Emotional bias modification weakens game-related compulsivity and reshapes fronto-striatal pathways.

Addiction is characterized by compulsive engagement despite adverse consequences. Psychobehavioral interventions targeting compulsivity in addictions are relatively rare, particularly for behavioral addictions like internet gaming disorder (IGD). Free from confounding drug-on-brain effects, IGD provides a promising model for understanding neuropsychological processes of addictions. IGD is a global concern in the setting of increasing internet use worldwide. Thus, developing interventions and understanding their mechanisms of action are important. Positive emotional association biases (EABs) towards addiction cues based on reward conditioning may underlie addiction-associated compulsivity. Here, we developed an EAB modification (EABM) protocol and examined whether modifying EABs via cognitive training would alter neurocognitive aspects of addiction-associated compulsivity in IGD. We recruited 90 IGD participants who were randomly assigned to receive EABM or sham training in a 1:1 ratio. The EABM intervention involved six consecutive days of exposure to negative emotional terms linked to gaming stimuli and positive terms linked to non-gaming healthy-alternative stimuli. The sham training involved similar stimuli linked to neutral words. Participants underwent event-related fMRI while performing a regulation-of-craving task and received several behavioral assessments pre-training and post-training. Primary efficacy measures were changes in gaming-related positive EABs, and compulsive gaming thoughts and behaviors. Behaviorally, EABM (vs. sham) training decreased gaming-related positive EABs and compulsive gaming thoughts and behaviors. Neurally, EABM training involved decreased activation in the bilateral dorsal striatum (DS) in the regulation-of-craving task, and altered left DS-centric functional connectivity with ventral prefrontal cortical regions, which correlated with decreases in gaming-related EABs or compulsive gaming thoughts and behaviors. EABM training also implicated activation changes in the right medial frontal gyrus and posterior insula. EABM may reduce compulsive gaming thoughts and behaviors via reshaping functional organization of fronto-striatal pathways and insular activity in IGD. The therapeutic potential of EABM should be examined in larger, longer-term studies, as should its application to other addictive disorders.