other behavioral addictions (Fauth-Buhler & Mann,
2015; Kuss, 2013). There are several arguments concerning whether In-
ternet/computer overuse can become an addiction (Griffiths, 2004,

http://dx.doi.org/10.1016/j.addbeh.2016.06.013
0306-4603/© 2016 Elsevier Ltd. All rights reserved.
358 H. Sakuma et al. / Addictive Behaviors 64 (2017) 357–362
2015). For instance, some claim that IGD simply characterizes other as-
pects of existing mental disorders (Blaszczynski, 2006; Shaffer, Hall, &
Vander Bilt, 2000). However, researchers have generally reached the
consensus that the overuse of or addiction to Internet gaming can be a
psychiatric issue (Petry, Rehbein, Ko, & O'Brien, 2015).
Although the prevalence of IGD varies according to country, culture,
and social background, many studies suggest that IGD typically occurs
more in younger ages. Approximately 1.5–3% of children aged 13–
16 years in the Netherlands may have IGD (Van Rooij, Schoenmakers,
Vermulst, Van Den Eijnden, & Van De Mheen, 2011). Studies from
other countries have shown similar results that IGD has “peak ages”
(Bakken, Wenzel, Gotestam, Johansson, & Oren, 2009; Papay et al.,
2013; Rehbein, Kleimann, & Mossle, 2010; Wang et al., 2014).
Since IGD commonly occurs in adolescents or young adults, it means
that their addictive behavior can critically affect their social develop-
ment and interaction. For instance, individuals with severe IGD typically
spend a long time gaming, occasionally exceeding 30 h or more a week
(Bouna-Pyrrou, Muhle, Kornhuber, & Lenz, 2015). Furthermore, they
tend to exhibit aggressive tendencies, which can influence their social
well-being (Lemmens, Valkenburg, & Peter, 2011), and exhibit impaired
sleep quality (Carli et al., 2013). Patients with IGD also often exhibit
symptoms or comorbidities such as hostility, social phobia, anxiety,
depression.
Typically, individuals with addictions have a high risk of comorbidi-
ties (Hogue, Henderson, & Schmidt, 2016; Marquez-Arrico, Lopez-Vera,
Prat, & Adan, 2016). Comorbidities such as developmental disorders or
anxiety disorders impair of the use of coping strategies and lower self-
efficacy in addictive disorders (Hermsen et al., 2016). Moreover, comor-
bidities are related to the severity of IGD (Baggio et al., 2016; Han, Kim,
Bae, Renshaw, & Anderson, 2015; Wei, Chen, Huang, & Bai, 2012).
It is important to provide effective treatment to patients with IGD
that tend to have comorbidities. Since IGD is a novel disease, there is
still insufficient evidence of therapeutic outcomes for IGD. However,
there is a concordance on the efficacy of psychosocial or
psychoeducational therapies for IGD. Hall and Parsons (2001) reported
that cognitive behavioral therapy (CBT) is effective for college student
patients. Furthermore, according to a review by King, Delfabbro,
Griffiths, and Gradisar (2011), there are many reports of non-
pharmacotherapeutic treatments for IGD, most of which focus on CBT,
motivational interviewing, and counseling.
The treatment or therapeutic effects described in these reports vary
widely. For instance, one study reported that the therapeutic effects of
CBT were sustained in 78% of those patients 6 months later (Young,
2013). However, according to King et al.'s (2011) review, despite the
large number of extant reports on IGD treatment, the efficacy of existing
treatments remains inconclusive.
Many of the studies that have focused on IGD are from Southeast
Asia (e.g., South Korea, Taiwan, and China; Wölfling, Beutel, Dreier, &
Müller, 2014). In these countries, various therapeutic approaches are
continually being developed. South Korea has been administering a gov-
ernment-provided therapeutic residential camp (TRC) as one option for
treatment (Koo, Wati, Lee, & Oh, 2011). The TRC involves 11 nights and
12 days of camp-style residence and intervention comprising occupa-
tional therapy, exercise therapy, CBT, and recreational activities.
Most patients with IGD have their own gaming environment (e.g.,
personal computer or gaming console in their house). It is difficult to
provide therapy while a patient is immersed in gaming in his or her
own house. Consequently, the TRC has many advantages: 1) patients
can maintain a distance from their gaming environment while in thera-
py, 2) patients are able to experience interpersonal relationships with
other attendees and staff without electronic devices, and 3) patients
are subjected to intensive psychoeducation and CBT. The beneficial out-
comes of TRC for IGD have been confirmed (Koo et al., 2011).
Although the basis of a treatment program has been established, the
efficacy of TRC in countries other than Korea has not yet been examined.
Furthermore, the efficacy of TRC for patients with comorbidities such as
attention-deficit hyperactivity disorder (ADHD) or developmental dis-
orders is also unknown. Verifying the treatment effects and feasibility
of TRC can help to spur further exploration of the effective treatment
of IGD.
The Kurihama Medical and Addiction Center has contributed to both
the treatment and research of Internet addiction in Japan (Tohyama,
Yokoyama, Matsushita, & Higuchi, 2014). In this study, we implemented
a Japanese version of the TRC, the “Self-Discovery Camp” (SDiC), and de-
signed a measure of its efficacy.
