(Get Answer)

*Include an introductory, concluding paragraph *What is the understanding of gambling disorder *https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4041397/ NancyPetry’sImpactontheGamblingDisorderField:Mechanisms,Treatment,andtheDSM–5DavidM.LedgerwoodWayneStateUniversityThegamblingdisorderfieldhasgrownsubstantiallyinthepastfewdecades,withanexplosionofresearchinnumerousareas.Dr.NancyPetryhasbeenoneofthepioneersinthisfieldwhohelpedtoinfluencebothitsgrowthanditsdirection.ThisreviewdescribesDr.Petry’slastinglegacyonthegamblingfieldthroughherinfluenceonthreeprimaryareas:gamblingdisordermechanismsofdelayandprobabilitydiscounting;treatmentefficacyandeffectiveness;andherroleinthedevelopmentoftheDSM–5criteriaforgamblingdisorder.Keywords:gamblingdisorder,delaydiscounting,impulsivity,cognitivebehaviortreatment,diagnosisThestudyofgamblingdisorder(GD)hasgrownexponentiallysincethewide-spreadlegalizationofcasinosandotherformsofgamblingthatbeganinthemid-1960sandcontinuestothisday.Asaresultofthisrapidexpansion,GDhasbeenthrustintothespotlight,withnumerousstudiesexaminingtheepidemiologyofGD,etiologicalandmechanisticfactors,neurobiology,treatmentapproaches,andnumerousotherareasofinquiry.Throughoutthisgrowth,therehavebeenrelativelyfewscientistswhohaveblazedtrailsofnewdiscoveryinmultipleareasofstudy.Overthecourseofhercareer,Dr.NancyPetrywasamongthemostgiftedscientistswhoshapedthewayweconceptualizeGD.TheaimsofthisreviewaretohighlightDr.Petry’saccomplishmentsthathelpedtoshapethedirectionofGDresearchinthreekeyareas:(a)GDmechanismsofdelayandprobabilitydiscounting;(b)GDtreat-ment;and(c)GD’snewplaceintheDSM–5.GamblingDisorderMechanismsDr.Petry’sworkonmechanismsofGDhasbeenbroadandhashelpedtoshapeourunderstandingoffactorsthatcontributetothedevelopmentandmaintenanceofGD,aswellasfactorsthataffecttreatmentandrecovery.BelowIfocusononeofthemostimportantconstructsaddressedbyherwork,impulsivityasmeasuredbydis-countingdelayedrewardsandprobabilitydiscounting.ImpulsivityisanimportantmechanismrelatedtoGD,aswellassubstanceusedisorders(SUDs).NumerousstudieshavefoundthatpeoplewithGDexperiencesignificantlygreaterimpulsivityasmeasuredbyself-reportmeasuresandusingexperimentaltasks(e.g.,Ledgerwood,Alessi,Phoenix,&Petry,2009;Petry,2001b;Steel&Blaszczynski,1998;Vitaro,Ferland,Jacques,&Ladouceur,1998).Oneparticularlyrobustwayofmeasuringimpulsivityamongpeo-plewithGDhasinvolvedtheextenttowhichtheydiscountdelayedmonetaryrewards.Discountingofdelayedrewards(orsimplydelaydiscounting)isamodelofimpulsivitybasedonthepremisethatasthetemporaldelaybetweenthepresentandthereceiptofarewardincreases,thesubjectivevalueofthatrewarddecreases(Green&Myerson,2004;Mazur,1984,1987;Myerson&Green,1995).Asaresult,asthetimeuntildeliveryofarewardincreases,mostpeoplewillshifttowardacceptingsmaller,moreimmediaterewardsoverthelarger,delayedrewards.Therateofdelaydiscountingisusuallybestexplainedbyahyperbolicfunctionbetweensubjectiverewardvalueanddelay,suchthat:VA⁄(1kD)whereby,krepresentsaparametergoverningtherateofdecreaseinvalue,Vrepresentsthesubjectivevalueofthefuturereward,Aistherewardamount,andDrepresentsthedelaytoreceivingthereward(Green&Myerson,2004;Mazur,1984,1987;Myerson&Green,1995;Petry&Casarella,1999)SeveralstudieshaveexaminedtheextenttowhichpeoplewithGDdiscountdelayedrewardstoagreaterextentthandononproblemgamblers.PetryandCasarella(1999)revealedthatsubstanceabusersdiscountdelayedrewardsatahigherratethandononsubstanceabusers,andthatproblemgamblingsubstanceabusersdiscountatevenhigherratesthandosubstanceabuserswithoutgamblingprob-lems.IndividualswithGD,withandwithoutsubstanceabusehistory,alsodiscountrewardsatasteeperratethandoindividualswithnoaddictionorgamblingdisorderhistory(Ledgerwoodetal.,2009;Petry,2001a).However,dataaremixedwithregardtowhetherpeoplewithGDwithSUDhistoriesdiscountdelayedrewardsatsteeperratesthanpeoplewithGDwhohavenoSUDhistories.Forexample,AndradeandPetry(2012)foundthatpeoplewithGDwithasub-Editor’sNote.JohnM.Rollservedastheactioneditorforthisarticle.—TCThisarticlewaspublishedOnlineFirstJuly18,2019.Partsofthisarticlewerepresentedatthe2019CollegeonProblemsofDrugDependenceConference.ThankyoutoNancyPetryforherdedica-tionandmanyyearsofmentorship.ThankyoutoLeslieLundahlforherhelpfulfeedback.CorrespondenceconcerningthisarticleshouldbeaddressedtoDavidM.Ledgerwood,DepartmentofPsychiatryandBehavioralNeurosciences,WayneStateUniversity,Ste.2A3901ChryslerDrive,Detroit,MI48201.E-mail:[email protected]hologicalAssociationoroneofitsalliedpublishers.Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.PsychologyofAddictiveBehaviors©2019AmericanPsychologicalAssociation2020,Vol.34,No.1,194–2000893-164X/20/$12.00http://dx.doi.org/10.1037/adb0000490194 stanceusedisorderhistoryexhibithigherdiscountingratesthangam-blerswithnosuchhistory.Incontrast,Ledgerwoodetal.(2009)foundnodifferencesbetweengamblerswithandwithoutsubstanceabusehistories.Further,onestudyfoundpeoplewithGDtodiscountmonetaryrewardsmoresteeplythandidcocainedependentindivid-uals(Albein-Urios,Martinez-González,Lozano,Clark,&Verdejo-García,2012).AlessiandPetry(2003)alsorevealedthatamongpeoplewithGD,gamblingseverityisasignificantpredictorofdis-counting,evenaftertakingintoaccountfactorssuchasage,gender,education,substanceabusetreatmenthistory,andcigarettesmoking.SomeindividualdifferencefactorsregardingdiscountingandGDhavealsobeenexplored.Forexample,datarevealthatWhiteindividualswithGDdiscountdelayedrewardsatlesssteepratesthandoAfricanAmericanandHispanicpeoplewithGD,evenaftercontrollingforincome,education,employment,gamblingseverity,anddrugseverity(Andrade&Petry,2014).Inanotherstudy,althoughthereweresomeassociationsbetweensex,antiso-cialpersonalitydisorder(ASPD),andprobabilitydiscounting(de-scribedbelow),therewerenodifferencesonthebasisoftemporal(delay)discounting(Andrade,Riven,&Petry,2014).ThefindingthatpeoplewithGDdiscountdelayedrewardsatasteeperratethanhealthycontrolsisconsistentwithstudiesbyotherresearchgroups(e.g.,Albein-Uriosetal.,2012;Dixon,Marley,&Jacobs,2003;MacKillop,Anderson,Castelda,Mattson,&Donovick,2006),althoughthisfindinghasnotbeenuniversalintheliteraturewithsomegroupsfindingnodelaydiscountingdifferencesbetweenpeoplewithGDandcontrols(Holt,Green,&Myerson,2003).Thesefindingsarealsolargelyconsistentwiththemultiplestudiesthatexamineddelaydiscountingamongvarioussubstanceusedisorderedpopulations(forreviewseeMadden&Bickel,2010).StudieshavealsoexploredtheroleofprobabilitydiscountinginunderstandingGD.Probabilitydiscountingisthetendencytodiscountriskier,probabilisticoutcomesinfavorofasurething(Rachlin,Raineri,&Cross,1991).Putanotherway,individualsmayoptforsmaller,lessriskyrewardsoverlargerbutriskieralternatives.Aswithdelaydiscounting,probabilitydiscountingmaybebestrepresentedbyahyperbolicfunction:VA⁄(1h)whereVisthesubjectivevalueoftheprobabilisticrewardamountA,hisaparameter(similartokindelaydiscounting)thatrepre-sentstherateofdecreaseinthesubjectivevalueofA,andrepresentsthatoddsthattheparticipantwillnotreceivetheprob-abilisticreward(Green&Myerson,2004;Rachlinetal.,1991).is[1p]/p,withprepresentingtheprobabilityofreceivingareward(Green&Myerson,2004).Intuitively,individualswithGD,whobydefinitionengageinriskychoices,shouldexhibitmoreshallowprobabilitydiscountingratevalues(representinggreaterpotentialimpulsivity,orahighervalueonriskierrewards),andtreatment-seekingindividualswithGDwithhigherhvalues(representinglowerimpulsivity)shouldbemorelikelytoreducetheirgamblingduringtreatment.Petry(2012),however,foundthatlowerhvalues(representinggreaterimpulsivity)wereassociatedwithreducedamountofmoneywa-geredduringtreatment,andwithgamblingabstinenceduringtreat-mentandat12-monthfollow-up.OneplausiblereasonprovidedforthiscounterintuitivefindingisthatpeoplewithGDwhodiscountprobabilisticrewardsmoresteeply,andwhoareseekingtreatment,maybeawarethattheywillhavegreaterdifficultystoppinggamblingoncetheystart.InanadditionalstudyofprobabilitydiscountingthatexaminedtheroleofASPDandsex,femalepeoplewithGDandASPDdiscountedprobabilisticmonetaryrewardsatalowerrate(i.e.,weremoreimpulsive)thanmenwithASPDandthanindividualsofbothsexeswhodidnothaveASPD(Andradeetal.,2014).Takentogether,thestudiesexaminingtheroleofdelayandprobabilitydiscountinghaveimplicationsforthetreatmentofpeoplewithGD.Highimpulsivityisoneofthemorerobustfactorstopredictpoorproblemgamblingtreatmentoutcomes(e.g.,Leb-lond,Ladouceur,&Blaszczynski,2003;Maccallum,Blaszczyn-ski,Ladouceur,&Nower,2007;Smithetal.,2010).However,itisnotablethatimpulsivityisnotuniversallyassociatedwithpoorergamblingtreatmentoutcomes(e.g.,Alvarez-Moyaetal.,2011;Echeburua,Fernandez-Montalvo,&Baez,2001).Yetotherstudieshavefoundthathighimpulsivity,althoughnotnecessarilyassoci-atedwithapoorerrecoverytrajectory,isassociatedwithgreaterbaselineproblemgamblingseveritythatultimatelyresultsinaneedforlongerand/ormoreintensiveproblemgamblingtreat-ments(Ledgerwood&Petry,2010).Withinthecontextoftheimpulsivityliterature,thereareveryfewstudiesthathaveexaminedtherelationshipbetweentreatmentoutcomesanddiscounting.Asnotedabove,Petry(2012)foundprobabilitydiscounting,butnotdelaydiscounting,tobeassociatedwithoutcomes.ThisfindingissomewhatinconsistentwithothersthatpeoplewithGDappeartodiscountprobabilisticrewardslesssteeplythandononaddictedcontrols(Holtetal.,2003;Madden,Petry,&Johnson,2009).Ascantnumberofstudieshavebeenconductedandfind,forthemostpart,thatsteeperdiscountingofdelayedrewardspredictssubstanceabusetreatmentoutcomes(seeLoree,Lundahl,&Ledgerwood,2015forreview).Thus,Dr.Petry’sfindingswithregardtodiscounting,alongwiththescantliteraturesuggestingthatdiscountingmaybeimportanttounder-standingtheroleofimpulsivityintreatmentandrecovery,suggestthatfuturestudiesshouldfurtherexploretheimportanceofdis-countingforexplainingtreatmentoutcomes,aswellasthedevel-opmentofnewproblemgamblingtreatments.GamblingDisorderTreatmentManyofthetreatmentapproachesweusetodayforGDwereadaptedfromthesubstanceabuseliterature.Theseincludestruc-turedevidence-basedapproachessuchascognitivebehaviorther-apy(CBT;Carroll,1998;Monti,Kadden,Rohsenow,Cooney,&Abrams,2002)andmotivationalinterviewing(MI;Miller&Roll-nick,1991),aswellasthefellowship-basedapproachofGamblersAnonymous(GA),whichisbasedonother12-steptraditionssuchasAlcoholicsAnonymous.Severalearlystudiesofcognitivether-apyandCBT,forexample,demonstratedinitialefficacyinanumberofclinicaltrials(e.g.,Ladouceuretal.,2001,2003).SeveralotherstudiesexaminingMIandmotivationalenhancementtherapyhavesimilarlydemonstratedefficacy(e.g.,Hodgins,Cur-rie,&el-Guebaly,2001;Hodgins,Currie,Currie&Fick,2009).Below,IreviewNancyPetry’sworkthathasspearheadedthegamblingdisordertreatmentfield,particularlywithregardtoCBTandbriefinterventionapproaches.Forathoroughreviewofre-searchonGDtreatment,thereaderisdirectedtoPetry,Ginley,andRash(2017).ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.195GAMBLINGDISORDER Petryetal.(2006)publishedoneofthemostrigorousclinicaltrialstodateexaminingcognitivebehaviortherapy(CBT)forgamblingdisorders.Participantswererandomlyassignedtore-ceive:(a)referraltoGA;(b)referraltoGAplusaneight-chapterCBTworkbook;or(c)referraltoGApluseightface-to-faceCBTsessions.Duringtreatment,thoseintheCBTconditionsdecreasedtheirdaysofgamblingtoagreaterextentthandidtheGAonlycondition,andthosewhoreceivedface-to-faceCBTreduceddol-larsgamblingcomparedwiththeworkbookcondition.Attheendoftreatment,59%ofthosewhoreceivedCBTtherapywereconsidered“recovered”(i.e.,SouthOaksGamblingScreen[SOGS]score5andsubstantiallyreducedgambling),comparedwith39%ofthoseintheworkbookcondition,and34%ofthosewhoreceivedonlyaGAreferral.At12-monthfollowup,timebytreatmentconditioneffectsremainedsignificantforgamblingseverityvariables(Addic-tionSeverityIndex[ASI-G]andSOGS),buttherewerenogroupdifferencesongamblingabstinence/reduction.Inaseriesofstudies,Petryetal.(Petry,Weinstock,Ledger-wood&Morasco,2008;Petry,Weinstock,Morasco&Ledger-wood,2009;Petry,Rash,&Alessi,2016)demonstratedthatbriefinterventionsconsistingofbriefadvice,CBT,and/ormotivationalenhancementtherapy(MET)canbeeffectiveinreducingtheimpactofgamblingsymptomsinindividualswithsubthresholdproblemgambling,andthosewithGDwhoarelessinclinedtocommittofulltreatment.Inonestudy,Petryetal.(2008)random-izedparticipantsrecruitedfromamongproblemgamblers(includ-ingbothpeoplediagnosedwithGDandthosewithsubdiagnosticproblems)atsubstanceabuseclinicsandmedicalclinicsthatserveunderprivilegedpatientstooneoffourtreatmentconditions:(a)assessmentonly;(b)10minofbriefadvicetoreducegambling;(c)one50-minsessionofMET;or(d)onesessionofMETandthreesessionsofCBT.Comparedwithassessmentonlycontrolpartic-ipants,briefadvicesignificantlydecreasedgamblingbetweenbaselineandWeek6,andwasassociatedwithadditionalreduc-tionsingamblingat9-monthfollow-up.METplusCBTdemon-stratedsomereductionsingamblingseveritybetweenWeek6andMonth9.Inasimilarlydesignedstudyexaminingproblemgamblingcollegestudents,Petryetal.(2009)revealedmorepositiveeffectsforMETandMETplusCBTtreatments(Petryetal.,2009).Specifically,comparedwithassessment-onlycontrolcondition,thosewhoreceivedMETexperiencedsignificantdecreasesinproblemgamblingseverity,reduceddollarswageredandhadin-creasedoddsofclinicallysignificantgamblingreductionsat9-monthfollow-up.BothbriefadviceandMETplusCBTresultedinreductionsinsome,butnotall,problemgamblingindicatorsrelativetoassessmentonlycontrol.Inathirdexaminationofbriefinterventions,Petryetal.