The Treatment of Internet Gaming Disorder: a Brief Overview of the PIPATIC Program

Over the last decade, there has been an increase in children and adolescents accessing psychology services regarding problematic use of online videogames. Consequently, providing effective treatment is essential. The present paper describes the design process of a manualized PIPATIC (Programa Individualizado Psicoterapéutico para la Adicción a las Tecnologías de la información y la comunicación) intervention program for 12- to 18-year-old adolescents with Internet Gaming Disorder. The design and application of the PIPATIC program integrates several areas of intervention structured into six modules: psychoeducational, treatment as usual, intrapersonal, interpersonal, family intervention, and development of a new lifestyle. The program’s goals are to reduce the addiction symptoms related to online videogames and to improve the well-being of adolescents. Preliminary findings suggest positive and encouraging effects.

researchers advocate a biopsychosocial model in explaining the interaction between different risk factors (e.g., Kelly 2004;Kuss and Griffiths 2012;Mazurek and Engelhardt 2013;Rehbein et al. 2010;Wittek et al. 2015;Yee 2006). Table 1 lists many of the main risk factors in the development of problematic online gaming.
Online gaming addiction has been associated with (and may initiate) other comorbid mood disorders such as depression, stress, and anxiety disorders (Ferguson et al. 2011;King and Delfabbro 2014;Pontes et al. 2014). Consequently, videogame addiction in the form of Internet Gaming Disorder (IGD) was included in Section 3 of the latest (fifth) revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013). The clinical diagnosis of IGD comprises persistent and recurrent use of the Internet to engage in games, leading to clinically significant impairment or distress over a period of 12 months as indicated by five (or more) of the following criteria: (i) pre-occupation with Internet games; (ii) withdrawal symptoms when Internet gaming is taken away; (iii) tolerance or, in other words, the need to increase the time devoted to videogames; (iv) unsuccessful attempts to control participation in Internet games; (v) loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games; (vi) continued excessive use of Internet games despite knowledge of psychosocial problems; (vii) deceiving family members, therapists, or others regarding the amount of Internet gaming; (viii) use of Internet games to escape or relieve negative moods; and (ix) jeopardizing or losing a significant relationship, job, or education or career opportunity because of participation in Internet games. The criteria proposed by the APA ( 2013) appear to have adequate validity and diagnostic precision (Ko et al. 2014). Its prevalence, according to the American Psychiatric Association (2013), is between 1 and 7%. Part of this variation is due to the fact that different instruments are used in different cultural contexts and for different ages (Feng et al. 2017;Ferguson et al. 2011;Müller et al. 2015; . According to Griffiths, King, and Demetrovics (Griffiths et al. 2014), the inclusion of IGD in the DSM-5 provided the opportunity for consensus and unification in the field. However, there is still no consensus on many issues related to the DSM-5 diagnostic criteria for IGD, and its psychological, social, and health consequences still require further study (Griffiths et al. 2016b;Király et al. 2015;Kuss et al. 2016). The lack of consensus concerning diagnostic criteria makes the work of clinical psychologists and other therapists difficult. Consequently, there is a need to clearly define IGD, clarify its most controversial aspects, and expand the study of specialized IGD treatments.

Psychological Treatment for Internet Gaming Disorder
Although the study of IGD has grown markedly in recent years (Griffiths et al. 2016a;Kuss and Griffiths 2012), evaluations of psychological treatments are still scarce. The most used treatment for online addictions appears to be cognitive behavioral therapy (CBT) based on the peer-reviewed literature (Greenfield 1999a(Greenfield , 1999bGriffiths and Meredith 2009;Kaptsis et al. 2016;King et al. 2010bKing et al. , 2011Young 2007Young , 2013. Other treatments used include pharmacotherapy (methylphenidate and bupropion) and counseling (King et al. 2011). Most of the therapeutic recommendations are based on substance abuse treatment (Huang et al. 2010;King et al. 2011) including motivational interviewing techniques, stimulus control, learning appropriate coping responses, self-monitoring strategies, cognitive restructuring, problem-solving related to addiction, and withdrawal regulation techniques with exposure (Griffiths and Meredith 2009;King et al. 2010a;Young 2007). Furthermore, there has been little evaluation concerning the efficacy of different psychological interventions with children and adolescents (King et al. 2013;King and Delfabbro 2016).
With regard to clinical practice, therapies for IGD based on substance abuse treatment have a number of limitations. One of the most important is the high rate of comorbid disorders with IGD that could influence the effect of the treatment. Some of the most common disorders associated with IGD include anxiety disorders, mood disorders, behavioral disorders, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and personality disorders (Ferguson et al. 2011;Gentile et al. 2011;Han et al. 2014;Kelleci and Inal 2010;Ko et al. 2006;Shapira et al. 2000). Most published IGD treatment studies have not taken into account these comorbidities; therefore, more integrated and comprehensive treatments taking these comorbid disorders into account would improve treatment outcomes for such individuals (Therien et al. 2014).
Consequently, there is both an empirical and clinical need to generate specialized, integrated, and comprehensive treatment protocols taking into account the specific characteristics of IGD along with its associated comorbid disorders. Furthermore, it is clinically important to develop treatments for adolescents. In recent years, psychiatric wards have reported an increase of consultations regarding adolescents with problematic use of cyber-technologies (Beranuy et al. 2012). On the other hand, the adolescent population regularly uses online video games and they also present with multiple psychological vulnerabilities that are intrinsic to this life stage.
As a result, the aim of the present paper describes a specialized and integrative treatment program based on the scientific and clinical need to design treatments specifically for the adolescent population with IGD. The treatment program provides essential and common factors concerning IGD and was developed for health professionals to utilize in the treatment of IGD in adolescence.