This study estimated the effectiveness of the SDiC for IGD and con-
firmed whether the effects are durable over time. We also examined
the correlations between participants' individual characteristics and
outcome measures.
2. Methods
2.1. Participants
Participants were 10 males diagnosed with IGD according to DSM-5
criteria. They also fulfilled Griffith's six components of addiction: sa-
lience, mood modification, tolerance, withdrawal, conflict, and relapse
(Griffiths, 2005). More specifically, our inclusion criteria were as fol-
lows: 1) satisfied both Griffith's six components of addiction and the
DSM-5 IGD criteria through an interview by one our center's psychia-
trists and 2) spoke Japanese. The exclusion criteria were as follows: 1)
have a substance use disorder or a past history of one, 2) have severe
mental or somatic symptoms that influenced continuous attendance
of the program (e.g. severe cognitive or intellectual dysfunction, severe
depression, suicidal tendency, severe diabetes), as determined by the
physician in charge; 3) have not provided oral and written agreement
to participate (both themselves and their parents or representatives);
and 4) are considered by their physician in charge to be at risk for dete-
rioration of symptoms if they attend the SDiC.
All participants were recruited from our center's population of inpa-
tients and outpatients with IGD. They were all diagnosed with IGD by
psychiatrists in our center's addiction department during their first
visit to our center, prior to being recruited. Seven outpatients had re-
ceived regular counseling by a psychiatrist before attending the SDiC.
However, their obsessive gaming continued despite this counseling,
and all of them satisfied the DSM-5's criteria for IGD at baseline. Three
inpatients, also evaluated by psychiatrists, started their treatment in
our center's outpatient clinic. However, their frequency of obsessive
gaming and aggressive behavior increased, so they were admitted to
our center within 1 month before the SDiC. The clinical characteristics
are shown in Table 1. We received applications from male participants
only. From both medical records and the baseline interview, we found
that all of the participants were absorbed in MMORPGs. This type of
Table 1
Participants' characteristics.
Participants
Characteristics N = 10
Age (years), mean ± SD 16.2 ± 2.15
Inpatient 3
Outpatient 7
Onset age of Internet/gaming (years), 9.1 ± 4.0
mean ± SD
Onset age (years), mean ± SD 13.6 ± 0.89
Treatment history (years), mean ± SD 0.8 ± 1.23
5 = attention deficit hyperactivity
disorder
Comorbidity 1 = pervasive developmental
disorder
4 = none
Note: SD = standard deviation. The estimated onset age was identified as the age when
they had satisfied at least one item of the 5th edition of The Diagnostic and Statistical Man-
ual of Mental Disorders criteria.
 H. Sakuma et al. / Addictive Behaviors 64 (2017) 357–362
game is very popular, and many individuals with IGD engage in
MMORPGs (Billieux et al., 2013).
The ethics committee of the Kurihama Medical and Addiction Center
approved this study, and all participants and their parents provided
written informed consent prior to participation.
2.2. The SDiC
The camp was held over 8 nights and 9 days in the National Central
Children's Center, Gotenba City, Japan, in August 2014. The SDiC was
commissioned by the Japan Ministry of Education, Culture, Sports, Sci-
ence and Technology (MEXT). The National Institution for Youth Educa-
tion contributed management, and the Kurihama Medical and
Addiction Center collaborated in the camp's design and execution. All
participants stayed in the dormitory for the duration of the program.
They were not allowed to bring PCs, mobile phones, gaming machines,
or any other digital equipment. The SDiC comprised 14 sessions of CBT
with clinical psychologists, 3 medical lectures provided by doctors, 8
sessions of personal counseling, and a workshop entitled, “Our relation-
ship with the Internet.” We chose non-pharmacotherapeutic ap-
proaches that had been studied and deemed effective by previous
studies (King et al., 2011). The SDiC also involved outdoor cooking, a
walk rally, trekking, and woodworking. The goals of these activities
were 1) to foster awareness of health, wellness, and a well-regulated
life; 2) to experience communication without the Internet or digital de-
vices; and 3) to collaborate with others and solve problems.
College student volunteers were recruited as mentors. All of them
were majoring in education and were confirmed to have no current psy-
chiatric diseases. They were responsible for motivating each participant
to remain in the program. The therapeutic program was conducted by
the Kurihama Medical and Addiction Center and the activity program
was planned by the National Institution for Youth Education. All partic-
ipants were guaranteed that they could withdraw from the program
any time they wished.
2.3. Assessments
We evaluated participants at baseline (prior to the SDiC) and con-
ducted endpoint assessments immediately after the SDiC (Evaluation
Point 1) and 3 months later (Evaluation Point 2). Since self-efficacy
scores are likely affected by many real-life events, self-efficacy was mea-
sured only immediately after the SDiC. In contrast, gaming time was ex-
pected to be zero immediately following the SDiC; therefore, the
assessment of gaming time was delayed 3 months to evaluate whether
the intervention effects continued in participants' everyday lives.
2.3.1. Characteristics
Participants' characteristics are shown in Table 1. Although six par-
ticipants had a psychiatric comorbidity, their symptoms did not inter-
fere with the SDiC program. All participants were students (1 in
college and 9 in junior high school or high school). IGD diagnosis and es-
timated age of onset were determined by our center's psychiatrists
using semi-structured interviews prior to their treatment.