(2016)randomlyassignedproblemgamblingindividualsinsubstanceabusetreatmentto:(a)10–15minofgamblingpsychoeducation;(b)10–15minofbriefadviceonquittinggambling;or(c)afour-session(50mineach)combinedMETplusCBTcondition.Gamblingdecreasedsig-nificantlyforallthreeconditionswiththegreatestdecreasesoccurringinthefirst5months.Briefadviceresultedinspeedierreductionsingamblingfrequency(butnototheroutcomes:dollarswageredorSOGSscore)thandidbriefpsychoeducationduringthisperiod.METplusCBTresultedinagreaterreductioninmoneywageredandSOGSscorecomparedwithbriefadviceduringthistimeframe,andresultedinlessmoneywageredatthe24-monthfollow-up.Takentogether,thesestudiesdemonstratethatbriefinterventionsconsistingofbriefadvice,METand/orCBTcanbeeffectiveinreducinggamblingproblemsamongindividualswhodonotseekmorecomprehensivecare.However,theyalsoshowthatdifferenttreatmentapproachesmightbemoreappropriatedependingontheneedsand/orpreferencesofthetargetpopulation.Dr.PetryhasalsohadanimpactonresearchintotheeffectivenessofGA.Priortoherwork,therewererelativelyfewstudiesofGA’seffectiveness,andanearlyinvestigationrevealedthatoneyearafterinitiatingGAattendance,only8%ofmembersmaintainedgamblingabstinence(Stewart&Brown,1988).Further,asmanyas22%ofGAmembersdroppedoutaftertheirfirstmeetingandabout70%droppedoutbytheir10thmeeting.Petryandcolleagues’workrevealedmorepositiveandcontextuallybasedoutcomesforGA.Forexample,Petryetal.(2006),foundthatparticipantsinaclinicaltrialwhowerereferredtoGAandattendedmeetingsexperiencedsignificantlygreaterreductionsintheirgamblingthandidthosewhodidnotattend.Similarly,amongpeoplewithGDwhoareseekingprofessionalproblemgamblingtreatment,thosewhohaveahistoryofattendingGAinthepastaremorelikelytoreengageinGAattendance,morelikelytobecomeactivelyengagedinprofessionaltreatment,andmorelikelytobegambling-abstinent2monthsintotreatment(Petry,2003).Thesestudiesunderscoretheimportanceofmutual-supportap-proachessuchasGAforindividualswhoaremorefullyengagedintheirrecovery.Innumerousadditionalinvestigations,Petryandcolleagueshaveexaminedpotentialpredictorsandmechanismsofproblemgamblingtreatmentoutcomes.Asdescribedabove,Petry(2012)revealedthatsteeperprobabilitydiscountingwasassociatedwithbetterGDtreat-mentoutcomes.Despitethisfinding,LedgerwoodandPetry(2010)foundthattreatmentseekingpeoplewithGDwithhighimpulsivityaswellasthosewithhighlevelsofco-occurringpsychopathology,improvedatthesamerateasthosewithlowimpulsivityandlowpsychopathology.Inastudyexploringtheimportanceofcopingskillsasamechanismforproblemgamblingrecovery,Petry,Litt,Kadden,andLedgerwood(2007)revealedthatCBTresultedingreateracqui-sitionofcopingskillsthanoccurredforpeoplewithGDreceivingonlyareferraltoGA.Further,changesincopingskillscoresmediatedtherelationshipbetweentreatmentassignment(CBTvs.GA)andgamblingoutcomesfrombaselinetoposttreatment.Additionally,Dr.Petryandhercolleagueshavefoundthatmorepositivegamblingtreatmentoutcomesareassociatedwithanumberoffactorsincludingsocialsupport(Petry&Weiss,2009),absenceofrecentgambling-relatedillegalbehaviors(Ledgerwood,Weinstock,Morasco,&Petry,2007),andreadinessforchanginggamblingbehaviors(Petry,2005),amongothers.Eachofthesestudiesprovidesdatatoinformthestudyanddevelopmentoffuturetreatments.GamblingDisorder,theDSM–5,andPolicyEffectonGamblingDiagnosisTheplaceofGDamongthepsychiatricnomenclaturehasbeendebatedforyears.Indeed,theterm“gamblingdisorder”wasdevelopedfortheDSM–5.PriortothisversionoftheDSM,thetermpathologicalgamblingwasusedtolabelthedisorder.Path-ologicalgamblingwasfirstplacedintheDSM–IIIandclassifiedbytheAmericanPsychiatricAssociationasanimpulsecontroldisordernotelsewhereclassified(APA,1980).AlthoughthereThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.196LEDGERWOOD werechangesindiagnosticcriteriaacrossDSM–IIIand–IVver-sions,pathologicalgamblingremainedintheimpulsecontrolcategory,separatedfromotherbehaviorsthatmightbeconsidered“addictions.”Further,theterm“addiction”wasnotusedtochar-acterizeSUDs,whichweredescribedbyterms“abuse”and“de-pendence”(APA,2000).ThedevelopmentofanewperspectiveonGDfortheDSM–5wasdrivenbyagrowingresearchliterature,andmanybegantodebatetheextenttowhichpathologicalgamblingresembledSUDs.Severalarticlesdescribedevidenceforandagainstinclud-ingsocalled“behavioraladdictions”suchaspathologicalgam-blingalongsideSUDs(Grant,Potenza,Weinstein,&Gorelick,2010;Petry,2006;Potenza,2006).Potenza(2006),forexample,notedthatmuchofthedataregardingclinicalcharacteristics/personality,biochemistry,neurocircuitry,genetic,andtreatmentcharacteristicsweresimilarforbothpathologicalgamblingandSUDs,butsignificantgapsexistedinresearchonimportantmech-anismsrelatedtogambling.TherehasalsobeenrecognitioninthesubstanceabuseliteraturethatbehavioraladdictionssuchasGDresembleSUDsinanumberofways(Koob&Volkow,2016).AsChairoftheDSM–5SubcommitteeonNon-SubstanceBe-havioralAddictions,Dr.Petryhadamajorroleinthereclassifi-cationofGDalongsideSUDsintheofficialAmericanpsychiatricnomenclature(APA,2013).ThroughouttheDSM–5process,herwritingsclearlyandsuccinctlydemonstratedimportantsimilaritiesbetweentheseillnesses.Petry(2006)identifiedseveralpotentialadvantagesofclassifyingGDalongsidetheSUDs,including:potentiallyincreasedawarenessofGD;possibleextensionoftreat-mentstopeoplewithGDwithinthecontextofsubstanceabusetreatment;reductionofthenumberofsymptomsfordiagnosis(inlinewiththoseofSUDs)mayincreasediagnosticaccuracy;con-siderationofasubdiagnosticcategoryofGD(e.g.,gamblingabuse);possibleencouragementofmoreresearchandtreatmenteffortsandfunding.Shealsoacknowledgedseveralpotentialrea-sonsnottoexpandaddictivedisorderstoincludeGD,including:thefactthatgamblingdoesnotinvolveingestionofasubstance;thereisnotadirectlinkbetweenSUDandGDintermsofdiagnosticcriteria(e.g.,chasinggamblinglosses);potentialforgreaterstigmatizationforgamblersgroupedwithsubstanceusers;andriskofcreatinga“catch-all”categoryofaddictivedisorders.Ultimately,GDwasincludedinDSM–5alongsidetheSUDs,withanumberofimportantchanges.Thedisordernamewaschangedtoremovepejorativeandredundant“pathological”mon-iker,thecriteriaaroundengaginginillegalactstofinancegam-blingwasremoved,andthediagnosticthresholdreducedto4toimproveclassificationaccuracy(Hasinetal.,2013;Petry,Blanco,Auriacombeetal.,2014).SeveralstudieshavebeenconductedthatjustifythevariouschangesmadeinGDcriteriafromDSM–IVtoDSM–5.Denis,Fatséas,andAuriacombe(2012)comparedfoursetsofgamblingdisordercriteria(DSM–IV,droppingillegalactsbutkeepingthresholdatfiveoutofninesymptoms,proposedDSM–5approach,andcriteriamodeledonDSM–IVsubstancedependencecriteria),andfoundthattheDSM–5approachdidnotchangetheimplicationsoftheDSM–IVpathologicalgamblingapproach.Stinchfieldetal.(2016)foundthatDSM–5criteriaevidencedmodestlybetterclassificationaccuracycomparedwithDSM–IVinalargesamplethatincludedeightdatasetsfromthreecountries.Changestothegambling-relatedillegalbehaviorscrite-riareliedonpriorstudiesthatdemonstratedthiscriterionwaslessimportantfordiagnosingpathologicalgamblingthanweretheothercriteria(e.g.,Strong&Kahler,2007;Toce-Gerstein,Ger-stein,&Volberg,2003).OnesubsequentstudyofSpanishpatientsseekingtreatmentforpathologicalgamblingrevealedthatremovaloftheillegalbehaviorscriteriondidnotsubstantiallyimpactratesofGD,nordiditimpactreliabilityofthepathologicalgamblingdiagnosis,orhaveanyimpactonrelationshipswithageorsex(Graneroetal.,2014).Additionalstudiessimilarlyrevealedthattheillegalbehaviorscriteriondidnotmakeasubstantialcontribu-tiontodiagnosticaccuracy(Stinchfieldetal.,2016).ApopulationstudyusingdatafromtheNationalEpidemiolog-icalSurveyofAlcoholandRelatedDisordersrevealedthat,com-paredwithDSM–IVpathologicalgamblingcriteria,DSM–5GDcriteriademonstratedspecificitygreaterthan99%andsensitivityof100%,showingthateliminatingtheillegalbehaviorscriteriondidnotsubstantiallychangedisorderrates(Petry,Blanco,Jin,&Grant,2014).Otherstudieshavesimilarlydemonstratedthatre-movingtheillegalactsitemdoesnotaffectratesofGDsubstan-tially(Petry,Blanco,Stinchfield,&Volberg,2013).Further,re-ducingthecutpointfromfiveoutof10tofouroutofninesymptoms,althoughincreasingtheprevalenceofGDslightly,mayresultinmoreconsistentdiagnoses(Petryetal.,2013).OtherstudieshaveexaminedavarietyofeffectsthatmayhaveoccurredasaresultofchangesfromDSM–IVtoDSM–5.Forexample,thepresenceofco-occurringpsychiatricdisordersamongthosewithGDremainedfairlystablewhencomparingDSM–IVandDSM–5criteria,butratesofco-occurringdisordersremainedsubstantiallyhigherthanthoseforindividualswithalcoholorcannabisusedisorders(Nicholson,Mackenzie,Afifi,Keough,&Sareen,2019).Othershavefounda20.4%increaseinGDpreva-lencewhencomparingDSM–5toDSM–IVcriteriaamongindivid-ualswithSUD(Rennertetal.,2014).EffectonPolicyAninitialhopewasthatchangestoGDinDSM–5wouldresultinincreasedpublicawarenessofthedisorder,andpossiblythathealthinsurerswouldbeencouragedormandatedtotreatit(Petry,Blanco,Auriacombe,etal.,2014).Butitisdifficulttodeterminewhetherthesechangeshavedirectlyinfluencedpolicyorserviceprovision.ThereisnocentralwaytodeterminewhetherinsurancecompanieswillcoverGDaspartoftheircomprehensivehealthplans,anddatamustbegleanedfromsecondarysources.Forexample,in2016theStateHelplineoftheMichiganDepartmentofHealthandHumanServicescitedincreasesinprivateinsurancecoverageforGDtreatmentasacauseofa35%declineintreat-mentenrollmenttotheStatetreatmentprogram(Marottaetal.,2017).ThecategorizationofGDalongsidetheSUDsmayhaveimpli-cationsforinsurancecoveragethroughtheAffordableCareAct(ACA)whichwassignedintolawin2010andincludeslanguageoncoverageofmentalhealthandsubstancedisorders,andthe2008MentalHealthParityandAddictionEquityAct(MHPAEA)whichrequiresallindividualandlarge-groupplansthatofferbehavioralhealthcoveragetoofferthosebenefits“atparity”withgeneralhealthcoverage(Kagan,Whyte,Esrick,&Carnevale,2014).However,thelanguageofbothpiecesoflegislationaresufficientlyopentointerpretation.BecauseessentialhealthbenefitpackagesdonotspecificallyincludeorexcludeGD,itisnotThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.197GAMBLINGDISORDER alwayscovered.Forexample,asof2016GDiscoveredinMed-icaidprogramsinonlysomestates;accordingtoasurveyoftheNationalCouncilonProblemGambling,16statesindicatedthatMedicaidcoveredGD,17statesnoteditdidnot,and17statesdidnotrespond(Marottaetal.,2017).Similarly,therewassomehopethatinclusionofGDasanaddic-tionmightresultinincreasedfederalfundingthroughtheNationalInstitutesofHealth(NIH)orotheragenciesforproblemgamblingresearch.AsearchoftheNIHReportersystemrevealsonlytwostudiesincludedGDorpathologicalgamblingastheprimarypathol-ogyunderstudy(searchreturned2/18/19;https://projectreporter.nih.gov/reporter_SearchResults.cfm?icde43325342).Similarly,are-viewoftheVeterans’Administrationextramuralresearchsiteforfiscalyears2017–2019revealedonlyoneresearchgrantfocusedonGD(searchreturned2/18/19,https://www.research.va.gov/about/funded-proj-details-FY2017.cfm?pid486693),andareviewoftheNationalScienceFoundationsiterevealednocurrentlyactiveawardsonGD(searchreturned2/18/19;https://www.nsf.gov/awardsearch/simpleSearchResult?queryTextgambling&ActiveAwardstrue).Otherfederalagencies,althoughnotnecessarilyfundinggamblingresearch,haveacknowledgedtheimportanceofGDasanaddiction,andinsomecasesprovidedclinicalresources(e.g.,SubstanceAbuseandMentalHealthServicesAdministration[SAMHSA,2014]).AreviewoftheSAMHSAsite,however,revealsnoGDfocusedgrantsin2018(searchreturned2/18/19;https://www.samhsa.gov/grants/awards).Thus,despitegreaterrecognitionthatGDisadisorderakintoSUDs,itdoesnotappearthatthishasresultedingreaterrecognitionoftheproblembyU.S.federalagenciesthatfundscientificandtreatment-relatedendeavorsasofthetimeofthiswriting.AlthoughthechangestoGDintheDSM–5havenotresultedinclearchangesinresearchfunding,itisnotablethatthereappearstobesomemovementinthedirectionofincreasedavailabilityoffundingfortreatment.Further,itappearsthatthereisconsiderableconsensusregardingGDintermsofitscurrentplacealongsidetheSUDsintheDSM–5.Itisnotable,forexample,thattheAmericanSocietyofAddictionMedicine(ASAM)categorizesGDunder“emergingunderstandingofaddiction”initspatientplacementcriteria,demonstratingthatthemedicalcommunitylargelyacceptsthatGDandSUDlegitimatelyfalltogetherbeneaththeaddictionumbrella(ASAM,2013;Kaganetal.,2014).Thus,thereiscer-tainlypotentialforincreasesinresearchandtreatmentfundingforGDinthefuture.ConclusionsDr.NancyPetry’sinfluencehasbeenfeltacrossnumerousareasoftheGDfield.Thethreeareasdescribedaboverepresent,argu-ably,theonesthatwillhavethemostindelibleimpact.AsingleunifyingcharacteristicofDr.Petry’sscientificworkwithinthefieldofGDisthatitfocusesonimprovingcareforindividualswhoareaffectedbyGD.HerworkonmechanismssuchasdelayandprobabilitydiscountingprovideessentialdataforunderstandinghowpeoplewithGDprocessmonetaryrewards,andhowdeficitsinthisareamayaffectGDrecovery.HerworkonCBTandbriefinterventionslaysafoundationforfuturescientistsandclinicianstocollaboratetoimproveuponcurrentlyavailabletreatments.Finally,herresearchintheseareasinformedherthoughtsontheplaceofGDwithinourpsychiatricdiagnosticsystem.AlthoughtheplacementofGDwiththeSUDshasnotnecessarilyresultedinsubstantialchangesinpolicyasyet,thereissomeindicationthattreatmentprovidersandpolicymakersarebeginningtorecognizetheimportanceofsupportingGDtreatment.Further,wemayberemindedthatpolicychangesdonotoccurovernight,asformerNationalInstituteonDrugAbuseDirectorAlanLeshner(1997)noted“Thebadnewsisthedramaticlagbetween...advancesinscienceandtheirappreciationineitherpracticeorpublicpolicysettings.”AlthoughhewasreferringprimarilytoSUDs,theargu-mentisalsorelevanttoGD,andwemaynotultimatelyknowtheimpactofDSM–5changesforsometime.Nevertheless,takenasawholealongwithherimportantworkexaminingadditionalfactorssuchasGDprevalence(Petry,Stinson,&Grant,2005),co-occurringpsychiatricandSUDs(e.g.,Ledgerwood&Petry,2006;Rash,Weinstock,&Petry,2011;Weinstock,Blanco,&Petry,2006),andhealth(e.g.,Morascoetal.,2006)conditions,aswellasclinicalanddemographiccharacteristicsofpeoplewithGD(e.g.,Blanco,Hasin,Petry,Stinson,&Grant,2006;Pietrzak,Molina,Ladd,Kerins,&Petry,2005),Dr.Petry’sworkprovidesasolidfoundationofresearchuponwhichfuturescientists,clinicians,policymakers,andotherstakeholdersmayimprovethelivesofindividualswhosufferfromthisdisorder.ReferencesAlbein-Urios,N.,Martinez-González,J.M.,Lozano,O.,Clark,L.,&Verdejo-García,A.(2012).Comparisonofimpulsivityandworkingmemoryincocaineaddictionandpathologicalgambling:Implicationsforcocaine-inducedneurotoxicity.DrugandAlcoholDependence,126,1–6.http://dx.doi.org/10.1016/j.drugalcdep.2012.03.008Alessi,S.M.,&Petry,N.M.