Stage I: Designing and Developing the Treatment Program
To develop bespoke psychotherapy (in this case, for IGD), manuals in clinical practice must be followed to define guidelines and strategies from basic outlines in order to promote empirically supported treatments (Carroll and Nuro 2002). In the development and design of the PIPATIC program, there are common and essential aspects that should be included in any program evaluation report (Moscosoa et al. 2013;Schulz et al. 2010). The word BPIPATIC^is an acronym for BPrograma Individualizado Psicoterapéutico para la Adicción a las Tecnologías de la información y la comunicación^. The English translation for this Spanish program is BIndividualized psychotherapy program for addiction to information and communication technologies.Î The guidelines proposed by Carroll and Nuro (2002) were used for the IGD treatment presented in the present paper due to their rigor and scientific underpinnings. Carroll and Nuro divide the development of treatment manuals into three stages: (i) the development of the treatment and a pilot application, (ii) the design of the methodology with a controlled clinical trial to evaluate the efficacy of the treatment, and (iii) the evaluation of the application of treatment in different contexts and the relationship between their effectiveness and costs.
The goal of the newly developed PIPATIC program (Torres-Rodriguez and Carbonell 2017) is to offer specialized psychotherapy for adolescents with symptoms of IGD and comorbid disorders. This program comprises six therapeutic work modules, in turn comprising further specific sub-objectives. Following previous studies in order to ensure therapeutic change in patients, the duration of the program is six-months (22 weekly sessions each lasting 45 min) (Hansen and Lambert 2003;Kadera et al. 1996;Lambert et al. 1994;Seligman 1995). The composition of the modules and sessions is briefly outlined in Tables 2, 3, 4, 5, 6, 7, and 8. Additionally, the PIPATIC program includes two floating sessions that can be incorporated into the module of the therapist's choosing, according to the needs of the patient. In this way, the set program offers some flexibility (Carroll and Nuro 2002;Therien et al. 2014). One of the main psychological treatments used in the PIPATIC program is CBT given its empirically supported efficacy (Hofmann et al. 2012;Nathan 2015). CBT therapies are commonly used and are effective in the treatment of addictive disorders (Du et al. 2010;King et al. 2012;Li and Wang 2013;Wölfling et al. 2014;Young 2007Young , 2013. However, the use of multiple psychotherapeutic strategies is considered more effective than one unique perspective (Dong and Potenza 2014;Orzack et al. 2006;Shek et al. 2009;Therien et al. 2014). Consequently, other eclectic and integrative treatment perspectives additional to CBT were included within the PIPATIC program such as motivational interviewing and psychoeducation techniques (see Table 2), strategies derived from person-centered therapy, self-regulation and maturation strategies for adolescents (see Table 4), family therapy (see Table 6), and solution-focused therapy (see Tables 4 and 7). The intervention, based on a cognitive behavioral approach, employs cross-cutting techniques and resources common in psychotherapy (Hofmann and Barlow 2014;Kleinke 1994;Laska et al. 2014) including empathy, active and reflexive listening, acceptance, trust, intermediate degree of directivity, paraphrasing, clarification, synthesis, confrontation, interpretation, feedback, promoting abilities, promoting responsibility, encouraging a feeling of self-efficacy, raising insight, and promoting a therapeutic alliance.
At the same time, adolescence is considered to be a vulnerable stage of life, defined by characteristics that generate a high risk of addictive behavior and/or other psychological disorders (Masten and Garmezy 1985;Steinhausen and Metzke 2001). For that reason, the strategies and techniques incorporated into the PIPATIC program have been adapted for adolescents. Consequently, the PIPATIC program is an integrative psychotherapy treatment intervention that focuses on multiple critical areas of the individual.

Stage II: Designing Application Methodologies
The second phase of program development focuses on the delimitation of methodologies for the application and effectiveness of the PIPATIC program. The CONSORT (Consolidated Standards of Reporting Trials) international guide (Schulz et al. 2010) was used to design the program. The CONSORT methodologies guarantee quality experimental or quasi-experimental studies: (i) design (clinical trial with randomization to avoid bias), (ii) dependent and independent variables and assessment instruments, (iii) inclusion and exclusion criteria, (iv) aims and hypothesis, (v) method, and (vi) ethics.