2.3.2. Internet use/gaming time
Internet use and/or gaming time per day (in hours) and per week (in
hours and days) was assessed at baseline and 3 months after the SDiC
(evaluation point 2). The data were collected by questionnaire and
checked during an interview with a clinical psychologist.
2.3.3. Self-efficacy
We used the Stages of Change Readiness and Treatment Eagerness
Scale (SOCRATES) to measure self-efficacy. This scale, developed by
Miller and Tonigan (1996), is frequently used to assess the outcome of
non-pharmacotherapeutic approaches to treating addictive disorders.
It assesses the degree of problem recognition and the necessity of
359
receiving support (Easton, Swan, & Sinha, 2000; Hunter-Reel,
McCrady, Hildebrandt, & Epstein, 2010). SOCRATES comprises 19
items. Responses are scored on a 5-point Likert scale from 1 (strongly
disagree) to 5 (strongly agree) and are summed for each of the following
domains: recognition, ambivalence, and taking steps. Recognition as-
sesses one's acknowledgement of their addictive behavior and whether
they aspire to change. Ambivalence measures the extent of ambition
one has, with or without the influence of addiction. Taking steps esti-
mates self-efficacy and the extent one takes action towards ceasing ad-
dictive behavior. This domain is known to be a predictor of cessation of
or reduction in addictive behavior (Burrow-Sanchez & Lundberg, 2007;
Demmel, Beck, Richter, & Reker, 2004; Sklar, Annis, & Turner, 1997;
Sklar & Turner, 1999). A Japanese version of SOCRATES was developed
(Matsumoto, Imamura, Kobayashi, Chiba, & Wada, 2009) and its validity
has been confirmed (Kobayashi et al., 2010).
2.4. Statistical analysis
A Wilcoxon rank sum test was used for a statistical analysis of con-
tinuous variables such as gaming time, and for ordinal scale variables
(i.e., each SOCRATES item). Spearman's rank correlation coefficients
were used to assess the association between variables. We considered
p-values less than 0.05 to be statistically significant. The effect size
was measured using Cohen's d (Rosenthal, 1994). SPSS Statistics version
17 for Windows was used for all statistical analyses (SPSS Inc., Chicago,
IL).
3. Results
Table 2 displays the results of the SDiC. Specifically, the median
hours of gaming time per day decreased (−3.18, 95% confidence inter-
val (CI) = −8.49 to 0.46) with a large effect size (d = 1.15). The median
hours of gaming per week also decreased (−27.04, 95% CI = −49.70 to
−4.40), again with a large effect size (d = 1.26). However, the gaming
time in days per week remained consistent.
Concerning SOCRATES scores, we observed no significant differences
in the recognition (baseline: 24.6, Evaluation Point 1: 26.9, p = 0.45,
mean improvement score: 2.3) and ambivalence subscales (baseline:
12.8, Evaluation Point 1: 14, p = 0.28, mean improvement score: 1.2)
between the baseline and Evaluation Point 1. However, the taking-
steps subscale scores improved significantly (baseline: 19.4, Evaluation
Point 1: 27, p = 0.012, mean improvement score: 7.6, 95% CI: 3.40 to
11.80).
We also investigated the correlations between the study variables. A
moderately large, positive correlation existed between onset age and
recognition scores (r = 0.781, p = 0.008).
4. Discussion
The total time of Internet use per day and per week in hours was sig-
nificantly reduced 3 months after the SDiC (evaluation point 2) com-
pared to baseline. Particularly, the effect size of improving gaming
time hours per week was large. This finding supports that our interven-
tion led to an improvement in addictive behavior and that its beneficial
effects were sustained 3 months later.
In contrast to the improvement of gaming time and self-efficacy,
gaming days per week did not improve. In other words, participants
were still gaming almost daily. This finding may reflect two aspects of
their conflicting motivations: 1) participants are still attracted to gam-
ing, but 2) they want to be able to control their behavior and pursue it
in a healthy way. The improvement of addictive behavior requires a cer-
tain period. Participants may have shortened their overall gaming time;
however, gaming still seems to play an important role in their lives.
Participants' taking-steps scores also improved significantly after the
SDiC. This suggests an increase in self-efficacy, or the sense that one can
solve problems. In general, addictive disorders tend to decrease
360 H. Sakuma et al. / Addictive Behaviors 64 (2017) 357–362
Table 2
The changes between baseline and each evaluation point.
Baseline
Mean (SD)
Amount of gaming time Gaming time (hour/day) 9.96 (2.95)
Gaming time (hour/week) 71.35 (23.84)
Gaming days (days/week) 6.79 (0.63)
SOCRATES Recognition 24.6 (7.32)
Self-efficacy Ambivalence 12.8 (3.85)
Taking Steps 19.4 (6.87)
Note: SOCRATES = Stages of Change Readiness and Treatment Eagerness Scale, Evaluation Point 1 = immediately after the Self-Discovery Camp ended, Evaluation Point 2 = three months
after the Self-Discovery Camp ended, SD = standard deviation.
individuals' self-efficacy (DiClemente, Fairhurst, & Piotrowski, 1995;
Strecher, DeVellis, Becker, & Rosenstock, 1986). Furthermore, the
more symptoms they experience, the greater the social impairment. In-
dividuals with addiction are apt to become isolated and withdraw from
social relationships (e.g., social roles or family membership), which can
in turn decrease their sense of competency in dealing with problems
(Bandura, Barbaranelli, Caprara, & Pastorelli, 1996). Thus, the progress
in taking-steps scores may have resulted from the program instilling
an increased sense of competency in how participants dealt with
difficulties.