(2003).Pathologicalgamblingseverityisassociatedwithimpulsivityinadelaydiscountingprocedure.BehaviouralProcesses,64,345–354.http://dx.doi.org/10.1016/S0376-6357(03)00150-5Alvarez-Moya,E.M.,Ochoa,C.,Jiménez-Murcia,S.,Aymamí,M.N.,Gómez-Peña,M.,Fernández-Aranda,F.,...Menchón,J.M.(2011).Effectofexecutivefunctioning,decision-makingandself-reportedim-pulsivityonthetreatmentoutcomeofpathologicgambling.JournalofPsychiatry&Neuroscience,36,165–175.http://dx.doi.org/10.1503/jpn.090095AmericanPsychiatricAssociation.(1980).Diagnosticandstatisticalman-ualofmentaldisorders(3rded.).Washington,DC:Author.AmericanPsychiatricAssociation.(2000).Diagnosticandstatisticalman-ualofmentaldisorders(4thed.,textrev.).Washington,DC:Author.AmericanPsychiatricAssociation.(2013).Diagnosticandstatisticalman-ualofmentaldisorders(5thed.).Arlington,VA:AmericanPsychiatricPublishing.AmericanSocietyofAddictionMedicine.(2013).TheASAMCriteria:Treatmentcriteriaforaddictive,substance-related,andco-occurringconditions(3rded.).CarsonCity,NV:TheChangeCompanies.Andrade,L.F.,&Petry,N.M.(2012).Delayandprobabilitydiscountinginpathologicalgamblerswithandwithoutahistoryofsubstanceuseproblems.Psychopharmacology,219,491–499.http://dx.doi.org/10.1007/s00213-011-2508-9Andrade,L.F.,&Petry,N.M.(2014).WhiteproblemgamblersdiscountdelayedrewardslesssteeplythantheirAfricanAmericanandHispaniccounterparts.PsychologyofAddictiveBehaviors,28,599–606.http://dx.doi.org/10.1037/a0036153Andrade,L.F.,Riven,L.,&Petry,N.M.(2014).Associationsbetweenantisocialpersonalitydisorderandsexondiscountingrates.ThePsy-chologicalRecord,64,639–644.http://dx.doi.org/10.1007/s40732-014-0085-0Blanco,C.,Hasin,D.S.,Petry,N.,Stinson,F.S.,&Grant,B.F.(2006).SexdifferencesinsubclinicalandDSM–IVpathologicalgambling:Re-sultsfromtheNationalEpidemiologicSurveyonAlcoholandRelatedThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.198LEDGERWOOD Conditions.PsychologicalMedicine,36,943–953.http://dx.doi.org/10.1017/S0033291706007410Carroll,K.M.(1998).Acognitive-behavioralapproach:Treatingcocaineaddiction.Rockville,MD:U.S.DepartmentofHealthandHumanSer-vices,NationalInstitutesofHealth.Denis,C.,Fatséas,M.,&Auriacombe,M.(2012).AnalysesrelatedtothedevelopmentofDSM–5criteriaforsubstanceuserelateddisorders:Anassessmentofpathologicalgamblingcriteria.DrugandAlcoholDepen-dence,122,22–27.http://dx.doi.org/10.1016/j.drugalcdep.2011.09.006Dixon,M.R.,Marley,J.,&Jacobs,E.A.(2003).Delaydiscountingbypathologicalgamblers.JournalofAppliedBehaviorAnalysis,36,449–458.http://dx.doi.org/10.1901/jaba.2003.36-449Echeburua,E.,Fernandez-Montalvo,J.,&Baez,C.(2001).Predictorsoftherapeuticfailureinslot-machinepathologicalgamblersfollowingbe-havioraltreatment.BehaviouralandCognitivePsychotherapy,29,379–383.http://dx.doi.org/10.1017/S1352465801003113Granero,R.,Penelo,E.,Stinchfield,R.,Fernández-Aranda,F.,Aymamí,N.,Gómez-Peña,M.,...Jiménez-Murcia,S.(2014).Contributionofillegalactstopathologicalgamblingdiagnosis:DSM–5implications.JournalofAddictiveDiseases,33,41–52.http://dx.doi.org/10.1080/10550887.2014.882730Grant,J.E.,Potenza,M.N.,Weinstein,A.,&Gorelick,D.A.(2010).Introductiontobehavioraladdictions.TheAmericanJournalofDrugandAlcoholAbuse,36,233–241.http://dx.doi.org/10.3109/00952990.2010.491884Green,L.,&Myerson,J.(2004).Adiscountingframeworkforchoicewithdelayedandprobabilisticrewards.PsychologicalBulletin,130,769–792.http://dx.doi.org/10.1037/0033-2909.130.5.769Hasin,D.S.,O’Brien,C.P.,Auriacombe,M.,Borges,G.,Bucholz,K.,Budney,A.,...Grant,B.F.(2013).DSM–5criteriaforsubstanceusedisorders:Recommendationsandrationale.TheAmericanJournalofPsy-chiatry,170,834–851.http://dx.doi.org/10.1176/appi.ajp.2013.12060782Hodgins,D.C.,Currie,S.R.,Currie,G.,&Fick,G.H.(2009).Random-izedtrialofbriefmotivationaltreatmentsforpathologicalgamblers:Moreisnotnecessarilybetter.JournalofConsultingandClinicalPsychology,77,950–960.http://dx.doi.org/10.1037/a0016318Hodgins,D.C.,Currie,S.R.,&el-Guebaly,N.(2001).Motivationalenhancementandself-helptreatmentsforproblemgambling.JournalofConsultingandClinicalPsychology,69,50–57.http://dx.doi.org/10.1037/0022-006X.69.1.50Holt,D.D.,Green,L.,&Myerson,J.(2003).Isdiscountingimpulsive?Evidencefromtemporalandprobabilitydiscountingingamblingandnon-gamblingcollegestudents.BehaviouralProcesses,64,355–367.http://dx.doi.org/10.1016/S0376-6357(03)00141-4Kagan,R.,Whyte,K.,Esrick,J.,&Carnevale,J.(2014).Problemgam-blinginthe21stcenturyhealthcaresystem.Washington,DC:NationalCouncilonProblemGambling.Koob,G.F.,&Volkow,N.D.(2016).Neurobiologyofaddiction:Aneurocircuitryanalysis.TheLancetPsychiatry,3,760–773.http://dx.doi.org/10.1016/S2215-0366(16)00104-8Ladouceur,R.,Sylvain,C.,Boutin,C.,Lachance,S.,Doucet,C.,&Leblond,J.(2003).Grouptherapyforpathologicalgamblers:Acogni-tiveapproach.BehaviourResearchandTherapy,41,587–596.http://dx.doi.org/10.1016/S0005-7967(02)00036-0Ladouceur,R.,Sylvain,C.,Boutin,C.,Lachance,S.,Doucet,C.,Leblond,J.,&Jacques,C.(2001).Cognitivetreatmentofpathologicalgambling.JournalofNervousandMentalDisease,189,774–780.http://dx.doi.org/10.1097/00005053-200111000-00007Leblond,J.,Ladouceur,R.,&Blaszczynski,A.(2003).Whichpathologicalgamblerswillcompletetreatment?BritishJournalofClinicalPsychol-ogy,42,205–209.http://dx.doi.org/10.1348/014466503321903607Ledgerwood,D.M.,Alessi,S.M.,Phoenix,N.,&Petry,N.M.(2009).Behavioralassessmentofimpulsivityinpathologicalgamblerswithandwithoutsubstanceusedisorderhistoriesversushealthycontrols.DrugandAlcoholDependence,105,89–96.http://dx.doi.org/10.1016/j.drugalcdep.2009.06.011Ledgerwood,D.M.,&Petry,N.M.(2006).Posttraumaticstressdisordersymptomsintreatment-seekingpathologicalgamblers.JournalofTrau-maticStress,19,411–416.http://dx.doi.org/10.1002/jts.20123Ledgerwood,D.M.,&Petry,N.M.(2010).Subtypingpathologicalgam-blersbasedonimpulsivity,depression,andanxiety.PsychologyofAddictiveBehaviors,24,680–688.http://dx.doi.org/10.1037/a0019906Ledgerwood,D.M.,Weinstock,J.,Morasco,B.J.,&Petry,N.M.(2007).Clinicalfeaturesandtreatmentprognosisofpathologicalgamblerswithandwithoutrecentgambling-relatedillegalbehavior.TheJournaloftheAmericanAcademyofPsychiatryandtheLaw,35,294–301.Leshner,A.I.(1997).Addictionisabraindisease,anditmatters.Science,278,45–47.http://dx.doi.org/10.1126/science.278.5335.45Loree,A.M.,Lundahl,L.H.,&Ledgerwood,D.M.(2015).Impulsivityasapredictoroftreatmentoutcomeinsubstanceusedisorders:Reviewandsynthesis.DrugandAlcoholReview,34,119–134.http://dx.doi.org/10.1111/dar.12132Maccallum,F.,Blaszczynski,A.,Ladouceur,R.,&Nower,L.(2007).Functionalanddysfunctionalimpulsivityinpathologicalgambling.Per-sonalityandIndividualDifferences,43,1829–1838.http://dx.doi.org/10.1016/j.paid.2007.06.002MacKillop,J.,Anderson,E.J.,Castelda,B.A.,Mattson,R.E.,&Donovick,P.J.(2006).Divergentvalidityofmeasuresofcognitivedistortions,impul-sivity,andtimeperspectiveinpathologicalgambling.JournalofGamblingStudies,22,339–354.http://dx.doi.org/10.1007/s10899-006-9021-9Madden,G.J.,&Bickel,W.K.(Eds.).(2010).Impulsivity:Thebehavioralandneurologicalscienceofdiscounting.Washington,DC:AmericanPsychologicalAssociation.http://dx.doi.org/10.1037/12069-000Madden,G.J.,Petry,N.M.,&Johnson,P.S.(2009).Pathologicalgamblersdiscountprobabilisticrewardslesssteeplythanmatchedcon-trols.ExperimentalandClinicalPsychopharmacology,17,283–290.http://dx.doi.org/10.1037/a0016806Marotta,J.,Hynes,J.,Rugle,L.,Whyte,K.,Scanlan,K.,Sheldrup,J.,&Dukart,J.(2017).2016SurveyofProblemGamblingServicesintheUnitedStates.Boston,MA:AssociationofProblemGamblingServiceAdministrators.Mazur,J.E.(1984).Testsofanequivalenceruleforfixedandvariablereinforcedelays.JournalofExperimentalPsychology:AnimalBehaviorProcesses,10,426–436.http://dx.doi.org/10.1037/0097-7403.10.4.426Mazur,J.E.(1987).Anadjustingprocedureforstudyingdelayedrein-forcement.InM.L.Commons,J.E.Mazur,J.A.Nevin,&H.Rachlin(Eds.),Quantitativeanalysisofbehavior:Vol.5.Theeffectofdelayandofinterveningeventsonreinforcementvalue(pp.55–73).Hillsdale,NJ:Erlbaum.Miller,W.R.,&Rollnick,S.(1991).Motivationalinterviewing:Preparingpeopletochangeaddictivebehavior.NewYork,NY:GuilfordPress.Monti,P.M.,Kadden,R.M.,Rohsenow,D.J.,Cooney,N.L.,&Abrams,D.B.(2002).Treatingalcoholdependence:Acopingskillstrainingguide(2nded.).NewYork,NY:GuilfordPress.Morasco,B.J.,Pietrzak,R.H.,Blanco,C.,Grant,B.F.,Hasin,D.,&Petry,N.M.(2006).Healthproblemsandmedicalutilizationassociatedwithgamblingdisorders:ResultsfromtheNationalEpidemiologicSurveyonAlcoholandRelatedConditions.PsychosomaticMedicine,68,976–984.http://dx.doi.org/10.1097/01.psy.0000238466.76172.cdMyerson,J.,&Green,L.(1995).Discountingofdelayedrewards:Modelsofindividualchoice.JournaloftheExperimentalAnalysisofBehavior,64,263–276.http://dx.doi.org/10.1901/jeab.1995.64-263Nicholson,R.,Mackenzie,C.,Afifi,T.O.,Keough,M.,&Sareen,J.(2019).Anexaminationofcomorbidpsychiatricdisordersindisorderedgamblersversusothersubstance-relateddisorders.JournalofGamblingStudies.Advanceonlinepublication.http://dx.doi.org/10.1007/s10899-019-09839-yThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.199GAMBLINGDISORDER Petry,N.M.(2001a).Pathologicalgamblers,withandwithoutsubstanceusedisorders,discountdelayedrewardsathighrates.JournalofAbnor-malPsychology,110,482–487.http://dx.doi.org/10.1037/0021-843X.110.3.482Petry,N.M.(2001b).Substanceabuse,pathologicalgambling,andimpul-siveness.DrugandAlcoholDependence,63,29–38.http://dx.doi.org/10.1016/S0376-8716(00)00188-5Petry,N.M.(2003).PatternsandcorrelatesofGamblersAnonymousattendanceinpathologicalgamblersseekingprofessionaltreatment.Addic-tiveBehaviors,28,1049–1062.http://dx.doi.org/10.1016/S0306-4603(02)00233-2Petry,N.M.(2005).Stagesofchangeintreatment-seekingpathologicalgamblers.JournalofConsultingandClinicalPsychology,73,312–322.http://dx.doi.org/10.1037/0022-006X.73.2.312Petry,N.M.(2006).Shouldthescopeofaddictivebehaviorsbebroadenedtoincludepathologicalgambling?Addiction,101(Suppl.1),152–160.Petry,N.M.(2012).Discountingofprobabilisticrewardsisassociatedwithgamblingabstinenceintreatment-seekingpathologicalgamblers.JournalofAbnormalPsychology,121,151–159.http://dx.doi.org/10.1037/a0024782Petry,N.M.,Ammerman,Y.,Bohl,J.,Doersch,A.,Gay,H.,Kadden,R.,...Steinberg,K.(2006).Cognitive-behavioraltherapyforpathologicalgamblers.JournalofConsultingandClinicalPsychology,74,555–567.http://dx.doi.org/10.1037/0022-006X.74.3.555Petry,N.M.,Blanco,C.,Auriacombe,M.,Borges,G.,Bucholz,K.,Crowley,T.J.,...O’Brien,C.(2014).AnoverviewofandrationaleforchangesproposedforpathologicalgamblinginDSM–5.JournalofGamblingStud-ies,30,493–502.http://dx.doi.org/10.1007/s10899-013-9370-0Petry,N.M.,Blanco,C.,Jin,C.,&Grant,B.F.(2014).ConcordancebetweengamblingdisorderdiagnosesintheDSM–IVandDSM–5:ResultsfromtheNationalEpidemiologicalSurveyofAlcoholandRelatedDisorders.PsychologyofAddictiveBehaviors,28,586–591.http://dx.doi.org/10.1037/a0034661Petry,N.M.,Blanco,C.,Stinchfield,R.,&Volberg,R.(2013).Anempiricalevaluationofproposedchangesforgamblingdiagnosisinthe.DSM–5.Addiction,108,575–581.http://dx.doi.org/10.1111/j.1360-0443.2012.04087.xPetry,N.M.,&Casarella,T.(1999).Excessivediscountingofdelayedrewardsinsubstanceabuserswithgamblingproblems.DrugandAlcoholDependence,56,25–32.http://dx.doi.org/10.1016/S0376-8716(99)00010-1Petry,N.M.,Ginley,M.K.,&Rash,C.J.(2017).Asystematicreviewoftreatmentsforproblemgambling.PsychologyofAddictiveBehaviors,31,951–961.http://dx.doi.org/10.1037/adb0000290Petry,N.M.,Litt,M.D.,Kadden,R.,&Ledgerwood,D.M.(2007).Docopingskillsmediatetherelationshipbetweencognitive-behavioralther-apyandreductionsingamblinginpathologicalgamblers?Addiction,102,1280–1291.http://dx.doi.org/10.1111/j.1360-0443.2007.01907.xPetry,N.M.,Rash,C.J.,&Alessi,S.M.(2016).Arandomizedcontrolledtrialofbriefinterventionsforproblemgamblinginsubstanceabusetreatmentpatients.JournalofConsultingandClinicalPsychology,84,874–886.http://dx.doi.org/10.1037/ccp0000127Petry,N.M.,Stinson,F.S.,&Grant,B.F.(2005).ComorbidityofDSM–IVpathologicalgamblingandotherpsychiatricdisorders:ResultsfromtheNationalEpidemiologicSurveyonAlcoholandRelatedCon-ditions.TheJournalofClinicalPsychiatry,66,564–574.http://dx.doi.org/10.4088/JCP.v66n0504Petry,N.M.,Weinstock,J.,Ledgerwood,D.M.,&Morasco,B.(2008).Arandomizedtrialofbriefinterventionsforproblemandpathologicalgamblers.JournalofConsultingandClinicalPsychology,76,318–328.http://dx.doi.org/10.1037/0022-006X.76.2.318Petry,N.M.,Weinstock,J.,Morasco,B.J.,&Ledgerwood,D.M.(2009).Briefmotivationalinterventionsforcollegestudentproblemgamblers.Addiction,104,1569–1578.http://dx.doi.org/10.1111/j.1360-0443.2009.02652.xPetry,N.M.,&Weiss,L.(2009).Socialsupportisassociatedwithgamblingtreatmentoutcomesinpathologicalgamblers.TheAmericanJournalonAddictions,18,402–408.http://dx.doi.org/10.3109/10550490903077861Pietrzak,R.H.,Molina,C.A.,Ladd,G.T.,Kerins,G.J.,&Petry,N.M.(2005).Healthandpsychosocialcorrelatesofdisorderedgamblinginolderadults.TheAmericanJournalofGeriatricPsychiatry,13,510–519.http://dx.doi.org/10.1097/00019442-200506000-00010Potenza,M.N.(2006).Shouldaddictivedisordersincludenon-substance-relatedconditions?Addiction,101,142–151.http://dx.doi.org/10.1111/j.1360-0443.2006.01591.xRachlin,H.,Raineri,A.,&Cross,D.(1991).Subjectiveprobabilityanddelay.JournaloftheExperimentalAnalysisofBehavior,55,233–244.http://dx.doi.org/10.1901/jeab.1991.55-233Rash,C.J.,Weinstock,J.,&Petry,N.M.(2011).Drinkingpatternsofpathologicalgamblersbefore,during,andaftergamblingtreatment.PsychologyofAddictiveBehaviors,25,664–674.http://dx.doi.org/10.1037/a0025565Rennert,L.,Denis,C.,Peer,K.,Lynch,K.G.,Gelernter,J.,&Kranzler,H.R.(2014).DSM–5gamblingdisorder:Prevalenceandcharacteristicsinasubstanceusedisordersample.ExperimentalandClinicalPsycho-pharmacology,22,50–56.http://dx.doi.org/10.1037/a0034518Smith,D.,Harvey,P.,Battersby,M.,Pols,R.,Oakes,J.,&Baigent,M.(2010).TreatmentoutcomesandpredictorsofdropoutforproblemgamblersinSouthAustralia:Acohortstudy.TheAustralianandNewZealandJournalofPsychiatry,44,911–920.http://dx.doi.org/10.3109/00048674.2010.493502Steel,Z.,&Blaszczynski,A.(1998).Impulsivity,personalitydisordersandpathologicalgamblingseverity.Addiction,93,895–905.http://dx.doi.org/10.1046/j.1360-0443.1998.93689511.xStewart,R.M.,&Brown,R.I.