PIPATIC Program Target Population
The target population of the PIPATIC program is the adolescents aged 12 to 18 years old.

Clinical Objectives
The main aim of the program is to provide specialized psychological assistance for adolescents with IGD. The clinical objectives are as follows: (i) to gain adaptive (rather than maladaptive) use of videogames and ICTs; (ii) to enable therapeutic change to different patient profiles; and (iii) to treat adolescents multidimensionally, attending to intrapersonal needs (including the comorbid disorders), interpersonal needs, family needs, and educational/occupational needs.  Relapse prevention To explore current emotions To point out risk situations To provide specific ideas and resources to avoid the relapses Anticipation strategies to prevent risk situations and relapses Activities and relapse prevention material

Summary of the PIPATIC Manual
The PIPATIC program was designed as a clinical manual comprising six modules with specific sub-modules. Each module includes several psychological techniques in addition to cross-psychotherapeutic strategies. The program is six month duration comprising twenty-two 45-minute weekly sessions each for both individuals and families. The PIPATIC intervention is an individual [person-to-person] therapy carried out by a qualified clinical psychologist. Before the commencement of treatment, several sessions are carried out with the following objectives: (i) to assess the inclusion and exclusion criteria, (ii) to talk to the patient and family and address any concerns they may have about the program, and (iii) to complete the first pre-treatment evaluation. Tables 2, 3, 4, 5, 6, 7, and 8 summarize all the modules belonging to the PIPATIC program. The tables outline the main content, the psychological strategies used within the module, and the intervention techniques and strategies of every module. In addition, all the modules include therapeutic homework to strengthen the establishment related to the therapeutic changes required to help change everyday behavior. In the PIPATIC program, the direct collaboration of family in the treatment program is essential to make progress. It is uncommon for adolescents to ask for therapeutic help on their own (Griffiths 2015), and it is usually the adolescent's family who ask for therapeutic care or psychological treatment (King et al. 2010b).
The efficacy of the treatment program shows excellent promise based on data collected on the 17 individuals that have undergone the program to date Carbonell, 2015, 2017;Torres-Rodríguez, Griffiths and Carbonell, 2017). These preliminary results of the PIPATIC program pilot application demonstrate a reduction of time spent playing videogames, a reduction in IGD-related symptoms and comorbid symptoms, and improvement in multiple important areas in day-to-day functioning (e.g., interpersonal and intrapersonal functioning, family functioning, and educational/occupational functioning). Furthermore, compared to other treatments for IGD and Internet addiction published in the peer-reviewed literature, the PIPATIC program is arguably one of the most comprehensive treatment intervention for Internet and online videogame addiction (see Table 9 for an in-depth comparison between studies published in the empirical clinical literature).

Conclusions
The present paper described the development of the PIPATIC program, a contemporary and integrative treatment based on CBT for the specialized treatment of adolescents with IDG. Its design is based on a theoretical robust empirical base, on previous treatment studies, and on a combination of perspectives and psychotherapeutic strategies that have proven to be effective on adolescents across different disorders (Du et al. 2010;Fang-ru and Wei 2005;Han et al. 2015;King et al. 2012;Nathan 2015;Winkler et al. 2013;Young 2009Young , 2013. At present, the efficacy of the program appears very promising but due to the time-intensive nature of the intervention, only 17 clients have completed treatment to date. As with any other treatment or manualized program, there are a number of limitations. The program was designed focusing on a very specific population (i.e., adolescents with IGD). The intervention has a specific rigidity because it must follow or adhere to specific methodological standards for its application and evaluation. Occasionally, such rigidity is difficult to adapt to the client's particular needs. Due to this, and to solve the Bstiffness^of the treatment, the modules could be applied independently and in different order to adapt to the most urgent need that the client has. Despite these limitations, the preliminary results suggest the program is efficacious.
Future plans include (i) studying the effectiveness of PIPATIC treatment comparing the participants of this treatment with other participants receiving treatment as usual for addictions; (ii) comparing the data already collected in relation to pre-treatment, middletreatment, post-treatment, and three-months follow-up; and (iii) analyzing various cases of different ages, clinical profiles, game genre, and context to confirm the efficacy of findings in other populations and environments. It is expected that the PIPATIC program will continue to be an effective and pioneering integrative treatment for problematic use and addictive behaviors related to online videogames as well as concomitant pathologies. The present paper attempts to provide an orientation and update for health professionals in this field who want to treat adolescents for IGD.
Funding Information This study was supported by personal Blanquerna Research Grant (BRB) awarded to Alexandra Torres-Rodríguez (Universitat Ramon Llull, Barcelona).

Compliance with Ethical Standards
Informed Consent The study was approved by the ethics committee of Universitat Ramon Llull. Consent is not applicable because no data were collected for the present paper.

Conflict of Interest
The authors' report no financial or any other conflicting relationship relevant to the topic of this paper. All authors' take responsibility for the integrity of the paper'scontent.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.