The SDiC, which is a combination of non-pharmacotherapeutic treat-
ment with an activity program, might have enhanced participants' mo-
tivation to improve IGD symptoms by increasing their awareness of the
problem and their confidence in solving it. The deepening of motivation
during CBT or personal counseling alone may have been effective
(Young, 2013); however, the formation of a fellowship and a sense of
unity with the support staff and other participants also likely contribut-
ed to this improvement, especially in the taking-steps domain. It is
known that self-help groups are an effective source of support for indi-
viduals recovering from addiction (Humphreys, Blodgett, & Wagner,
2014; Lee & Mysyk, 2004; Petry & Armentano, 1999; Sussman, 2010).
In the context of the SDiC, the increased interactions similar to those
in a self-help group environment most likely influenced participants'
taking-steps scores. Rice, Hagler, and Tonigan (2014) reported that im-
provement in taking-steps scores predicted self-help group attendance.
Thus, it is possible that participants who showed improved scores in
taking-steps scores will implement more therapeutic behaviors (e.g., re-
ceived treatment, accepted advice) or show reduced addictive behav-
iors in the future.
Six of the ten participants also had a developmental disorder, which
was mainly ADHD. One of ADHD's symptoms—namely, decreased exec-
utive functioning, including self-control—can affect the severity of IGD
(Han, Han, et al., 2015). Such individuals tend to concentrate on stimu-
lating phenomena, and treatment of such symptoms requires a certain
amount of time. Moreover, all participants were male and in their ado-
lescence. Japanese adolescents use electronic devices not only for gam-
ing, but also for communication and assistance with school activities.
Consequently, it may be difficult for these individuals to avoid playing
games while still relying on these devices, especially if they have
ADHD or another developmental disorder. Nevertheless, participants'
amount of gaming time decreased significantly 3 months after the
SDiC. This finding supports the sustained efficacy of the SDiC program.
Furthermore, although half of the SDiC participants had ADHD, their
gaming time and taking steps scores similarly improved. In general,
the inattention and hyperactivity symptoms of ADHD make individuals
afflicted with it highly distracted. However, the intensive series of ther-
apies in the SDiC might have reduced this distraction through repetition.
In addition, promotive interactions with other participants and mentors
may have enhanced their learning.
Participants' recognition scores positively correlated with onset age.
The lower the onset age, the more participants' recognition of addictive
behavior decreased. This may reflect a strong attachment to Internet
Evaluation Point 1 Evaluation Point 2
Mean (SD) Mean (SD) p Effect size (Cohen's d)
6.78 (2.57) 0.044 1.15
44.31 (18.76) 0.024 1.26
6.56 (0.83) 0.18 0.31
26.9 (4.53) 0.28 0.38
14 (2.58) 0.45 0.37
27 (8.22) 0.012 1.00
gaming from an early age. An earlier onset age is known to be associated
with lower levels of problem recognition, less awareness of problematic
behavior, and an increased rate of substance use disorders such as alco-
hol or drug dependence (Hingson, Heeren, & Winter, 2006; Johnson,
Cloninger, Roache, Bordnick, & Ruiz, 2000; Robins & Przybeck, 1985).
Early onset is also a predictor of the severity of both alcohol use disorder
(Schuckit & Smith, 2011) and substance use disorder (Chen, Storr, &
Anthony, 2009). This is perhaps related to the fact that motivated be-
havior and decision-making develops concomitantly with reward pro-
cessing in adolescents (Ernst, Pine, & Hardin, 2006; Yaxley et al.,
2011); as such, the increased impulsivity and heightened response to
rewards characteristic of those with early-onset alcohol use disorder
may weaken their decision-making ability (Finn, Mazas, Justus, &
Steinmetz, 2002; Mazas, Finn, & Steinmetz, 2000). Our findings do indi-
cate that there is a similarity between IGD and other addictions. Onset
age might be a prognostic indicator of problem recognition, such that
early onset age may predict poorer problem recognition. Therefore, fig-
uring out how to protect children from Internet gaming addiction may
be key to IGD prevention. However, it would be rash to make any con-
clusions regarding these similarities between IGD and other addictions,
so further exploration of these similarities in a more direct way is
needed.
The main limitations of this study are the possibility of selection bias,
single-group threat, and the small sample size.
First, all participants joined the SDiC voluntarily, which means we
cannot eliminate the possibility of selection bias—it may be that only
those participants who were ready to change or to undergo treatment
took part in this study. Furthermore, all participants underwent psychi-
atric treatment prior to attending the SDiC. An evaluation of the effects
of prior psychiatric treatment was not carried out, making it is difficult
to estimate and exclude the magnitude of the effects of this treatment
on our outcomes.