(1988).Anoutcomestudyofgamblersanonymous.TheBritishJournalofPsychiatry,152,284–288.http://dx.doi.org/10.1192/bjp.152.2.284Stinchfield,R.,McCready,J.,Turner,N.E.,Jimenez-Murcia,S.,Petry,N.M.,Grant,J.,...Winters,K.C.(2016).Reliability,validity,andclassificationaccuracyoftheDSM–5diagnosticcriteriaforgamblingdisorderandcomparisontoDSM–IV.JournalofGamblingStudies,32,905–922.http://dx.doi.org/10.1007/s10899-015-9573-7Strong,D.R.,&Kahler,C.W.(2007).EvaluationofthecontinuumofgamblingproblemsusingtheDSM–IV.Addiction,102,713–721.http://dx.doi.org/10.1111/j.1360-0443.2007.01789.xSubstanceAbuseandMentalHealthServicesAdministration.(2014).Gamblingproblems:Anintroductionforbehavioralhealthservicesproviders.Advisory,13(1),1–8.Toce-Gerstein,M.,Gerstein,D.R.,&Volberg,R.A.(2003).Ahierarchyofgamblingdisordersinthecommunity.Addiction,98,1661–1672.http://dx.doi.org/10.1111/j.1360-0443.2003.00545.xVitaro,F.,Ferland,F.,Jacques,C.,&Ladouceur,R.(1998).Gambling,substanceuse,andimpulsivityduringadolescence.PsychologyofAd-dictiveBehaviors,12,185–194.http://dx.doi.org/10.1037/0893-164X.12.3.185Weinstock,J.,Blanco,C.,&Petry,N.M.(2006).Healthcorrelatesofpathologicalgamblinginamethadonemaintenanceclinic.ExperimentalandClinicalPsychopharmacology,14,87–93.http://dx.doi.org/10.1037/1064-1297.14.1.87ReceivedMarch1,2019RevisionreceivedJune14,2019AcceptedJune19,2019ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.200LEDGERWOOD UtilityofDSM-5CriteriaforInternetGamingDisorderKristyCarlisleDepartmentofCounselingandHumanServices,OldDominionUniversity,Norfolk,VA,USAAbstractTheAmericanPsychiatricAssociation(APA)hascalledforfurtherresearchonInternetGamingDisorder(IGD)byplacingitinSectionIIIoftheDiagnosticandStatisticalManual(DSM-5).Researchonprevalence,riskfactors,anddevelopmentofcriteriaforadiagnosisofIGDismixedintheliterature.Thisstudysoughttocon-tributetothesetopicsbyexaminingadiversesampleofInternetgamers(N¼1,881)fromaroundtheworld.Resultsshowedaprevalencerateof4.2%,withvaryingprevalenceratesbasedondemographiccharacteristics.SignificantriskfactorsforIGDincludedgenderandhoursspentgaming.Finally,frequencycountsofIGDcri-teriashowedsignificantdifferencesbetweenparticipantsmeetingIGDcriteriaandthosenotmeetingcriteria,aswellassignificantdifferencesbygenderandage.Lowfrequencycountsandsignificantdifferencesbasedondemographicspointtocriteriathatmaybelessappropriateforadiagnosis,aswellasconsiderationsfordiagnosingdiversepopulations.Limitationsandfutureresearcharediscussed.KeywordsDSM-5,internetgamingdisorder,diagnosticcriteriaIntroductionIntheDSM-5releasedin2013,“EmergingMeasuresandModels”appearinSectionIIIofthemanual.ThesepotentialareasrequirefurtherresearchuntilCorrespondingAuthor:KristyCarlisle,DepartmentofCounselingandHumanServices,OldDominionUniversity,4301HamptonBlvd.,Norfolk,VA23508,USA.Email:[email protected]!TheAuthor(s)2020Articlereuseguidelines:sagepub.com/journals-permissionsDOI:10.1177/0033294120965476journals.sagepub.com/home/prx2021, Vol. 124(6) 2613 –2632Mental & Physical Health 2614 Psychological Reports 124(6)theycanbeconsideredforinclusioninthemanual’smainsection(APA,2013b).InpreviousDSMeditions,thismaterialwasplacedintheappendices;however,theAmericanPsychiatricAssociation(APA)hasreservedaseparatesectioninthemanualinthehopesthatclinicianswillhaveagreaterawarenessofthecriteriawithinit.Internetgamingdisorder(IGD)isoneofeightconditionslistedforfurtherresearchinSectionIII.Eachconditionpresentssuggesteddiagnosticcriteria,aswellasinformationincludingdiagnosticfeatures,preva-lence,riskfactors,functionalconsequences,differentialdiagnosis,andcomor-bidity.TheninediagnosticcriteriaforIGDproposedinSectionIIIinclude:(1)preoccupationwithInternetgames;(2)withdrawalsymptomswhenInternetgamingistakenaway;(3)tolerance:theneedtospendincreasingamountsoftimeengagedinInternetgames,(4)unsuccessfulattemptstocontroltheparticipationinInternetgames;(5)lossofinterestinprevioushobbiesandentertainmentasaresultof,andwiththeexceptionof,Internetgames;(6)continuedexcessiveuseofInternetgamesdespiteknowledgeofpsychosocialproblems;(7)hasdeceivedfamilymembers,therapists,orothersregardingtheamountofInternetgaming;(8)useofInternetgamingtoescapeorrelieveanegativemood;and(9)hasjeop-ardizedorlostasignificantrelationship,job,oreducationalorcareeropportunitybecauseofparticipationinInternetgames(APA,2013a,p.795).Fiveoftheseninecriteriamustbeobservedover12monthsforadiagnosisofIGD.IssueswithinternetgamingdisordercriteriaResearchershopethatthepublicationofninediagnosticcriteriainSectionIIIoftheDSM-5willleadtomoreconsistentevidence-basedstudiestoinformpre-vention,diagnosis,andtreatmentofIGD(Dowling,2014;Kuss&Griffiths,2012a).However,IGD’sinclusioninthesectionengenderscontroversyinthehelpingandaddictionsfields.WithoutaclearconceptualizationanddefinitionofIGDandwithoutevidence-baseddiagnosticcriteria,thereisroomnegativeimpactonpublichealth(vanRooijetal.,2018).Historically,IGDisclassifiedasabehavioralorprocessaddiction(Demetrovics&Griffiths,2012),henceitsinclusionintheDSM-5withcriteriaofcompulsive-likebehaviorsassociatedwithcravings,urges,anddisruptionofsocialandoccupationalfunctioningresemblingsubstanceusedisordersandgamblingdisorder(APA,2013a).Diagnosticcriteriashouldservethepurposeofdistinguishinghealthybehav-iorfrompathology,yetresearchersexpressconcernaboutpathologizingrecre-ationalgamingbehaviorbasedonthecriteriaastheyarecurrentlywritten(e.g.,vanRooij&Prause,2014).Researchers(Billieuxetal.,2015)havefoundaspectrumofInternetgamingbehaviorsandpsychiatricfeaturesthatarenotcapturedbybehavioraladdictionsmodelsandthusnotbytheninecriteriain2PsychologicalReports0(0) Carlisle 2615theycanbeconsideredforinclusioninthemanual’smainsection(APA,2013b).InpreviousDSMeditions,thismaterialwasplacedintheappendices;however,theAmericanPsychiatricAssociation(APA)hasreservedaseparatesectioninthemanualinthehopesthatclinicianswillhaveagreaterawarenessofthecriteriawithinit.Internetgamingdisorder(IGD)isoneofeightconditionslistedforfurtherresearchinSectionIII.Eachconditionpresentssuggesteddiagnosticcriteria,aswellasinformationincludingdiagnosticfeatures,preva-lence,riskfactors,functionalconsequences,differentialdiagnosis,andcomor-bidity.TheninediagnosticcriteriaforIGDproposedinSectionIIIinclude:(1)preoccupationwithInternetgames;(2)withdrawalsymptomswhenInternetgamingistakenaway;(3)tolerance:theneedtospendincreasingamountsoftimeengagedinInternetgames,(4)unsuccessfulattemptstocontroltheparticipationinInternetgames;(5)lossofinterestinprevioushobbiesandentertainmentasaresultof,andwiththeexceptionof,Internetgames;(6)continuedexcessiveuseofInternetgamesdespiteknowledgeofpsychosocialproblems;(7)hasdeceivedfamilymembers,therapists,orothersregardingtheamountofInternetgaming;(8)useofInternetgamingtoescapeorrelieveanegativemood;and(9)hasjeop-ardizedorlostasignificantrelationship,job,oreducationalorcareeropportunitybecauseofparticipationinInternetgames(APA,2013a,p.795).Fiveoftheseninecriteriamustbeobservedover12monthsforadiagnosisofIGD.IssueswithinternetgamingdisordercriteriaResearchershopethatthepublicationofninediagnosticcriteriainSectionIIIoftheDSM-5willleadtomoreconsistentevidence-basedstudiestoinformpre-vention,diagnosis,andtreatmentofIGD(Dowling,2014;Kuss&Griffiths,2012a).However,IGD’sinclusioninthesectionengenderscontroversyinthehelpingandaddictionsfields.WithoutaclearconceptualizationanddefinitionofIGDandwithoutevidence-baseddiagnosticcriteria,thereisroomnegativeimpactonpublichealth(vanRooijetal.,2018).Historically,IGDisclassifiedasabehavioralorprocessaddiction(Demetrovics&Griffiths,2012),henceitsinclusionintheDSM-5withcriteriaofcompulsive-likebehaviorsassociatedwithcravings,urges,anddisruptionofsocialandoccupationalfunctioningresemblingsubstanceusedisordersandgamblingdisorder(APA,2013a).Diagnosticcriteriashouldservethepurposeofdistinguishinghealthybehav-iorfrompathology,yetresearchersexpressconcernaboutpathologizingrecre-ationalgamingbehaviorbasedonthecriteriaastheyarecurrentlywritten(e.g.,vanRooij&Prause,2014).Researchers(Billieuxetal.,2015)havefoundaspectrumofInternetgamingbehaviorsandpsychiatricfeaturesthatarenotcapturedbybehavioraladdictionsmodelsandthusnotbytheninecriteriain2PsychologicalReports0(0)SectionIIIoftheDSM-5.Furthermore,Billieuxetal.(2015)alongwithotherresearchers(e.g.,Billieuxetal.,2019;Musettietal.,2019)haveproducedfind-ingsthatdistinguishbetweenproblematicandnon-problematicgaminginmorenuancedwaysthantheninecriteriaallow.Inaddition,theninecriteriaforthepotentialdisorder,astheyarecurrentlyworded,donotadequatelydistinguishIGDfromamoregeneraladdictiontotheInternet(Kussetal.,2014).Authorsetal.(2016)explainthattheInternetisabroadforumwhereuserscanengageinmanyreinforcingactivities,notjustgaming.OtheractivitiesforwhichtheInternetisthemediumincludeInternetgamblingaddiction(Leeetal.,2012),sexaddictionfacilitatedbytheInternet(Jones&Hertlein,2012),Internetaddic-tionassociatedwithonlineauctions(Tonionietal.,2012),andsocialmediaandshopping(Murali&Onuba,2009).Authorsetal.(2016)suggestthatInternetaddictionmaybeusefulasanumbrelladiagnosis(Luoetal.,2015)tohelpexplaincomorbidaddictionstothespecificactivities.ManyresearchersarecallingforrefinementoftheIGDcriteriaastheyarecurrentlywritten(Dowling,2014;Taoetal.,2012).Specifically,Taoetal.sug-gestthatsomeofthecriteriaarenotaccurateandsomemaybemorecentraltothediagnosisofIGDthanothers.KingandDelfabbro(2015)believethatthepreoccupationcriterionshouldemphasizethekindsofcognitionsgamersexpe-rience,nothowoftentheyexperiencethem.Further,thiscriterionmaypathol-ogizeenthusiasticrecreationalplaywhenaddictiondoesnotexist(Kardefelt-Winther,2014,2015)andfailtotakegamingcontextintoconsideration,sinceprofessionalorhighachievinggamersmaydevotesignificanttimetoconsideringanddiscussinggamingstrategy(Faustetal.,2013;Koetal.,2014).Next,tol-eranceandwithdrawalcriteriamaynotbemeasurableinthesamewayforaprocessaddictionasitisforasubstanceaddictionbecausethereisnophysio-logicalinputfromabehavior(vanRooij&Prause,2014).Ko(2014)suggeststhattoleranceforIGDmaybemeasurablebasedonthedecreasedsatisfactiongamersexperienceinsteadoftheneedtogamemore.Specifictowithdrawal,researchersexplainthatwithdrawaltoIGDisnottheunpleasantfeelingsexpe-riencedbygamerswhentheyaresuddenlyforcedtostopgaming,suchastheangerachildmightfeelwhenaparentforceshertostopgaming.Instead,itisthesymptoms,i.e.,irritability,anxiety,orsadness,experiencedfromonehouruptotwoweeksaftergaminghasceased(Kiralyetal.,2015).Next,thecriterionillustratinglossofinterestinotheractivitiesdrawscriticismfromresearchersbecauseitdoesnotconsiderthedevelopmentalofthegamer(Kussetal.,2017),whomightbeengaginginnewactivitiesinadevelopmentallyappropriateway,e.g.,anadolescent.Otherdebatedcriteriaincludetheescapeanddeceptioncriteria.DerivedfromDSM-IVcriteriaforpathologicalgamblingandsubstancedependence,thesecriteriamaynotbeaccurateforIGD,astheyshowlowfre-quencyamongstproblematicgamers(Koetal.,2014).Finally,researcherssuggestthatthecriteriaareconfusingbecausetheyareconceptuallytoosimilartocriteriaforgamblingandsubstanceusedisordersCarlisle3 2616 Psychological Reports 124(6)(Petryetal.,2014)andbecausethedisorderisoftencomorbidwithsuchawidevarietyofotherdisorders(Dowling&Brown,2010).DisordersmostcommonlycomorbidwithIGDincludedepression,anxiety,panicdisorder,socialphobia(Allisonetal.,2006),ADHD(Batthya´nyetal.,2009),andsubstanceaddiction(Koetal.,2012).Thus,itisdifficulttoconcludehowIGDisassociatedwiththeseissues.Forexample,itcouldbedifficulttodetermineifIGDisbeingusedasacopingmechanismforaconditionlikeanxietyoriftheIGDisanexacer-batingfactorfortheanxiety.Authorsetal.(2016)suggestthatfutureresearchshouldbeconductedtodeterminehowpeoplewithIGDmaybeusingInternetgamingtocopewithsymptomsofothermentalhealthconcerns,similarlytohowpeoplewithsubstanceaddictionusethesubstancetocopewithsymptomsfromothermentalhealthconcerns.PrevalencePrevalenceratesforproblematicInternetgamingvaryinthestudiesreviewedbasedonpopulation,criteria,andassessmenttools.Infact,over20differentinstrumentsassessingforIGDhavebeennotedintheliteraturewhenprevalenceisbeingreported(Griffiths,2016).Kingetal.(2013)reviewed18oftheseinstru-mentsandfounddiscrepanciesamongstindicatorsofaddiction,poorinforma-tiononcutoffscores,andlackofinterraterreliabilityandpredictivevalidity.ThislackofconsistencymakesithardtopinpointevenameaningfulrangerelativetoprevalenceofIGD.Thefollowingstudiesdemonstratethisinconsis-tency.AstudyofGermanadolescents(N¼11,003)usingcriteriaadaptedfromtheDSM-5reportedaprevalencerateof1.16%forIGD(Rehbeinetal.,2015).ADutchstudyusingtheCompulsiveInternetUseScale(CIUS)andstudyingtwosamples(N¼1,572,N¼1,476)ofadolescentonlinegamersage13-16showedthat3%ofparticipantsreportedaddiction-likeproblemsincludingwithdrawal,lossofcontrol,salience,conflict,andcopingformoodmodification(vanRooijetal.,2011).Similarly,inaSouthKoreanstudyofstudentsbetween12and18yearsofage(N¼600),2.2%ofparticipantsmetcriteriaforaddictionaccordingtoYoung’sInternetAddictionTest(IAT)(Jeong&Kim,2010).Rehbeinetal.(2010)surveyedGermanninthgraders(N¼44,610)withavideogamedependencyscalebasedontheIATtofindthat3%ofmaleand0.3%offemalestudentswouldbediagnosedasaddictedtovideogames.InanAustralianstudyofhighschoolandcollegestudents(N¼2,031),5%ofpartic-ipantsmetcriteriaforaddictiontocomputergamesandtheInternetrespective-ly,accordingtoDSM-IV-TRcriteriaforpathologicalgambling(Thomas&Martin,2010).Inaninternationalstudyofadolescentandadultgamers(N¼1,945),researchersusedDSM-IVcriteriaforsubstancedependencetodeterminethat8%ofparticipantsmetcriteriaforproblematicgaming(Porteretal.,2010).The8%reportedhavingfewerfriendsintherealworldthannon-problematicgamersandconsiderediteasiertomeetpeopleonlinethaninthe4PsychologicalReports0(0) Carlisle 2617(Petryetal.,2014)andbecausethedisorderisoftencomorbidwithsuchawidevarietyofotherdisorders(Dowling&Brown,2010).DisordersmostcommonlycomorbidwithIGDincludedepression,anxiety,panicdisorder,socialphobia(Allisonetal.,2006),ADHD(Batthya´nyetal.,2009),andsubstanceaddiction(Koetal.,2012).Thus,itisdifficulttoconcludehowIGDisassociatedwiththeseissues.Forexample,itcouldbedifficulttodetermineifIGDisbeingusedasacopingmechanismforaconditionlikeanxietyoriftheIGDisanexacer-batingfactorfortheanxiety.Authorsetal.