Second, single-group threats due to the lack of a control group may
have influenced our results. Although we administered the SOCRATES
immediately after the SDiC, we could not eliminate the possibility of sin-
gle-group threat. In particular, participants' posttest answers may have
been affected by their pretest answers, or they might have felt pressure
to choose the better options when responding to the questionnaire at
posttest.
Third, we could only recruit 10 participants, which is clearly insuffi-
cient for robust statistical evidence. As sample size is a critical factor for
ensuring the concreteness of statistical test results, a larger sample size
in a future study would be essential.
A fourth limitation was that we did not recruit any female partici-
pants. Thus, it is unclear whether our findings can apply to female IGD
patients. Further studies including women will be needed. However, it
should be noted that male IGD patients tend to show a higher preva-
lence of IGD, more severe symptoms, lower self-esteem, and lower sat-
isfaction in daily life compared with female patients (Haghbin,
Shaterian, Hosseinzadeh, & Griffiths, 2013; Ko, Yen, Chen, Chen, & Yen,
2005). Therefore, female IGD patients may not require such an intensive
treatment as the SDiC.
 H. Sakuma et al. / Addictive Behaviors 64 (2017) 357–362
The final limitation was our lack of measuring the long-term out-
come of the SDiC. To clarify the efficacy and limitation of the SDiC, a me-
dium- to long-term evaluation is essential.
In summary, more studies involving larger sample sizes and
matched control groups will be needed to investigate the efficacy of
the SDiC intervention more comprehensively, while also minimizing
or eliminating selection bias and single-group threat. Moreover, it
would be necessary to recruit participants who have not received
prior treatment or to accurately evaluate the efficacy of the treatment
prior to their participation. Of course, an appropriate sample size with
a balance of genders and other demographic characteristics must also
be obtained in order to establish robust statistical evidence and elimi-
nate the gender bias. Finally, measuring the medium- to long-term out-
comes using appropriate instruments such as formal diagnostic criteria
for IGD will be needed.
4.1. Conclusion
The improvements we observed were limited to the changes in
hours spent online and self-efficacy. These findings should be linked
to real behavior (e.g., deleting one's gaming account, ceasing school re-
fusal or social withdrawal, and improving relationships with family or
others). Towards this end, continuous psychosocial support and treat-
ment is essential. Participation in the SDiC is only the beginning of a life-
style change; encouraging patients to make real changes in their
everyday lives is the ultimate end goal.
Role of funding sources
Funding for this study was provided by National Hospital Organization Kurihama
Medical and Addiction Center. Therapeutic camp “SDiC” was funded by the Japan Ministry
of Education, Culture, Sports, Science and Technology (MEXT).
Contributors
Hiroshi Sakuma, Satoko Mihara, and Susumu Higuchi wrote the protocol and designed
this research. All authors contributed the planning and execution of the camp. Data collec-
tion was carried out by Satoko Mihara, Takashi Kitayuguchi, and Kumiko Miura. Literature
review was conducted by Hideki Nakayama. Masaki Maezono and Takuma Hashimoto
conducted and carried out statistical analyses. Hiroshi Sakuma wrote the first draft of
the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
We are grateful to Junko Matsumura and Kouhei Fukuoka from the National Institu-
tion for Youth Education in Japan. They managed the SDiC, including the activity program.
References
American Psychiatric Association (2013). Conditions for further study. Diagnostic and sta-
tistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric
Publishing.
Baggio, S., Dupuis, M., Studer, J., Spilka, S., Daeppen, J. B., Simon, O., ... Gmel, G. (2016).
Reframing video gaming and internet use addiction: Empirical cross-national com-
parison of heavy use over time and addiction scales among young users. Addiction,
111, 513–522. http://dx.doi.org/10.1111/add.13192.
Bakken, I. J., Wenzel, H. G., Gotestam, K. G., Johansson, A., & Oren, A. (2009). Internet ad-
diction among Norwegian adults: A stratified probability sample study. Scandinavian
Journal of Psychology, 50, 121–127. http://dx.doi.org/10.1111/j.1467-9450.2008.
00685.x.
Bandura, A., Barbaranelli, C., Caprara, G. V., & Pastorelli, C. (1996). Multifaceted impact of
self-efficacy beliefs on academic functioning. Child Development, 67, 1206–1222.
http://dx.doi.org/10.2307/1131888.
Billieux, J., Van der Linden, M., Achab, S., Khazaal, Y., Paraskevopoulos, L., Zullino, D., &
Thorens, G. (2013). Why do you play World of Warcraft? An in-depth exploration
of self-reported motivations to play online and in-game behaviours in the virtual
world of Azeroth. Computers in Human Behavior, 29, 103–109. http://dx.doi.org/10.
1016/j.chb.2012.07.021.
Blaszczynski, A. (2006). Internet use: In search of an addiction. International Journal of
Mental Health and Addiction, 4, 7–9. http://dx.doi.org/10.1007/s11469-006-9002-3.
Bouna-Pyrrou, P., Muhle, C., Kornhuber, J., & Lenz, B. (2015). Internet gaming disorder, so-
cial network disorder and laterality: Handedness relates to pathological use of social
networks. Journal of Neural Transmission, 122, 1187–1196. http://dx.doi.org/10.1007/
s00702-014-1361-5.
361
Burrow-Sanchez, J. J., & Lundberg, K. J. (2007). Readiness to change in adults waiting for
publicly funded substance abuse treatment. Addiction Behavior, 32, 199–204. http://
dx.doi.org/10.1007/s00702-014-1361-5.
Carli, V., Durkee, T., Wasserman, D., Hadlaczky, G., Despalins, R., Kramarz, E., ... Kaess, M.
(2013). The association between pathological internet use and comorbid psychopa-
thology: A systematic review. Psychopathology, 46, 1–13. http://dx.doi.org/10.1159/
000337971.
Chen, C. -Y., Storr, C. L., & Anthony, J. C. (2009). Early-onset drug use and risk for drug de-
pendence problems. Addictive Behaviors, 34, 319–322.
Demmel, R., Beck, B., Richter, D., & Reker, T. (2004). Readiness to change in a clinical sam-
ple of problem drinkers: Relation to alcohol use, self-efficacy, and treatment out-
come. European Addiction Research, 10, 133–138. http://dx.doi.org/10.1159/
000077702.
DiClemente, C. C., Fairhurst, S. K., & Piotrowski, N. A. (1995). Self-efficacy and addictive
behaviors. In J. E. Maddux (Ed.), Self-efficacy, adaptation, and adjustment
(pp. 109–141). New York: Springer. http://dx.doi.org/10.1007/978-1-4419-6868-5_
4.
Easton, C., Swan, S., & Sinha, R. (2000). Motivation to change substance use among of-
fenders of domestic violence. Journal of Substance Abuse Treatment, 19, 1–5. http://
dx.doi.org/10.1016/s0740-5472(99)00098-7.
Ernst, M., Pine, D. S., & Hardin, M. (2006). Triadic model of the neurobiology of motivated
behavior in adolescence. Psychological Medicine, 36, 299–312.
Fauth-Buhler, M., & Mann, K. (2015). Neurobiological correlates of Internet gaming disor-
der: Similarities to pathological gambling. Addiction Behavior. http://dx.doi.org/10.
1016/j.addbeh.2015.11.004.
Finn, P. R., Mazas, C. A., Justus, A. N., & Steinmetz, J. (2002). Early-onset alcoholism with
conduct disorder: Go/no go learning deficits, working memory capacity, and person-
ality. Alcoholism: Clinical and Experimental Research, 26, 186–206.
Griffiths, M. (2004). Does internet and computer “addiction” exist? Some case study evi-
dence. Cyberpsychology & Behavior, 3, 211–218. http://dx.doi.org/10.1089/
109493100316067.
Griffiths, M. (2005). A ‘components’ model of addiction within a biopsychosocial frame-
work. Journal of Substance Use, 10, 191–197. http://dx.doi.org/10.1080/
14659890500114359.
Griffiths, M. (2015). The role of context in online gaming excess and addiction: Some case
study evidence. International Journal of Mental Health and Addiction, 8, 119–125.
http://dx.doi.org/10.1007/s11469-009-9229-x.
Griffiths, M., Kuss, D., & King, D. (2012). Video game addiction: Past, present and future.
Current Psychiatry Reviews, 8, 308–318. http://dx.doi.org/10.2174/
157340012803520414.
Haghbin, M., Shaterian, F., Hosseinzadeh, D., & Griffiths, M. D. (2013). A brief report on the
relationship between self-control, video game addiction and academic achievement
in normal and ADHD students. Journal of Behavioral Addictions, 2, 239–243. http://
dx.doi.org/10.1556/JBA.2.2013.4.7.
Hall, A. S., & Parsons, J. (2001). Internet addiction: College student case study using best
practices in cognitive behavior therapy. Journal of Mental Health Counseling, 23,
312–327. http://dx.doi.org/10.1007/s11469-015-9622-6.
Han, J. W., Han, D. H., Bolo, N., Kim, B., Kim, B. N., & Renshaw, P. F. (2015a). Differences in
functional connectivity between alcohol dependence and internet gaming disorder.
Addiction Behavior, 41, 12–19. http://dx.doi.org/10.1016/j.addbeh.2014.09.006.
Han, D. H., Kim, S. M., Bae, S., Renshaw, P. F., & Anderson, J. S. (2015b). Brain connectivity
and psychiatric comorbidity in adolescents with internet gaming disorder. Addiction
Biology. http://dx.doi.org/10.1111/adb.12347.
Hermsen, L. A., van der Wouden, J. C., Leone, S. S., Smalbrugge, M., van der Horst, H. E., &
Dekker, J. (2016). The longitudinal association of cognitive appraisals and coping
strategies with physical functioning in older adults with joint pain and comorbidity:
A cohort study. BMC Geriatrics, 16, 29. http://dx.doi.org/10.1186/s12877-016-0204-7.
Hingson, R. W., Heeren, T., & Winter, M. R. (2006). Age at drinking onset and alcohol de-
pendence: Age at onset, duration, and severity. Archives of Pediatrics & Adolescent
Medicine, 160, 739–746. http://dx.doi.org/10.1001/archpedi.160.7.739.
Hogue, A., Henderson, C. E., & Schmidt, A. T. (2016). Multidimensional predictors of treat-
ment outcome in usual care for adolescent conduct problems and substance use.
Administration and Policy in Mental Health and Mental Health Services Research.
http://dx.doi.org/10.1007/s10488-016-0724-7.