(2016)suggestthatfutureresearchshouldbeconductedtodeterminehowpeoplewithIGDmaybeusingInternetgamingtocopewithsymptomsofothermentalhealthconcerns,similarlytohowpeoplewithsubstanceaddictionusethesubstancetocopewithsymptomsfromothermentalhealthconcerns.PrevalencePrevalenceratesforproblematicInternetgamingvaryinthestudiesreviewedbasedonpopulation,criteria,andassessmenttools.Infact,over20differentinstrumentsassessingforIGDhavebeennotedintheliteraturewhenprevalenceisbeingreported(Griffiths,2016).Kingetal.(2013)reviewed18oftheseinstru-mentsandfounddiscrepanciesamongstindicatorsofaddiction,poorinforma-tiononcutoffscores,andlackofinterraterreliabilityandpredictivevalidity.ThislackofconsistencymakesithardtopinpointevenameaningfulrangerelativetoprevalenceofIGD.Thefollowingstudiesdemonstratethisinconsis-tency.AstudyofGermanadolescents(N¼11,003)usingcriteriaadaptedfromtheDSM-5reportedaprevalencerateof1.16%forIGD(Rehbeinetal.,2015).ADutchstudyusingtheCompulsiveInternetUseScale(CIUS)andstudyingtwosamples(N¼1,572,N¼1,476)ofadolescentonlinegamersage13-16showedthat3%ofparticipantsreportedaddiction-likeproblemsincludingwithdrawal,lossofcontrol,salience,conflict,andcopingformoodmodification(vanRooijetal.,2011).Similarly,inaSouthKoreanstudyofstudentsbetween12and18yearsofage(N¼600),2.2%ofparticipantsmetcriteriaforaddictionaccordingtoYoung’sInternetAddictionTest(IAT)(Jeong&Kim,2010).Rehbeinetal.(2010)surveyedGermanninthgraders(N¼44,610)withavideogamedependencyscalebasedontheIATtofindthat3%ofmaleand0.3%offemalestudentswouldbediagnosedasaddictedtovideogames.InanAustralianstudyofhighschoolandcollegestudents(N¼2,031),5%ofpartic-ipantsmetcriteriaforaddictiontocomputergamesandtheInternetrespective-ly,accordingtoDSM-IV-TRcriteriaforpathologicalgambling(Thomas&Martin,2010).Inaninternationalstudyofadolescentandadultgamers(N¼1,945),researchersusedDSM-IVcriteriaforsubstancedependencetodeterminethat8%ofparticipantsmetcriteriaforproblematicgaming(Porteretal.,2010).The8%reportedhavingfewerfriendsintherealworldthannon-problematicgamersandconsiderediteasiertomeetpeopleonlinethaninthe4PsychologicalReports0(0)realworld.AGermanstudysampledyoungadultInternetgamerswithameanageof21years(N¼7,069)andfoundthat11.9%ofparticipantsmetcriteriaforaddiction(Gru¨sseretal.,2007).Yee(2006b)reportsthat50%ofMMORPGplayers(N¼30,000),ranginginagefrom11-68,considerthemselvestobeaddicted.AlthoughhedidnotperformaclinicalassessmentofIGDontheparticipants,theauthorreportedthestatistictoillustratetheemotionalinvest-mentusershaveinthegames,aswellasthehighlevelofappealofthegames.Theabovestudiesutilizeddifferentassessmentinstruments,criteria,andpop-ulations;however,thefindingsindicatethepotentialofasignificantproblemacrossgenerationsandnationalitiesofInternetgamerswithrealworldconsequences.DemographicriskfactorsRiskfactorsareanimportantconsiderationinpreventionresearch.SeveraldemographicriskfactorsaredocumentedintheliteratureonIGD,butothergroupsareunderrepresented.First,beingmalehasbeenshowntobeariskfactorforIGD(Authorsetal.,2019;Batthya´nyetal.,2009),butlessresearchhasbeenconductedonfemalegamers,andmoststudiesreportamuchhigherpercentageofmaleparticipants(e.g.,Fusteretal.,2012).Still,recentstudieshavereportedthatthereisarisingtrendoffemalegamers(Kuss&Griffiths,2012b),specificallyfemalegamersovertheageof50(ESA,2014).OtherresearcherswhohaveexaminedgenderandIGDhavefoundthemesrelatedtotheirmotivationtoplayInternetgames.Authorsetal.(2019)foundmalenesstobeapredictorofbothsocialandachievementmotivationtoplay.However,Yee’s(2006a)studyreportedanassociationbetweenmalenessandachievementmotivationandnogenderdifferencesforsocialmotivation,alsonotinganasso-ciationbetweenfemalenessandrelationship-building.Parketal.(2011)alsofoundfemalenesstobeassociatedwithrelationship-building.Yee(2006a)andYeeetal.(2012)notedthatmalesandfemalesmaybothbemotivatedtoengagesociallywhileplayingInternetgames,buttheymaypursueonlinerelationshipdifferently.Authorsetal.(2019)notedtheimportanceofrecognizingthenuancednatureofsocialinteractionsandsocialmotivation,bothonlineandintherealworld,inordertoavoidputtinggamersintoanyoneparticularbox.Next,livinginanAsiancountryisreportedasariskfactorforInternet-relatedaddiction(Linetal.,2011).However,muchoftheresearchonIGDhasbeenconductedinAsiancountries,andmoreresearchshouldbeconductedintheUnitedStatestodetermineriskfactorsspecifictothisculture(Kuss&Griffiths,2012a).Finally,collegestudentshavebeenshowntobemorehighlysusceptibletoInternet-relatedaddictions(Frangosetal.,2010;Linetal.,2011).Conversely,Authorsetal.(2019)testedforage,gender,ethnicity,andstudentstatus,andonlymalenesswasasignificantpredictorofIGD.However,bothAuthorsetal.(2019)andYee(2006a)foundyoungeragetobeapredictorofCarlisle5 2618 Psychological Reports 124(6)motivationtoachieveinInternetgames.Ultimately,IGDhasthepotentialtoaffectanypopulationwithInternetaccess,andriskfactorsgowellbeyonddemographicfactorstoincludepsychologicalandpsychosocialfactors(Dowling&Brown,2010).TheAmericanPsychiatricAssociationrecognizesthepotentialproblemofIGDandhascalledforfurtherresearchonthedisorderbyplacingitinSectionIIIofthemostupdatededitionoftheDSM(APA,2013a).MethodThisstudyusedanon-experimentalgroupcorrelationaldesignandreportedbothdescriptiveandinferentialstatisticstoanswerthefollowingresearchques-tions:WhatistheprevalencerateforIGDusingthecurrentDSM-5criteria?WhataredemographicriskfactorspredictingIGD?WhatistheutilityoftheDSM-5criteriaforIGDbasedonfrequencycountsandsignificantdifferencesbetweengroups?ParticipantsParticipantswereadult(18þ)InternetgameswhohaveplayedaMassivelyMultiplayerOnlineGame(MMO)withinthepast12months.ParticipantswereprimarilyrecruitedonlineviaFacebookandReddit.Thesampleof1,881gamerscollectedrepresentedboththeUnitedStates(n¼1,563)andabroad(n¼318).Theresearcherreportsdemographicdetailsforthepopulationsampledintheresultssection.MeasuresIGDwasmeasuredusingtheTen-ItemInternetGamingDisorderTest(IGD-10)(Kiralyetal.,2015).ParticipantswhomeetfiveormoreofthefollowingninecriteriamayhaveadiagnosisofIGD:Preoccupation;withdrawal;tolerance;failedattemptstostopgaming;lossofinterestinotheractivities;continuedusedespitepsychosocialproblems;deception;escapism;andrelational,educational,orvocationalconsequences.Ademographicquestionnairecollectedinformationonage,gender,ethnicity,studentstatus,hoursspentonworkperweek,andhoursspentgamingperweek.ProcedureDatacollectionbeganafterinstitutionalreviewboardapproval,entaileddigitalandface-to-facemethods,andusedpurposefulsamplingtoreachadiversesampleofgamers.Thedigitalmeasures,namelyusingFacebookandReddit,allowedforthousandsofgamersfromaroundtheworldtocompletethesurvey.Theresearchercleaneddataformissingcases,transformedvariablesfor6PsychologicalReports0(0) Carlisle 2619motivationtoachieveinInternetgames.Ultimately,IGDhasthepotentialtoaffectanypopulationwithInternetaccess,andriskfactorsgowellbeyonddemographicfactorstoincludepsychologicalandpsychosocialfactors(Dowling&Brown,2010).TheAmericanPsychiatricAssociationrecognizesthepotentialproblemofIGDandhascalledforfurtherresearchonthedisorderbyplacingitinSectionIIIofthemostupdatededitionoftheDSM(APA,2013a).MethodThisstudyusedanon-experimentalgroupcorrelationaldesignandreportedbothdescriptiveandinferentialstatisticstoanswerthefollowingresearchques-tions:WhatistheprevalencerateforIGDusingthecurrentDSM-5criteria?WhataredemographicriskfactorspredictingIGD?WhatistheutilityoftheDSM-5criteriaforIGDbasedonfrequencycountsandsignificantdifferencesbetweengroups?ParticipantsParticipantswereadult(18þ)InternetgameswhohaveplayedaMassivelyMultiplayerOnlineGame(MMO)withinthepast12months.ParticipantswereprimarilyrecruitedonlineviaFacebookandReddit.Thesampleof1,881gamerscollectedrepresentedboththeUnitedStates(n¼1,563)andabroad(n¼318).Theresearcherreportsdemographicdetailsforthepopulationsampledintheresultssection.MeasuresIGDwasmeasuredusingtheTen-ItemInternetGamingDisorderTest(IGD-10)(Kiralyetal.,2015).ParticipantswhomeetfiveormoreofthefollowingninecriteriamayhaveadiagnosisofIGD:Preoccupation;withdrawal;tolerance;failedattemptstostopgaming;lossofinterestinotheractivities;continuedusedespitepsychosocialproblems;deception;escapism;andrelational,educational,orvocationalconsequences.Ademographicquestionnairecollectedinformationonage,gender,ethnicity,studentstatus,hoursspentonworkperweek,andhoursspentgamingperweek.ProcedureDatacollectionbeganafterinstitutionalreviewboardapproval,entaileddigitalandface-to-facemethods,andusedpurposefulsamplingtoreachadiversesampleofgamers.Thedigitalmeasures,namelyusingFacebookandReddit,allowedforthousandsofgamersfromaroundtheworldtocompletethesurvey.Theresearchercleaneddataformissingcases,transformedvariablesfor6PsychologicalReports0(0)analysis,identifiedandeliminatedoutliers,andconducteddescriptivestatisticstotestforlinearregressionandANOVAassumptions.TheresearcherusedSPSS(Version24.0)toconductallanalyses.StatisticalanalysisTheresearcherreporteddescriptivestatisticsrelatedtopopulationdemo-graphics,prevalenceofIGD,andfrequencyofIGDcriteriabydemographicgroup.TheresearcheridentifiedsignificantpredictorsofIGDusinglinearregressionandsignificantdifferencesbetweengroupsusingt-testsandone-wayANOVAtests.ResultsPopulationdemographicsDatacollectioninthisstudyproducedaninternationalsampleofInternetgamers(N¼1,881)from56differentcountriesaroundtheworldonsixcon-tinents,andfrom49ofthe50UnitedStates,plusWashingtonD.C.andPuertoRico.BasedonthewidenetcasttocollectdatafromtheInternetgamingpop-ulationandontheinternationalaccesstogamersaffordedbyelectronicmeansofdatacollection,theresearcherexpecteddemographicdiversityrelatedtoage,gender,ethnicity,andstudentstatus.However,thepopulationsampledwasparticularlyhomogenousintheareasofageandethnicity.Ofthepopulationsampled45.5%ofthegamersinthestudywere25yearsofageorunder(n¼853),and70.5%were30yearsofageorunder(n¼1,320).Theother29.5%ofthepopulationsampledrepresentedparticipantsintheir30s,40s,50s,andbeyond(n¼561),withonly2.4%ofthepopulationsampledovertheageof51(n¼53).Inaddition,morethanthree-quartersofthepopulationsampledidentifiedasWhite/Caucasian(n¼1,456),leavinglessthan20%rep-resentedbyAfricanAmerican,Hispanic/Latino/Latina,Asian,andmultiracialethnicities(n¼356).Thepopulationsampledismorediverserelatedtogender,withalmost60%ofparticipants(n¼1,118)identifyingasmaleandalmost40%identifyingasfemale(n¼732).Whiletheauthorofferednon-binarychoicesforgender,fewparticipants(n¼31)chosethoseoptions.Finally,38%ofthepop-ulationreportedstudentstatus(n¼722),providinganadequateproportiontocomparetothenon-studentpopulation.Becauseoftheyoungeragereportedbyparticipantsinthestudy,itislogicalthatasignificantproportionwouldbestudents.Overall,ifthesedemographicstatisticswereappliedtothegeneralpopulation,itwouldappearthatyounger,WhitemalesandfemalesaremostrepresentativeoftheInternetgamingpopulation.ThepopulationsampledinthisstudyiscomparabletopopulationssampledintheliteraturewhenIGDisCarlisle7 2620 Psychological Reports 124(6)examined,anditisgenerallymorerepresentativeofageandethnicitythantheseothersamples.InternetgamingdisorderprevalenceOneofthemostvaluableaspectsofthisstudyistheresultsrelatedtoIGDprevalenceandthespecificcriteriareportedbythegamingpopulation,ingen-eral,andbythepopulationwithadiagnosisofIGD.Ofthepopulationsampled,4.2%metcriteriaforIGD(n¼79),meaningtheyreportedfiveormoreofthecriterialistedinSectionIIIoftheDSM-5,asmeasuredbytheIGD-10.Thisprevalencerateisslightlyhigherthanprevalenceratesforotherprocessaddic-tions,includingAnorexiaNervosaatupto1.5%(APA,2013a),gamblingaddic-tionat2%,sexaddictionat3%,exerciseaddictionat2%,andeatingaddictionat2%(Sussmanetal.,2011).PotentialriskfactorsforinternetgamingdisorderTheresearcheralsoconductedanalysestoreportprevalenceratesfordemo-graphicgroups,includinggender,age,ethnicity,studentstatus,andgeographiclocation(USornon-US).Forgender,8outof10participantswithIGDweremale.Logically,theprevalencerateofIGDwashigherformalesinthestudyat5.7%,andtheprevalencerateforfemaleswas1.5%.Similarly,85%ofpartic-ipantswithIGDwereage30oryounger.Prevalenceratesinthecurrentstudyweresignificantlyhigherforparticipantsage30oryounger(5.1%)versus31orolder(2.1%).Overall,prevalencerateformales(5.7%)andforpeopleage30oryounger(5.1%)werehigherthantheprevalenceratefortheoverallpopulationsampledinthestudy(4.2%),indicatingthatmalegenderandyoungeragestatusmayberiskfactorsforIGD.Forethnicity,IGDprevalenceamongstthesamplewhoidentifiedasWhitewas3.6%,lowerthantheoverallprevalencerate.Andprevalenceforstudentswas4.3%,justslightlyhigherthantheoverallrateofIGD.Finally,prevalenceratesvariedbasedongeographiclocation.ParticipantslivingintheUShadaprevalencerateof3.4%,lowerthanthegeneralIGDprevalencerate,whileparticipantslivingoutsidetheUShadasignificantlyhigherprevalencerateof7.8%.Thesefindingsareimportantforinformingscreeningandpreventionwhencounselorsareworkingwithdiversepopulations.Inordertofurtherclarifyifgender,age,ethnicity,studentstatus,orgeo-graphiclocationmayberiskfactorsforIGD,theresearcherconductedaregres-sionofIGDongender,ethnicity,age,studentstatus,andgeographiclocation,aswellashoursspentgaminginordertounderstandtheirpredictiverelation-shipswithIGD.ThesevariablessignificantlypredictedIGDintheoverallmodel,F(6,1723)¼17.626,p<.001,R2¼.058.However,onlygender(b¼�.13)andhoursspentgaming(b¼.22)weresignificantpredictorsof8PsychologicalReports0(0) Carlisle 