Humphreys, K., Blodgett, J. C., & Wagner, T. H. (2014). Estimating the efficacy of Alcoholics
Anonymous without self-selection bias: An instrumental variables re-analysis of ran-
domized clinical trials. Alcoholism, Clinical and Experimental Research, 38, 2688–2694.
http://dx.doi.org/10.1111/acer.12557.
Hunter-Reel, D., McCrady, B. S., Hildebrandt, T., & Epstein, E. E. (2010). Indirect effect of
social support for drinking on drinking outcomes: The role of motivation. Journal of
Studies on Alcohol and Drugs, 71, 930–937. http://dx.doi.org/10.15288/jsad.2010.71.
930.
Johnson, B. A., Cloninger, C. R., Roache, J. D., Bordnick, P. S., & Ruiz, P. (2000). Age of onset
as a discriminator between alcoholic subtypes in a treatment–seeking outpatient
population. The American Journal on Addictions, 9, 17–27. http://dx.doi.org/10.1080/
10550490050172191.
Kim, N. R., Hwang, S. S., Choi, J. S., Kim, D. J., Demetrovics, Z., Kiraly, O., ... Choi, S. W.
(2016). Characteristics and psychiatric symptoms of internet gaming disorder
among adults using self-reported DSM-5 criteria. Psychiatry Investigation, 13, 58–66.
http://dx.doi.org/10.4306/pi.2016.13.1.58.
King, D. L., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2011). Assessing clinical trials
of internet addiction treatment: A systematic review and CONSORT evaluation.
Clinical Psychology Review, 31, 1110–1116. http://dx.doi.org/10.1016/j.cpr.2011.06.
009.
Ko, C. H., Yen, J. Y., Chen, C. C., Chen, S. H., & Yen, C. F. (2005). Gender differences and re-
lated factors affecting online gaming addiction among Taiwanese adolescents. Journal
362 H. Sakuma et al. / Addictive Behaviors 64 (2017) 357–362
of Nervous and Mental Disease, 193, 273–277. http://dx.doi.org/10.1097/01.nmd.
0000158373.85150.57.
Kobayashi, O., Matsumoto, T., Chiba, Y., Imamura, F., Morita, N., & Wada, K. (2010). Factor
structure of a Korean-language version of the Stages of Change Readiness and Treat-
ment Eagerness Scale (SOCRATES) in a clinical sample of clients with alcohol depen-
dence. Psychology of Addictive Behaviors, 24, 555–562. http://dx.doi.org/10.1037/
a0021492.
Koo, C., Wati, Y., Lee, C. C., & Oh, H. Y. (2011). Internet-addicted kids and South Korean
government efforts: Boot-camp case. Cyberpsychology, Behavior and Social
Networking, 14, 391–394. http://dx.doi.org/10.1089/cyber.2009.0331.
Kuss, D. J. (2013). Internet gaming addiction: Current perspectives. Psychology Research
and Behavior Management, 6, 125–137. http://dx.doi.org/10.2147/prbm.s39476.
Lee, S., & Mysyk, A. (2004). The medicalization of compulsive buying. Social Science &
Medicine, 58, 1709–1718. http://dx.doi.org/10.1016/s0277-9536(03)00340-x.
Lemmens, J. S., Valkenburg, P. M., & Peter, J. (2011). The effects of pathological gaming on
aggressive behavior. Journal of Youth and Adolescence, 40, 38–47. http://dx.doi.org/10.
1007/s10964-010-9558-x.
Marquez-Arrico, J. E., Lopez-Vera, S., Prat, G., & Adan, A. (2016). Temperament and char-
acter dimensions in male patients with substance use disorders: Differences relating
to psychiatric comorbidity. Psychiatry Research, 237, 1–8. http://dx.doi.org/10.1016/j.
psychres.2016.01.061.
Matsumoto, T., Imamura, F., Kobayashi, O., Chiba, Y., & Wada, K. (2009). Development and
evaluation of a relapse prevention tool for drug-abusing delinquents incarcerated in a
juvenile classification home: A self-teaching workbook for adolescents, the “SMARPP-
Jr”. Nihon Arukōru Yakubutsu Igakkai Zasshi, 44, 121–138.
Mazas, C. A., Finn, P. R., & Steinmetz, J. E. (2000). Decision-making biases, antisocial per-
sonality, and early-onset alcoholism. Alcoholism: Clinical and Experimental Research,
24, 1036–1040.
Mentzoni, R. A., Brunborg, G. S., Molde, H., Myrseth, H., Skouverøe, K. J. M., Hetland, J., &
Pallesen, S. (2011). Problematic video game use: Estimated prevalence and associa-
tions with mental and physical health. Cyberpsychology, Behavior, and Social
Networking, 14, 591–596. http://dx.doi.org/10.1089/cyber.2010.0260.
Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation for change: The stages
of change readiness and treatment eagerness scale (SOCRATES). Psychology of
Addictive Behaviors, 10, 81. http://dx.doi.org/10.1037/0893-164x.10.2.81.
Papay, O., Urban, R., Griffiths, M. D., Nagygyorgy, K., Farkas, J., Kokonyei, G., ... Demetrovics,
Z. (2013). Psychometric properties of the problematic online gaming questionnaire
short-form and prevalence of problematic online gaming in a national sample of ad-
olescents. Cyberpsychology, Behavior, and Social Networking, 16, 340–348. http://dx.
doi.org/10.1089/cyber.2012.0484.
Petry, N. M., & Armentano, C. (1999). Prevalence, assessment, and treatment of patholog-
ical gambling: A review. Psychiatric Services, 50, 1021–1027. http://dx.doi.org/10.
1176/ps.50.8.1021.
Petry, N. M., Rehbein, F., Ko, C. H., & O'Brien, C. P. (2015). Internet gaming disorder in the
DSM-5. Current Psychiatry Reports, 17, 72. http://dx.doi.org/10.1007/s11920-015-
0610-0.
Rehbein, F., Kleimann, M., & Mossle, T. (2010). Prevalence and risk factors of video game
dependency in adolescence: Results of a German nationwide survey.
Cyberpsychology, Behavior, and Social Networking, 13, 269–277. http://dx.doi.org/10.
1089/cyber.2009.0227.
Rice, S. L., Hagler, K. J., & Tonigan, J. S. (2014). Longitudinal trajectories of readiness to
change: Alcohol use and help-seeking behavior. Journal of Studies on Alcohol and
Drugs, 75, 486–495. http://dx.doi.org/10.15288/jsad.2014.75.486.
Robins, L. N., & Przybeck, T. R. (1985). Age of onset of drug use as a factor in drug and
other disorders. NIDA Research Monographs, 56, 178–192. http://dx.doi.org/10.1037/
e472252004-001.
Rosenthal, R. (1994). Parametric measures of effect size. In H. Cooper, & L. Hedges (Eds.),
The handbook of research synthesis (pp. 231–244). New York: Russell Sage
Foundation.
Schuckit, M. A., & Smith, T. L. (2011). Onset and course of alcoholism over 25 years in mid-
dle class men. Drug and Alcohol Dependence, 113, 21–28.
Shaffer, H. J., Hall, M. N., & Vander Bilt, J. (2000). “Computer addiction”: A critical consid-
eration. American Journal of Orthopsychiatry, 70, 162–168. http://dx.doi.org/10.1037/
h0087741.
Sklar, S. M., & Turner, N. E. (1999). A brief measure for the assessment of coping self-effi-
cacy among alcohol and other drug users. Addiction, 94, 723–729. http://dx.doi.org/
10.1046/j.1360-0443.1999.94572310.x.
Sklar, S. M., Annis, H. M., & Turner, N. E. (1997). Development and validation of the drug-
taking confidence questionnaire: A measure of coping self-efficacy. Addiction
Behavior, 22, 655–670. http://dx.doi.org/10.1016/s0306-4603(97)00006-3.
Strecher, V. J., DeVellis, B. M., Becker, M. H., & Rosenstock, I. M. (1986). The role of self-ef-
ficacy in achieving health behavior change. Health Education & Behavior, 13, 73–92.
http://dx.doi.org/10.1177/109019818601300108.
Sussman, S. (2010). A review of Alcoholics Anonymous/Narcotics Anonymous programs
for teens. Evaluation & the Health Professions, 33, 26–55. http://dx.doi.org/10.1177/
0163278709356186.
Tohyama, T., Yokoyama, A., Matsushita, S., & Higuchi, S. (2014). Addiction research cen-
tres and the nurturing of creativity. Addiction, 109, 5–11. http://dx.doi.org/10.1111/
add.12320.
Van Rooij, A. J., Schoenmakers, T. M., Vermulst, A. A., Van Den Eijnden, R. J. J. M., & Van De
Mheen, D. (2011). Online video game addiction: Identification of addicted adolescent
gamers. Addiction, 106, 205–212. http://dx.doi.org/10.1111/j.1360-0443.2010.03104.
x.
Wang, C. W., Chan, C. L., Mak, K. K., Ho, S. Y., Wong, P. W., & Ho, R. T. (2014). Prevalence
and correlates of video and internet gaming addiction among Hong Kong adoles-
cents: A pilot study. The Scientific World Journal, 2014, 874648. http://dx.doi.org/10.
1155/2014/874648.
Wei, H. T., Chen, M. H., Huang, P. C., & Bai, Y. M. (2012). The association between online
gaming, social phobia, and depression: An internet survey. BMC Psychiatry, 12, 92.
http://dx.doi.org/10.1186/1471-244x-12-92.
Wölfling, K., Beutel, M. E., Dreier, M., & Müller, K. W. (2014). Treatment outcomes in pa-
tients with internet addiction: A clinical pilot study on the effects of a cognitive-be-
havioral therapy program. BioMed Research International, 2014, 425924. http://dx.
doi.org/10.1155/2014/425924.
Yaxley, R. H., Van Voorhees, E. E., Bergman, S., Hooper, S. R., Huettel, S. A., & De Bellis, M. D.
(2011). Behavioral risk elicits selective activation of the executive system in adoles-
cents: Clinical implications. Frontiers in Psychiatry, 2, 68.
Young, K. S. (2013). Treatment outcomes using CBT-IA with internet-addicted patients.
Journal of Behavioral Addictions, 2, 209–215. http://dx.doi.org/10.1556/jba.2.2013.4.3.