2621examined,anditisgenerallymorerepresentativeofageandethnicitythantheseothersamples.InternetgamingdisorderprevalenceOneofthemostvaluableaspectsofthisstudyistheresultsrelatedtoIGDprevalenceandthespecificcriteriareportedbythegamingpopulation,ingen-eral,andbythepopulationwithadiagnosisofIGD.Ofthepopulationsampled,4.2%metcriteriaforIGD(n¼79),meaningtheyreportedfiveormoreofthecriterialistedinSectionIIIoftheDSM-5,asmeasuredbytheIGD-10.Thisprevalencerateisslightlyhigherthanprevalenceratesforotherprocessaddic-tions,includingAnorexiaNervosaatupto1.5%(APA,2013a),gamblingaddic-tionat2%,sexaddictionat3%,exerciseaddictionat2%,andeatingaddictionat2%(Sussmanetal.,2011).PotentialriskfactorsforinternetgamingdisorderTheresearcheralsoconductedanalysestoreportprevalenceratesfordemo-graphicgroups,includinggender,age,ethnicity,studentstatus,andgeographiclocation(USornon-US).Forgender,8outof10participantswithIGDweremale.Logically,theprevalencerateofIGDwashigherformalesinthestudyat5.7%,andtheprevalencerateforfemaleswas1.5%.Similarly,85%ofpartic-ipantswithIGDwereage30oryounger.Prevalenceratesinthecurrentstudyweresignificantlyhigherforparticipantsage30oryounger(5.1%)versus31orolder(2.1%).Overall,prevalencerateformales(5.7%)andforpeopleage30oryounger(5.1%)werehigherthantheprevalenceratefortheoverallpopulationsampledinthestudy(4.2%),indicatingthatmalegenderandyoungeragestatusmayberiskfactorsforIGD.Forethnicity,IGDprevalenceamongstthesamplewhoidentifiedasWhitewas3.6%,lowerthantheoverallprevalencerate.Andprevalenceforstudentswas4.3%,justslightlyhigherthantheoverallrateofIGD.Finally,prevalenceratesvariedbasedongeographiclocation.ParticipantslivingintheUShadaprevalencerateof3.4%,lowerthanthegeneralIGDprevalencerate,whileparticipantslivingoutsidetheUShadasignificantlyhigherprevalencerateof7.8%.Thesefindingsareimportantforinformingscreeningandpreventionwhencounselorsareworkingwithdiversepopulations.Inordertofurtherclarifyifgender,age,ethnicity,studentstatus,orgeo-graphiclocationmayberiskfactorsforIGD,theresearcherconductedaregres-sionofIGDongender,ethnicity,age,studentstatus,andgeographiclocation,aswellashoursspentgaminginordertounderstandtheirpredictiverelation-shipswithIGD.ThesevariablessignificantlypredictedIGDintheoverallmodel,F(6,1723)¼17.626,p<.001,R2¼.058.However,onlygender(b¼�.13)andhoursspentgaming(b¼.22)weresignificantpredictorsof8PsychologicalReports0(0)IGD.SincehoursgamingwasalsoasignificantpredictorofIGD,somedetailsareprovidedaboutthewaythatvariableinteractedwithIGD.Whentheentiresamplewasanalyzedtheaveragegameplayperweekwas16.73hours,butwhentheIGDpopulationwasanalyzedtheaverageplayperweekincreasedto36.45hours.Inthenon-IGDpopulation33.5%(n¼587)reportedplaying16hoursaweekormore,whileintheIGDpopulation78%(n¼59)reported16hoursperweekormore.FrequencyofinternetgamingdisordercriteriaTheresearcheralsoexamineddescriptivestatisticsforthenineindividualcriteriameasuredbytheIGD-10.Table1displaysthecriteriaasreportedbypartici-pantsinthestudyfrommostfrequentlyreportedtoleastfrequentlyreported.ThetableshowsthefrequencycountsforthesamplepopulationwithoutIGDandfortheparticipantsinthestudymeetingIGDcriteria.Percentagesofbothpopulationsthatreporteachcriterionareprovided.Theresearcherconducedt-teststocompareIGDscoresinparticipantswithIGDandparticipantswithoutIGD.TherewasasignificantdifferenceinthescoresforparticipantswithIGDandparticipantswithoutIGD,t(1880)¼9.079,p<.000.TherewerealsosignificantdifferencesbetweenindividualscoresforallnineitemsoftheIGD-10forparticipantswithIGDandparticipantswithoutIGDatthep<.000level.SeeTable2formeanscores,standarddeviations,andeffectsize.InanefforttoaddculturalcontexttotheunderstandingoftheIGDcriteria,theresearcherexaminedgender,age,andethnicitydifferencesinfrequencyofcriteriareportedinthestudy.Table3showsfrequencydifferencesbygender,Table4showsfrequencydifferencesbyage,andTable5showsfrequencyTable1.IGDcriteria.CriteriaFrequencyofcriteriaforparticipantswithoutIGDPercenttoreportcriteriaFrequencyofcriteriaforparticipantswithIGDPercenttoreportcriteriaEscape48426.9%6887.2%Preoccupation47526.4%6887.2%Tolerance21111.7%6380.8%Psychosocial1649.1%6988.5%LossInterest995.5%5064.1%Withdrawal985.4%5874.4%Jeopardizedjob/rel593.3%4152.6%Deception613.4%3342.3%Reducetime472.6%1721.8%Total1,80178Carlisle9 2622 Psychological Reports 124(6)differencesbyethnicity.Reportsonsignificanceofthedifferencesbetweengroupsfollowseachtable.Theresearcherconducedone-wayANOVAteststocompareIGDscoresbasedongender.ResultswerenonsignificantfordifferencesbetweenmalesandfemaleswithIGD.Table2.Means,standarddeviations,andTtest.MeasureWithoutIGDWithIGDMSDMSDt(1880)Cohen’sdIGD0.941.156.031.1238.546***4.43***p<.001.Table3.GenderdifferencesinIGDcriteriaamongparticipantswithIGD.CriteriaFrequencyformalesPercentageformalesFrequencyforfemalesPercentageforfemalesPsychosocial5585.9%11100%Escape5585.9%1090.9%Preoccupation5484.4%11100%Tolerance5179.7%1090.9%Withdrawal4773.4%981.8%Lossinterest4062.5%872.7%Jeopardizedjob/rel3757.8%327.3%Deception2945.3%327.3%Reducetime1421.9%327.3%Total(N¼75)6411Table4.AgedifferencesinIGDcriteriaamongparticipantswithIGD.CriteriaFrequencyfor30andunderPercentagefor30andunderFrequencyfor31þPercentagefor31þPsychosocial5886.6%12100%Escape5988.1%1083.3%Preoccupation5785.1%12100%Tolerance5379.1%1191.7%Withdrawal4973.1%1083.3%Lossinterest4262.7%975%Jeopardizedjob/rel3552.2%758.3%Deception2841.8%650%Reducetime1522.4%325%Total(N¼79)671210PsychologicalReports0(0) Carlisle 2623differencesbyethnicity.Reportsonsignificanceofthedifferencesbetweengroupsfollowseachtable.Theresearcherconducedone-wayANOVAteststocompareIGDscoresbasedongender.ResultswerenonsignificantfordifferencesbetweenmalesandfemaleswithIGD.Table2.Means,standarddeviations,andTtest.MeasureWithoutIGDWithIGDMSDMSDt(1880)Cohen’sdIGD0.941.156.031.1238.546***4.43***p<.001.Table3.GenderdifferencesinIGDcriteriaamongparticipantswithIGD.CriteriaFrequencyformalesPercentageformalesFrequencyforfemalesPercentageforfemalesPsychosocial5585.9%11100%Escape5585.9%1090.9%Preoccupation5484.4%11100%Tolerance5179.7%1090.9%Withdrawal4773.4%981.8%Lossinterest4062.5%872.7%Jeopardizedjob/rel3757.8%327.3%Deception2945.3%327.3%Reducetime1421.9%327.3%Total(N¼75)6411Table4.AgedifferencesinIGDcriteriaamongparticipantswithIGD.CriteriaFrequencyfor30andunderPercentagefor30andunderFrequencyfor31þPercentagefor31þPsychosocial5886.6%12100%Escape5988.1%1083.3%Preoccupation5785.1%12100%Tolerance5379.1%1191.7%Withdrawal4973.1%1083.3%Lossinterest4262.7%975%Jeopardizedjob/rel3552.2%758.3%Deception2841.8%650%Reducetime1522.4%325%Total(N¼79)671210PsychologicalReports0(0)Whenone-wayANOVAswereconductedonIGDscoresbasedonage,theresearcherfoundastatisticallysignificantdifferencebetweengroups(F(1,77)¼4.864,p¼.030).Table6reportsmeanscores,standarddeviations,andeffectsize.TheresearcherfoundnosignificantdifferencesbetweenethnicitygroupswhenANOVAtestswereconducted.DiscussionThepopulationsampledinthisstudyiscomparabletopopulationssampledintheliteraturewhenIGDisexamined,anditisgenerallymorerepresentativeofageandethnicity.Yee(2006a)collecteddatafrom3,035participantswhowere91%male.Yeeetal.(2012)sampledtwopopulations,onewith2,071partic-ipants(65.6%male)withanaverageageof29.95,andanotherwith645partic-ipantsfromTaiwanandHongKong(80%male)withanaverageageof23.59.Theyfoundthat22.2%ofthepopulationhesampledwasrepresentedbystu-dents.Thisauthor’ssamplehadmoremaleparticipantsthanthecurrentstudy,thoughaverageageiscomparable,asisthepercentageofparticipantswithstudentstatus.Next,JengandTeng(2008)sampled92Taiwanesecollegestu-dents(age18-27)with60%beingmale.Parketal.(2011)alsosampledAsianTable5.EthnicitydifferencesinIGDcriteriaamongparticipantswithIGD.CriteriaFrequencyforWhitesPercentageforWhitesFrequencyforNon-WhitesPercentagefornon-WhitesPreoccupation4892.3%1381.3%Psychosocial4586.5%1593.8%Escape4586.5%16100%Tolerance4382.7%1381.3%Withdrawal4280.8%1062.5%Lossinterest3159.6%1275%Jeopardizedjob/rel2548.1%850%Deception2242.3%637.5%Reducetime917.3%531.3%Total(N¼78)5216Table6.Means,standarddeviations,andone-wayanalysesofvariance.Measure30andunder31þMSDMSDF(1,77)g2IGD5.911.106.671.074.864***.06***p¼.030.Carlisle11 2624 Psychological Reports 124(6)collegestudentsbetweentheagesof17and28.Ofthe524respondents,47.6%weremale.Thesesmallersamplepopulationsareequallyrepresentativeofgenderasthecurrentstudy,butlackrepresentationintheareasofageandethnicity.Next,Caplanetal.(2009)sampled4,278participantsranginginagefrom18to65withameanageof32.47and81%beingmale.Thislargersamplehadasimilaragerangeasthecurrentstudywithaslightlyolderaverageageandasignificantlylargermalepopulation.Similarly,GrahamandGosling(2013)reportedonapopulationof1,413comprisedof88%males,whohadanaverageageof26.04.Comparedtothesetwostudies,thepopulationinthecurrentstudyhadamoreequalsampleofmales(60%)andfemales(40%).ColeandHooley(2013)collecteddataon163participants(56%male,40%female)withanaverageageof27.3.Thissmallsampleiscomparabletothedemographicsofthepopulationcollectedinthecurrentstudyrelatedtogenderandage.Prevalenceratesintheliteraturevarysignificantlybasedonpopulationsam-pled,criteriaused,andassessmenttoolemployed.Thus,itismostusefultocompareprevalenceratesamongstudiesthatusethesameDSM-5criteria.ComparedtootherstudiesusingDSM-5criteriaforIGD,theprevalencerateinthisstudy(4.2%)appearsnormaltohigh.Rehbeinetal.(2015)foundthat1.16%oftheadolescents(N¼11,003)intheirstudyhadIGDaccordingtoDSM-5criteria.Maleparticipantsinthestudyhadahigherprevalencerate(2.02%)thanfemales(.26%).Mu¨lleretal.(2014)alsoassessedprevalenceinanadolescentsample(N¼12,938)acrosssevenEuropeancountriesandfoundthat1.6%metIGDcriteria.AstudyofDutchadolescentsandadults(N¼2,444)foundthat5.4%hadIGDaccordingtoDSM-5diagnosis(Lemmensetal.,2015).Theresearchersalsoreportedahigherprevalencerateamongmaleparticipants(6.8%)thanfemaleparticipants(4.0%),consistentwiththecurrentstudy.PrevalenceratesforIGDarebasedontheninecriteriainSectionIIIoftheDSM-5.Thecriteriaarecurrentlyunderresearchtodeterminetheirappropri-atenessfordiagnosingIGD.ThefrequencyorderofcriteriareportedamongthepopulationsampledinthisstudywithIGDwere:psychosocialconsequences,escape,preoccupation,tolerance,withdrawal,lossofinterestinotheractivities,jeopardizedjoborrelationship,deception,andunsuccessfulattemptstoreducetimeplaying.Rehbeinetal.(2015)alsoreportedonthefrequencyofcriteriareportedamongthepopulationmeetingIGDcriteriaintheDSM-5and,simi-larlytothecurrentstudy,foundescapeandpreoccupationtobethemosthighlyreportedcriteriaamongthepopulationtheysampledmeetingIGDcriteria.However,thoseresearchersreportedthatthelowestfrequencycriteriawerelossofinterestinotheractivitiesandjeopardizedrelationships,whichfellintoslotssixandsevenoutofnineinthecurrentstudy.Futureresearchisneededtodeterminetheleastfrequentlyreportedcriteriaamongthenine,aspartofdecid-ingthemostappropriatediagnosticcriteriaforIGD.12PsychologicalReports0(0) Carlisle 2625collegestudentsbetweentheagesof17and28.Ofthe524respondents,47.6%weremale.Thesesmallersamplepopulationsareequallyrepresentativeofgenderasthecurrentstudy,butlackrepresentationintheareasofageandethnicity.Next,Caplanetal.(2009)sampled4,278participantsranginginagefrom18to65withameanageof32.47and81%beingmale.Thislargersamplehadasimilaragerangeasthecurrentstudywithaslightlyolderaverageageandasignificantlylargermalepopulation.Similarly,GrahamandGosling(2013)reportedonapopulationof1,413comprisedof88%males,whohadanaverageageof26.04.Comparedtothesetwostudies,thepopulationinthecurrentstudyhadamoreequalsampleofmales(60%)andfemales(40%).ColeandHooley(2013)collecteddataon163participants(56%male,40%female)withanaverageageof27.3.Thissmallsampleiscomparabletothedemographicsofthepopulationcollectedinthecurrentstudyrelatedtogenderandage.Prevalenceratesintheliteraturevarysignificantlybasedonpopulationsam-pled,criteriaused,andassessmenttoolemployed.Thus,itismostusefultocompareprevalenceratesamongstudiesthatusethesameDSM-5criteria.ComparedtootherstudiesusingDSM-5criteriaforIGD,theprevalencerateinthisstudy(4.2%)appearsnormaltohigh.Rehbeinetal.(2015)foundthat1.16%oftheadolescents(N¼11,003)intheirstudyhadIGDaccordingtoDSM-5criteria.Maleparticipantsinthestudyhadahigherprevalencerate(2.02%)thanfemales(.26%).Mu¨lleretal.(2014)alsoassessedprevalenceinanadolescentsample(N¼12,938)acrosssevenEuropeancountriesandfoundthat1.6%metIGDcriteria.AstudyofDutchadolescentsandadults(N¼2,444)foundthat5.4%hadIGDaccordingtoDSM-5diagnosis(Lemmensetal.,2015).Theresearchersalsoreportedahigherprevalencerateamongmaleparticipants(6.8%)thanfemaleparticipants(4.0%),consistentwiththecurrentstudy.PrevalenceratesforIGDarebasedontheninecriteriainSectionIIIoftheDSM-5.Thecriteriaarecurrentlyunderresearchtodeterminetheirappropri-atenessfordiagnosingIGD.ThefrequencyorderofcriteriareportedamongthepopulationsampledinthisstudywithIGDwere:psychosocialconsequences,escape,preoccupation,tolerance,withdrawal,lossofinterestinotheractivities,jeopardizedjoborrelationship,deception,andunsuccessfulattemptstoreducetimeplaying.Rehbeinetal.(2015)alsoreportedonthefrequencyofcriteriareportedamongthepopulationmeetingIGDcriteriaintheDSM-5and,simi-larlytothecurrentstudy,foundescapeandpreoccupationtobethemosthighlyreportedcriteriaamongthepopulationtheysampledmeetingIGDcriteria.However,thoseresearchersreportedthatthelowestfrequencycriteriawerelossofinterestinotheractivitiesandjeopardizedrelationships,whichfellintoslotssixandsevenoutofnineinthecurrentstudy.Futureresearchisneededtodeterminetheleastfrequentlyreportedcriteriaamongthenine,aspartofdecid-ingthemostappropriatediagnosticcriteriaforIGD.12PsychologicalReports0(0)OfadditionalimportanceistheobservationthatIGDcriteriareportedbyparticipantswithadiagnosisofIGDcloselymatchestheorderoffrequencyofIGDcriteriareportedbythegeneralpopulationnotmeetingdiagnosticcriteria,withthemainexceptionsthatpsychosocialproblemsismoreprevalentthanescape,preoccupation,andtolerance;withdrawalismoreprevalentthanlossofinterestinotheractivities;andjeopardizingofjobandrelationshipsismoreprevalentthandeceptionintheIGDpopulation.However,eventhoughthepopulationmeetingIGDcriteriareportedIGDcriteriainalmostthesameorderoffrequencyasthegeneralpopulation,therewasahigherpercentageofeachcriterionreportedintheIGDpopulation.Forexample,usinggamesasameansofescapingfromnegativeemotionsisthenumberonecriteriareportedinthegeneralpopulationandthenumbertwocriteriaintheIGDpopulation.Inthegeneralpopulation26.8%ofparticipantsreportedusinggamingtoescape,butamuchlarger87.3%ofthepopulationwithIGDreportedthecriteria.Similarly,preoccupationwasreportedby26.9%ofthegeneralpopulation,butby87.3%ofpeoplewithIGD.Itislogicaltoreportthatmorecriteriaarereportedmorefrequentlyamongthepopulationmeetingdiagnosticcriteriaforthedisorder.However,thisfindingcallsintoquestionwhetherthecriteriaastheyarecurrentlypresentedintheDSM-5aremeaningfultodiscriminategamerswithaddictionfromgamerswithoutaddiction.Lemmensetal.(2015)explainedthatsomecriteriamaylackspecificitytoIGD.Theseresearchersfoundthatpreoccupation,tolerance,andwithdrawalwereparticularlyspecifictogamerswithIGD,butthatescapewasnotespeciallyusefulforthispurpose,despiteitshighfrequencyrate.Furtherresearch,beyondjustfrequencycount,isneededtoassessfortheusefulnessoftheninecriteriainSectionIIIoftheDSM-5fordetermininganactualaddictiontoInternetgames.InanefforttoaddculturalcontexttotheunderstandingoftheIGDcriteria,theresearcherexaminedgender,age,andethnicitydifferencesinfrequencyofcriteriareportedinthestudy.Onlydifferencesbyageproducedstatisticallysignificantresults,whichmaybeduetothesmallnumberofparticipantswhometcriteriaforIGD(n¼79).Still,itisnoteworthythat60%ofparticipantsinthestudyweremale,but80%ofparticipantsmeetingcriteriaforIGDweremale.Furthermore,thoughinaslightlydifferentorder,femaleparticipantsmeetingcriteriaforIGDhadthesametopfivecriteriaforfrequencyreported:psychosocialconsequences,preoccupation,escape,tolerance,andwithdrawal.Oneareaofinterest,however,isthatasignificantlylowpercentageoffemalegamerswithIGDreportjeopardizingjoborrelationship,deceptionaboutgamingbehavior,anddifficultyreducingtimespentgaming.ThenonsignificantdifferencebetweenmalesandfemalesmeetingIGDcriteriaandthesimilarityintopreportedIGDcriteriaindicatesthatscreeningusingcurrentDSM-5criteriaforIGDcanbeconductedsimilarlyformalesandfemales,butsomecriteriamaybelessrelevantforfemalesthanformales.Carlisle13 2626 Psychological Reports 124(6)Implicationsforageandethnicitygroupsfollowsuit.Forage,7outof10participantsinthestudywere30oryounger,yet85%ofparticipantsmeetingIGDcriteriawereinthisyoungeragebracket.However,while85%ofpartic-ipantswithIGDwere30oryounger,theirmeanIGDscore(5.91)waslowerthanthemeanIGDscore(6.67)forparticipants31andolder.Similarlytogender,olderparticipantswithIGDreportedthesametopfivecriteria,support-ingsimilarscreeningforpeopleofallages.Forethnicity,three-quartersofparticipantsidentifiedasWhite/Caucasianandtwo-thirdsofparticipantsmeet-ingIGDcriteriawereWhite/Caucasian.Again,thoughinaslightlydifferentorder,non-WhiteparticipantswithIGDhadsimilartopfivecriteriaforIGDasthedominantWhite/Caucasiangroup.However,non-WhiteparticipantswithIGDreportedlossofinterestinothernon-gamingactivitiesasthefifthmostfrequentcriteriamet,whileWhiteparticipantswithIGDmaintainedwithdrawalasthefifthmostfrequentcriteria.Thoughtheydidnotachievestatisticalsig-nificancefordifferencesbetweengroups,theseresultspointtothepossibilitythattheremaybesubtledifferencesbetweenWhiteandnon-WhitegroupswhenscreeningforIGDcriteria,butthatscreeningwithcurrentDSMcriteriacanbeconductedsimilarlyacrossethnicgroups.Moreresearchwithamorediversesample,specificallyrelatedtoageandethnicity,isneededtodrawdefinitiveconclusions.Frequencyofcriteriaisjustonewaytomeasurehowappropriatecriteriamaybeformakingaparticulardiagnosis.However,theliteraturesuggestspotentialproblemswithseveraloftheIGDcriterialistedinSectionIIIoftheDSM-5.Koetal.(2014)suggestthatlowfrequencyoftheescapeanddecisioncriteriamayindicatethattheyareinaccurateforIGD.However,thecurrentstudyshowedthatescapewasthesecondmostfrequentlyreportedcriterionamongpartici-pantswithIGD,with87.3%reportingthebehavior.Deception,ontheotherhand,wasreportedwithlowerfrequencybythepopulationinthecurrentstudy,withonly43%ofparticipantswithIGDidentifyingthebehavior.Itwasnottheleastfrequentcriterionreported,however,withunsuccessfulattemptstoreducetimegamingcominginlastslotat22.8%.BothdeceptionandunsuccessfulattemptstoreducetimegamingwerereportedwithparticularlylowfrequencyamongthefemaleparticipantswithIGD.FurtherresearchmayindicatethatdeceptionisnotanappropriatecriterionfordiagnosingIGD,buttheescapecriterionwasconsistentlyreportedacrossgender,ethnic,andgeneralpopulationgroups,andmayremainasavalidcriterionforassessingIGD.LimitationsandfutureresearchThedescriptivenatureofthecurrentstudydoesnotmeasurecausationandissubjecttoflawsininternalandexternalvalidity.Equivalencybetweengroups,includingageandethnicity,wasalsoalimitingfactor.However,sincethedemo-graphicstatisticsinthecurrentstudymatchedsamplesinotherstudies14PsychologicalReports0(0) Carlisle 2627Implicationsforageandethnicitygroupsfollowsuit.Forage,7outof10participantsinthestudywere30oryounger,yet85%ofparticipantsmeetingIGDcriteriawereinthisyoungeragebracket.However,while85%ofpartic-ipantswithIGDwere30oryounger,theirmeanIGDscore(5.91)waslowerthanthemeanIGDscore(6.67)forparticipants31andolder.Similarlytogender,olderparticipantswithIGDreportedthesametopfivecriteria,support-ingsimilarscreeningforpeopleofallages.Forethnicity,three-quartersofparticipantsidentifiedasWhite/Caucasianandtwo-thirdsofparticipantsmeet-ingIGDcriteriawereWhite/Caucasian.Again,thoughinaslightlydifferentorder,non-WhiteparticipantswithIGDhadsimilartopfivecriteriaforIGDasthedominantWhite/Caucasiangroup.However,non-WhiteparticipantswithIGDreportedlossofinterestinothernon-gamingactivitiesasthefifthmostfrequentcriteriamet,whileWhiteparticipantswithIGDmaintainedwithdrawalasthefifthmostfrequentcriteria.Thoughtheydidnotachievestatisticalsig-nificancefordifferencesbetweengroups,theseresultspointtothepossibilitythattheremaybesubtledifferencesbetweenWhiteandnon-WhitegroupswhenscreeningforIGDcriteria,butthatscreeningwithcurrentDSMcriteriacanbeconductedsimilarlyacrossethnicgroups.Moreresearchwithamorediversesample,specificallyrelatedtoageandethnicity,isneededtodrawdefinitiveconclusions.Frequencyofcriteriaisjustonewaytomeasurehowappropriatecriteriamaybeformakingaparticulardiagnosis.However,theliteraturesuggestspotentialproblemswithseveraloftheIGDcriterialistedinSectionIIIoftheDSM-5.Koetal.(2014)suggestthatlowfrequencyoftheescapeanddecisioncriteriamayindicatethattheyareinaccurateforIGD.However,thecurrentstudyshowedthatescapewasthesecondmostfrequentlyreportedcriterionamongpartici-pantswithIGD,with87.3%reportingthebehavior.Deception,ontheotherhand,wasreportedwithlowerfrequencybythepopulationinthecurrentstudy,withonly43%ofparticipantswithIGDidentifyingthebehavior.Itwasnottheleastfrequentcriterionreported,however,withunsuccessfulattemptstoreducetimegamingcominginlastslotat22.8%.BothdeceptionandunsuccessfulattemptstoreducetimegamingwerereportedwithparticularlylowfrequencyamongthefemaleparticipantswithIGD.FurtherresearchmayindicatethatdeceptionisnotanappropriatecriterionfordiagnosingIGD,buttheescapecriterionwasconsistentlyreportedacrossgender,ethnic,andgeneralpopulationgroups,andmayremainasavalidcriterionforassessingIGD.LimitationsandfutureresearchThedescriptivenatureofthecurrentstudydoesnotmeasurecausationandissubjecttoflawsininternalandexternalvalidity.Equivalencybetweengroups,includingageandethnicity,wasalsoalimitingfactor.However,sincethedemo-graphicstatisticsinthecurrentstudymatchedsamplesinotherstudies14PsychologicalReports0(0)examiningIGD,itmaybethatmembersoftheInternetgamingpopulationaremorelikelytobeWhiteandyounger.Next,theself-reportnatureofthedatainthisstudyisaltoathreattointernalvalidity.Selectionbiasisapotentialrisktogeneralizabilityinthisstudy;however,thesimilaritiesbetweenthissample’sdemographiccharacteristicsandotherstudiesexaminingthepopulationshowthistobeaminimalrisk.Aboveall,theuseofelectronicmethodsallowedforcollectionfromadiversesample,andgamersfromallsixcontinentswereabletocontributetothesamplepool.FutureresearchneedstodeterminetheappropriatenessofthenineproposeddiagnosticcriteriainSectionIIIoftheDSM-5.ResearchersneedtodetermineifIGDisaseparateconditionorconstructthanothertypesofproblematicInternetconditions.Itwouldseemthatthenextstepinthislineofresearchwouldbetodesignameasuretotestthediagnosticcriteriaforproblematicinternetconditions(perhapsfactoranalysis)toseeifthesymptomologyoftheseconditionsclusterononefactor(perhapssuggestingonediagnosis)orloadonmultiplefactors(disorders).Furthermore,qualitativeinquirycouldhelptodescribethecontextofInternetgamingandtheexperiencesgamershavewiththetechnology,simulation,andsocialinteractionsinthegames,espe-ciallywhentheymeetcriteriaforaddictionoridentifyashavinganaddiction.ConclusionAboveall,shouldresearchshowthatIGDisalegitimatediagnosismeritinginclusionintheDSM,thediagnosticcriteriashouldreflectthecontextofgaming,i.e.,thetechnology,simulation,andsocialnatureofthegames.Theremaybeoverlapwithsubstanceusedisordercriteriabecauseofcommonfeaturesinaddictionsandwithgamblingdisorderasanotherprocess/behavioraladdiction.However,criteriashouldalsobewordedtorecognizeboththesim-ilaritiesanddifferencesbetweenthedigitalandrealworld.Alsotoberecognizedshouldbethelegitimatesocialrelationshipsgamesmayhaveinthegames,aswellastheuseofgamingasawaytosocializewithrealworldfriends.Inadditiontoaddingcontexttoexistingcriteria,removingsomecriteriamayimprovethediagnosticprocessaswell.Deception,consistentlyquestionedintheliterature,isofparticularconcern.Itmaybedifficulttodeceiveothers,becausegamingisahardactivitytohide.Whenplaying,gamersarevisiblyengagedintheactivity,oftenwearingheadphones,lookingatascreen,andusingagamingconsole.Evenifnotphysicallyvisibletosignificantothers,gamers’usernamesareoftenvisibleonlineandtheiractivitymaybetrackable.Finally,unsuccessfulattemptstostop,alsoconsistentlyquestioned,maynotberelevantbecauseitisbasedonanabstinencemodel.Fullyabstainingfromprocess/behavioraladdic-tionsisalesscommonpracticethanitiswithsubstanceaddictions,anditmaynotbeadesirableorfeasibleapproachtotakewhenattemptingtotreatormanagetheaddiction.Carlisle15 2628 Psychological Reports 124(6)Escape,preoccupation,tolerance,andpsychosocialproblemsarethemostcommonlyreportedcriteria.DevelopingthesecriteriabyaddinggamingcontextandgamingreferencescouldimprovethediagnosticspecificityforthepotentialofanInternetGamingDisorderdiagnosis.Forexample,psychosocialproblemscoulddistinguishbetweensocialinteractionthegameandintherealworld.Escapefromnegativefeelingscouldpullfromemergingresearchontheeffectstechnologyhasondopaminereleaseinthebrain.Preoccupationcouldconsiderthelevelofsimulationpossibleinthegamingworldandspecifytherolegamingplaysinthegamer’slife(e.g.,competition,occupation).Whilethesearejustsuggestions,furtherresearchwillshowwhatcontextismostessentialtothesepotentialdiagnosticcriteria,inordertomoveawayfromthegenericterminol-ogyinthecriteriacurrentlyinSectionIII.DeclarationofConflictingInterestsTheauthor(s)declarednopotentialconflictsofinterestwithrespecttotheresearch,authorship,and/orpublicationofthisarticle.FundingTheauthor(s)receivednofinancialsupportfortheresearch,authorship,and/orpubli-cationofthisarticle.ORCIDiDKristyCarlislehttps://orcid.org/0000-0003-3871-4001ReferencesAllison,S.E.,vonWahlde,L.,Shockley,T.,&Gabbard,G.O.(2006).Thedevelopmentoftheselfintheeraoftheinternetandrole-playingfantasygames.TheAmericanJournalofPsychiatry,163(3),381–385.AmericanPsychiatricAssociation.(2013a).Diagnosticandstatisticalmanualofmentaldisorders(5thed.).AmericanPsychiatricAssociation.(2013b).SectionIII.file:///Users/Kristy/Downloads/APA_DSM-5-Section-III.pdfCarlisle,K.L.,Carlisle,R.M.,Polychronopoulos,G.,Goodman-Scott,E.,&Kirk-Jenkins,A.(2016).ExploringInternetaddictionasaprocessaddiction.JournalofMentalHealthCounseling,38(2),170–182.Carlisle,K.L.,Neukrug,E.,Pribesh,S.,&Krahwinkel,J.(2019).Personality,motiva-tion,andInternetgamingdisorder:Conceptualizingthegamer.JournalofAddictionsandOffenderCounseling,40(2),107–122.https://doi.org/10.0000/j.0000-0000.2013.00000.xBatthya´ny,D.,Mu¨ller,K.W.,Benker,F.,&W€olfling,K.(2009).Computergameplay-ing:Clinicalcharacteristicsofdependenceandabuseamongadolescents.TheCentralEuropeanJournalofMedicine,121,502–509.16PsychologicalReports0(0) Carlisle 2629Escape,preoccupation,tolerance,andpsychosocialproblemsarethemostcommonlyreportedcriteria.DevelopingthesecriteriabyaddinggamingcontextandgamingreferencescouldimprovethediagnosticspecificityforthepotentialofanInternetGamingDisorderdiagnosis.Forexample,psychosocialproblemscoulddistinguishbetweensocialinteractionthegameandintherealworld.Escapefromnegativefeelingscouldpullfromemergingresearchontheeffectstechnologyhasondopaminereleaseinthebrain.Preoccupationcouldconsiderthelevelofsimulationpossibleinthegamingworldandspecifytherolegamingplaysinthegamer’slife(e.g.,competition,occupation).Whilethesearejustsuggestions,furtherresearchwillshowwhatcontextismostessentialtothesepotentialdiagnosticcriteria,inordertomoveawayfromthegenericterminol-ogyinthecriteriacurrentlyinSectionIII.DeclarationofConflictingInterestsTheauthor(s)declarednopotentialconflictsofinterestwithrespecttotheresearch,authorship,and/orpublicationofthisarticle.FundingTheauthor(s)receivednofinancialsupportfortheresearch,authorship,and/orpubli-cationofthisarticle.ORCIDiDKristyCarlislehttps://orcid.org/0000-0003-3871-4001ReferencesAllison,S.E.,vonWahlde,L.,Shockley,T.,&Gabbard,G.O.(2006).Thedevelopmentoftheselfintheeraoftheinternetandrole-playingfantasygames.TheAmericanJournalofPsychiatry,163(3),381–385.AmericanPsychiatricAssociation.(2013a).Diagnosticandstatisticalmanualofmentaldisorders(5thed.).AmericanPsychiatricAssociation.(2013b).SectionIII.file:///Users/Kristy/Downloads/APA_DSM-5-Section-III.pdfCarlisle,K.L.,Carlisle,R.M.,Polychronopoulos,G.,Goodman-Scott,E.,&Kirk-Jenkins,A.(2016).ExploringInternetaddictionasaprocessaddiction.JournalofMentalHealthCounseling,38(2),170–182.Carlisle,K.L.,Neukrug,E.,Pribesh,S.,&Krahwinkel,J.(2019).Personality,motiva-tion,andInternetgamingdisorder:Conceptualizingthegamer.JournalofAddictionsandOffenderCounseling,40(2),107–122.https://doi.org/10.0000/j.0000-0000.2013.00000.xBatthya´ny,D.,Mu¨ller,K.W.,Benker,F.,&W€olfling,K.(2009).Computergameplay-ing:Clinicalcharacteristicsofdependenceandabuseamongadolescents.TheCentralEuropeanJournalofMedicine,121,502–509.16PsychologicalReports0(0)Billieux,J.,Flayelle,M.,Rumpf,H.J.,&Stein,D.J.(2019).Highinvolvementversuspathologicalinvolvementinvideogames:Acrucialdistinctionforensuringthevalid-ityandutilityofgamingdisorder.CurrentAddictionReports,6(3),323–330.https://doi.org/10.1007/s40429-019-00259-xBillieux,J.,Thorens,G.,Khazaal,Y.,Zullino,D.,Achab,S.,&VanderLinden,M.(2015).Problematicinvolvementinonlinegames:Aclusteranalyticapproach.ComputersinHumanBehavior,43,242–250.https://doi.org/10.1016/j.chb.2014.10.005Caplan,S.E.,Williams,D.,&Yee,N.(2009).Problematicinternetuseandpsychosocialwell-beingamongMMOplayers.ComputersinHumanBehavior,25(6),1312–1319.Cole,S.S.,&Hooley,J.M.(2013).ClinicalandpersonalitycorrelatesofMMOgaming:Anxietyandabsorptioninproblematicinternetuse.SocialScienceComputerReview,31(4),424–436.https://doi.org/10.1177/0894439312475280Demetrovics,Z.,&Griffiths,M.D.(2012).Behavioraladdictions:Past,presentandfuture.JournalofBehavioralAddictions,1(1),1–2.Dowling,N.A.(2014).IssuesraisedbytheDSM-5internetgamingdisorderclassificationandproposeddiagnosticcriteria.Addiction,109,1407–1413.Dowling,N.A.,&Brown,M.(2010).Commonalitiesinthepsychologicalfactorsasso-ciatedwithproblemgamblingandinternetdependence.CyberPsychology,Behavior&SocialNetworking,13,437–441.EntertainmentSoftwareAssociation.(2014).Essentialfactsaboutthecomputerandvideogameindustry.http://www.theesa.com/facts/pdfs/esa_ef_2014.pdfFaust,K.,Meyer,J.,&Griffiths,M.D.(2013).Competitiveandprofessionalgaming:Discussionpotentialbenefitsofscientificstudy.InternationalJournalofCyberBehavior,PsychologyandLearning,3(1),67–76.https://doi.org/10.4018/ijcbpl.2013010106Flisher,C.(2010).Gettingpluggedin:Anoverviewofinternetaddiction.JournalofPediatrics&ChildHealth,46(10),557–559.https://doi.org/10.1111/j.1440-1754.2010.01879.xFrangos,C.C.,Frangos,C.C.,&Kiohos,A.P.(2010).InternetaddictionamongGreekuniversitystudents:Demographicassociationswiththephenomenon,usingtheGreekversionofYoung’sinternetaddictiontest.InternationalJournalofEconomicSciencesandAppliedResearch,3(1),49–74.Fuster,H.,Oberst,U.,Griffiths,M.,Carbonell,X.,Chamarro,A.,&Talarn,A.(2012).Psychologicalmotivationinonlinerole-playinggames:AstudyofSpanishWorldofWarcraftplayers.AnalesdePsicologia,28(1),274–280.Graham,L.T.,&Gosling,S.D.(2013).PersonalityprofilesassociatedwithdifferentmotivationsforplayingWorldofWarcraft.Cyberpsychology,BehaviorandSocialNetworking,16(3),189–193.https://doi.org/10.1089/cyber.2012.0090Griffiths,M.D.(2016).Playingthefield:Anotherlookatinternetgamingdisorder.http://www.gamasutra.com/blogs/MarkGriffiths/20160211/265709/Playing_the_field_Another_look_at_Internet_Gaming_Disorder.phpGru¨sser,S.M.,Thalemann,R.,&Griffiths,M.D.(2007).Excessivecomputergameplaying:Evidenceforaddictionandaggression?Cyberpsychology&Behavior,10(2),290–292.Jeng,S.P.,&Teng,C.I.(2008).Personalityandmotivationsforplayingonlinegames.SocialBehaviorandPersonality,36(8),1053–1060.Carlisle17 2630 Psychological Reports 124(6)Jeong,E.J.,&Kim,D.W.(2010).Socialactivities,self-efficacy,gameattitudes,andgameaddiction.Cyberpsychology,Behavior&SocialNetworking,14(4),213–221.Jones,K.,&Hertlein,K.(2012).Fourkeydimensionsfordistinguishinginternetinfi-delityfrominternetandsexaddiction:Conceptsandclinicalapplication.AmericanJournalofFamilyTherapy,40,115–125.https://doi.org/10.1080/01926187.2011.600677Kardefelt-Winther,D.(2014).Problematizingexcessiveonlinegaminganditspsycholog-icalpredictors.ComputersinHumanBehavior,31,118–122.https://doi.org/10.1016/j.chb.2013.10.017Kardefelt-Winther,D.(2015).AcriticalaccountofDSM-5criteriaforinternetgamingdisorder.AddictionResearch&Theory,23(2),93–98.https://doi.org/10.3109/16066359.2014.935350King,D.L.,&Delfabbro,P.H.(2015).OnfindingtheCinCBT:Thechallengesofapplyinggambling-relatedcognitiveapproachestovideo-gaming.JournalofGamblingStudies,31,315–329.https://doi.org/10.1007/s10899-013-9416-3King,D.L.,Haagsma,M.C.,Delfabbro,P.H.,Gradisar,M.,&Griffiths,M.D.(2013).Towardaconsensusdefinitionofpathologicalvideo-gaming:Asystematicreviewofpsychometricassessmenttools.ClinicalPsychologyReview,33,331–342.Kiraly,O.,Griffiths,M.D.,&Demetrovics,Z.(2015).InternetgamingdisorderandtheDSM-5:Conceptualization,debates,andcontroversies.CurrentAddictionsReport,2(3),254–262.Ko,C.H.(2014).Internetgamingdisorder.CurrentAddictionReports,1,177–185.Ko,C.H.,Yen,J.Y.,Chen,S.H.,Wang,P.W.,Chen,C.C.,&Yen,C.F.(2014).EvaluationofthediagnosticcriteriaofinternetgamingdisorderintheDSM-5amongyoungadultsinTaiwan.JournalofPsychiatricResearch,53,103–110.Ko,C.H.,Yen,J.Y.,Yen,C.F.,Chen,C.S.,&Chen,C.C.(2012).Theassociationbetweeninternetaddictionandpsychiatricdisorder:Areviewoftheliterature.EuropeanPsychiatry,27,1–8.Kuss,D.,&Griffiths,M.D.(2012a).Internetgamingaddiction:Asystematicreviewofempiricalresearch.InternationalJournalofMentalHealth&Addiction,10(2),278–296.https://doi.org/10.1007/s11469-011-9318-5Kuss,D.,&Griffiths,M.D.(2012b).Onlinegamingaddictioninchildrenandadoles-cents:Areviewofempiricalresearch.JournalofBehavior&Addiction,1,3–22.Kuss,D.J.,Griffiths,M.D.,Karila,L.,&Billieux,J.(2014).Internetaddiction:Asystematicreviewofepidemiologicalresearchforthelastdecade.CurrentPharmaceuticalDesign,20,4026–4052.https://doi.org/10.2174/13816128113199990617Kuss,D.,Griffiths,M.D.,&Pontes,H.M.(2017).ChaosandconfusioninDSM-5diagnosisofinternetgamingdisorder:Issues,concerns,andrecommendationsforclarityinthefield.JournalofBehavioralAddictions,6(2),103–109.https://doi.org/10.1556/2006.5.2016.062Lee,H.W.,Choi,J.S.,Shin,Y.C.,Lee,J.Y.,Jung,H.Y,&Kwon,J.S.(2012).Impulsivityininternetaddiction:Acomparisonwithpathologicalgambling.Cyberpsychology,Behavior,andSocialNetworking,15(7),373–377.https://doi.org/10.1089/cyber.2012.0063Lemmens,J.,Valkenburg,P.,Gentile,D.,&Reynolds,CecilR.(2015).Theinternetgamingdisorderscale.PsychologicalAssessment,27(2),567–582.18PsychologicalReports0(0) Carlisle 2631Jeong,E.J.,&Kim,D.W.(2010).Socialactivities,self-efficacy,gameattitudes,andgameaddiction.Cyberpsychology,Behavior&SocialNetworking,14(4),213–221.Jones,K.,&Hertlein,K.(2012).Fourkeydimensionsfordistinguishinginternetinfi-delityfrominternetandsexaddiction:Conceptsandclinicalapplication.AmericanJournalofFamilyTherapy,40,115–125.https://doi.org/10.1080/01926187.2011.600677Kardefelt-Winther,D.(2014).Problematizingexcessiveonlinegaminganditspsycholog-icalpredictors.ComputersinHumanBehavior,31,118–122.https://doi.org/10.1016/j.chb.2013.10.017Kardefelt-Winther,D.(2015).AcriticalaccountofDSM-5criteriaforinternetgamingdisorder.AddictionResearch&Theory,23(2),93–98.https://doi.org/10.3109/16066359.2014.935350King,D.L.,&Delfabbro,P.H.(2015).OnfindingtheCinCBT:Thechallengesofapplyinggambling-relatedcognitiveapproachestovideo-gaming.JournalofGamblingStudies,31,315–329.https://doi.org/10.1007/s10899-013-9416-3King,D.L.,Haagsma,M.C.,Delfabbro,P.H.,Gradisar,M.,&Griffiths,M.D.(2013).Towardaconsensusdefinitionofpathologicalvideo-gaming:Asystematicreviewofpsychometricassessmenttools.ClinicalPsychologyReview,33,331–342.Kiraly,O.,Griffiths,M.D.,&Demetrovics,Z.(2015).InternetgamingdisorderandtheDSM-5:Conceptualization,debates,andcontroversies.CurrentAddictionsReport,2(3),254–262.Ko,C.H.(2014).Internetgamingdisorder.CurrentAddictionReports,1,177–185.Ko,C.H.,Yen,J.Y.,Chen,S.H.,Wang,P.W.,Chen,C.C.,&Yen,C.F.(2014).EvaluationofthediagnosticcriteriaofinternetgamingdisorderintheDSM-5amongyoungadultsinTaiwan.JournalofPsychiatricResearch,53,103–110.Ko,C.H.,Yen,J.Y.,Yen,C.F.,Chen,C.S.,&Chen,C.C.(2012).Theassociationbetweeninternetaddictionandpsychiatricdisorder:Areviewoftheliterature.EuropeanPsychiatry,27,1–8.Kuss,D.,&Griffiths,M.D.(2012a).Internetgamingaddiction:Asystematicreviewofempiricalresearch.InternationalJournalofMentalHealth&Addiction,10(2),278–296.https://doi.org/10.1007/s11469-011-9318-5Kuss,D.,&Griffiths,M.D.(2012b).Onlinegamingaddictioninchildrenandadoles-cents:Areviewofempiricalresearch.JournalofBehavior&Addiction,1,3–22.Kuss,D.J.,Griffiths,M.D.,Karila,L.,&Billieux,J.(2014).Internetaddiction:Asystematicreviewofepidemiologicalresearchforthelastdecade.CurrentPharmaceuticalDesign,20,4026–4052.https://doi.org/10.2174/13816128113199990617Kuss,D.,Griffiths,M.D.,&Pontes,H.M.(2017).ChaosandconfusioninDSM-5diagnosisofinternetgamingdisorder:Issues,concerns,andrecommendationsforclarityinthefield.JournalofBehavioralAddictions,6(2),103–109.https://doi.org/10.1556/2006.5.2016.062Lee,H.W.,Choi,J.S.,Shin,Y.C.,Lee,J.Y.,Jung,H.Y,&Kwon,J.S.(2012).Impulsivityininternetaddiction:Acomparisonwithpathologicalgambling.Cyberpsychology,Behavior,andSocialNetworking,15(7),373–377.https://doi.org/10.1089/cyber.2012.0063Lemmens,J.,Valkenburg,P.,Gentile,D.,&Reynolds,CecilR.(2015).Theinternetgamingdisorderscale.PsychologicalAssessment,27(2),567–582.18PsychologicalReports0(0)Lin,M.,Ko,H.,&Wu,J.(2011).PrevalenceandpsychosocialriskfactorsassociatedwithinternetaddictioninanationallyrepresentativesampleofcollegestudentsinTaiwan.Cyberpsychology,Behavior&SocialNetworking,14(12),741–746.https://doi.org/10.1089/cyber.2010.0574Luo,S.X.,Brennan,T.K.,&Wittenauer,J.(2015).Internetaddiction:ThecaseofHenry,the“reluctanthermit”.InM.S.Ascher&P.Levounis(Eds.),Thebehavioraladdictions(pp.81–99).AmericanPsychiatricPublishing.Mu¨ller,K.W.,Beutel,M.E.,Egloff,B.,&W€olfling,K.(2014).Investigatingriskfactorsforinternetgamingdisorder:Acomparisonofpatientswithaddictivegaming,path-ologicalgamblersandhealthycontrolsregardingtheBigFivePersonalityTraits.EuropeanAddictionResearch,20(3),129–136.https://doi.org/10.1159/000355832Murali,V.,&Onuba,I.(2009).Managementofinternetaddiction.GeneralPracticeUpdate,2,32–35.Musetti,A.,Mancini,T.,Corsana,P.,Santoro,G.,Cavallini,M.C.,&Schimmenti,A.(2019).Maladapticpersonalityfunctioningandpsychopathologicalsymptomsinproblematicvideogameplayers:Aperson-centeredapproach.FrontiersinPsychology,10,1–14.https://doi.org/10.3389/fpsyg.2019.02559Park,J.,Song,Y.,&Teng,C.(2011).Exploringthelinksbetweenpersonalitytraitsandmotivationstoplayonlinegames.Cyberpsychology,Behavior&SocialNetworking,14(12),747–751.Petry,N.M.,Rehbein,F.,Gentile,D.A.,Lemmens,J.S.,Rumpf,H.,M€oßle,T.,...O’Brien,C.P.(2014).Aninternationalconsensusforassessinginternetgamingdis-orderusingthenewDSM-5approach.Addiction,109(9),1399–1406.https://doi.org10.1111/add.12457Porter,G.,Starcevic,V.,Berle,D.,&Fenech,P.(2010).Recognizingproblemvideogameuse.Australian&NewZealandJournalofPsychiatry,44(2),120–128.Rehbein,F.,Psych,G.,Kleimann,M.,Mediasci,G.,&Mossle,T.(2010).Prevalenceandriskfactorsofvideogamedependencyinadolescence:ResultsofaGermannation-widesurvey.CyberPsychology,Behavior&SocialNetworking,13(3),269–277.Rehbein,F.,Kliem,S.,Baier,D.,M€oßle,T.,&Petry,N.(2015).PrevalenceofinternetgamingdisorderinGermanadolescents:DiagnosticcontributionofthenineDSM-5criteriainastate-widerepresentativesample.Addiction,110(5),842–851.Shapira,N.A.,Goldsmith,T.D.,Keck,P.E.,Jr.,Khosla,U.M.,&McElroy,S.L.(2000).Psychiatricfeaturesofindividualswithproblematicinternetuse.JournalofAffectiveDisorders,57(1–3),267–272.https://doi.org/10.1016/S0165-0327(99)00107-XSussman,S.,Lisha,N.,&Griffiths,M.(2011).Prevalenceoftheaddictions:Aproblemofthemajorityortheminority.EvaluationsandtheHealthProfessions,34(1),3–56.https://doi.org/10.1177/0163278710380124Tao,R.,Huang,X.,Wang,J.,Zhang,H.,Zhang,Y.,&Li,M.(2012).Proposeddiag-nosticcriteriaforinternetaddiction.Addiction,105,556–564.Thomas,N.J.,&Martin,F.H.(2010).Video-arcadegame,computergameandinternetactivitiesofAustralianstudents:Participationhabitsandprevalenceofaddiction.AustralianJournalofPsychology,62(2),59–66.Tonioni,F.,D’Alessandris,L.,Lai,C.,Martinelli,D.,Corvino,S.,Vasale,M.,...Bria,P.(2012).Internetaddiction:Hoursspentonline,behaviorsandpsychologicalCarlisle19 2632 Psychological Reports 124(6)symptoms.GeneralHospitalPsychiatry,34,80–87.https://doi.org/10.1016/j.genhosppsych.2011.09.013vanRooij,A.J.,Ferguson,C.J.,Carras,M.C.,Kardefelt-Winther,D.,Shi,J.,Aarseth,E.,Bean,A.,Bergmark,K.H.,Brus,A.,Coulson,M.,Deleuze,J.,Dullur,P.,Dunkels,E.,Etchells,P.,Fiskaali,A.,Granic,I.,Jansz,J.,Karlsen,F.,Kaye,L.,...&Przbylski,A.K.(2018).Aweakscientificbasisforgamingdisorder:Letuserronthesideofcaution.JournalofBehavioralAddictions,7(1),1–9.https://doi.org/10.1556/2006.7.2018.19vanRooij,A.J.,&Prause,N.(2014).Acriticalreviewofinternetaddictioncriteriawithsuggestionsforthefuture.JournalofBehavior&Addiction,3,203–213.vanRooij,A.J.,Schoenmakers,T.M.,Vermulst,A.A.,vandenEijnden,R.M.,&VanDeMheen,D.(2011).Onlinevideogameaddiction:identificationofaddictedadoles-centgamers.Addiction,106(1),205–212.https://doi.org/10.1111/j.1360-0443.2010.03104.xYee,N.(2006a).Motivationsforplayinonlinegames.JournalofCyberPsychologyandBehavior,9,772–775.Yee,N.(2006b).Thedemographics,motivationsandderivedexperiencesofusersofmassively-multiuseronlinegraphicalenvironments.TeleoperatorsandVirtualEnvironments,15,309–329.Yee,N.,Ducheneaut,N.,&Nelson,L.(2012).Onlinegamingmotivationsscale:devel-opmentandvalidation.InProceedingsoftheSIGCHIConferenceonHumanFactorsinComputingSystems(CHI’12).AssociationforComputingMachinery,NewYork,NY,USA,2803–2806.DOI:https://doi.org/10.1145/2207676.2208681AuthorBiographyKristyCarlisleisanAssistantProfessorinOldDominionUniversity’sCounselingandHumanServicesDepartment.ShehasworkexperienceasaPK-12teacher,schoolcounselor,therapist,andcasemanager/supervisor.Shehasservedchild,adolescent,andadultpopulationsinschool,inpatientresiden-tial,andcommunitymentalhealthsettings.Herresearchinterestsincludepro-cessaddictions,namelyInternetgamingdisorder,onlineeducation,andethicalhelpingbehavior,particularlywithmarginalizedpopulations.20PsychologicalReports0(0) CopyrightofPsychologicalReportsisthepropertyofSagePublicationsInc.anditscontentmaynotbecopiedoremailedtomultiplesitesorpostedtoalistservwithoutthecopyrightholder'sexpresswrittenpermission.However,usersmayprint,download,oremailarticlesforindividualuse.