While research on gaming disorder and other internet use disorders has been proceeding, less is known about factors influencing treatment outcomes in patients. Life satisfaction is a construct of positive psychology that has been demonstrated to be predictive of mental health and also acting as a resilience factor against relapse in addictive disorders (McGaffin et al., 2015; Müller, Dreier, et al., 2017; Müller, Naab, et al., 2017). So far, cross-sectional studies have shown that life satisfaction is decreased among individuals meeting criteria for IUD (Cheng & Li, 2014). Yet, the nature of these relationships is unclear. In this study we took a closer look at different dimensions of life satisfaction and their effects in patients receiving a disorder-specific treatment program for IUD. Firstly, we were interested in assessing, if life satisfaction is increasing during treatment. Secondly, we investigated, if life satisfaction is predictive of remission of IUD symptoms at follow-up and again might be influenced by personality traits.
First of all, we found that among the intervention group dimensions of life satisfaction were increasing through the course of treatment. This was particularly the case for health satisfaction and life satisfaction that yielded large effect sizes. Interestingly, increases were only found immediately after terminating treatment; they afterwards remained stable over the next six months. There was also an increase in health satisfaction among patients of the wait list yet the effect size was negligible. Consequently, increases in life satisfaction and health satisfaction were stronger among patients of the intervention condition.
Not surprisingly, moderate negative effects were found for depressive symptoms on life and health satisfaction at post-treatment. This finding stresses the need for taking comorbid disorders in IUD into consideration and to separately address depression-specific symptoms in IUD treatment in general. This is especially relevant, since depressive disorders are one of the most frequently associated mental disorders in IUD (Carli et al., 2013).
The increase of life satisfaction over treatment is of particular importance since we also found a negative relationship to IUD symptoms at follow-up. Higher life satisfaction immediately after treatment was predictive for decreased IUD symptom severity six months later. One can conclude that successfully addressing life satisfaction as a part of treatment corresponds to benefits in the longer run. Thus, higher life satisfaction can be perceived as a protective factor against recurrence of IUD symptoms with a total of 36% of explained variance. This is consistent with findings on alcohol dependence and gambling disorder (McGaffin et al., 2015; Müller, Dreier, et al., 2017; Müller, Naab, et al., 2017). A potential explanation for this might be seen in the stress-buffering effects of wellbeing and life satisfaction. Generally, it has been argued that high life satisfaction is associated with an optimized biopsychological functioning with wellbeing modulating psychoneuroimmunological responsiveness towards stressful events (Ryff, Singer, & Dienberg Love, 2004).
Vulnerability to stress is one key risk factor for relapse in addictive disorders (Lin, Fried, & Eaton, 2020) and perceived stress has been reported to be increased in IUD (Dreier et al., 2017; Ko et al., 2012). More specifically, high life satisfaction is related to social functioning (e.g. regarding the quality and perceived meaningfulness of social relationships). In many IUD patients, the lack of meaningful (real life) social relationships represents an important theme and social isolation as well as deficits in social skills have repeatedly been documented as correlates of IUD (Festl, Scharkow, & Quandt, 2013; Müller, Dreier, et al., 2017; Müller, Naab, et al., 2017). In some etiological models for IUD, like the Integrative Process Model of Internet Addiction (InPrIA; Wölfling et al., 2019) or the Interaction of Person-Affect-Cognition-Execution model (I-PACE; Brand et al., 2019), difficulties in social contexts are perceived as a maintaining factor for the disorder. Addressing these deficits by established psychotherapeutic methods (e.g. social skills trainings; identification and modification of dysfunctional attachment styles) can be one promising way. Another approach could be applying strategies of enhancing life satisfaction, e.g. by cognitive restructuring or instructed re-evaluation of social relationships.
A second interesting finding regarded the role of health satisfaction. Patients with greater health satisfaction before entering the treatment program showed an improved treatment outcome. This might mean that these patients displayed more favorable resources at the beginning. These resources could serve as positive prognostic factors in profiting from intervention steps. One could also argue that health satisfaction could be a useful variable for treatment indication. Patients with a poorer (subjective and objective) health status might be more in need of a higher treatment intensity. Either in terms of receiving a higher frequency of inpatient contacts or by receiving inpatient treatment.
Finally, we found a moderating effect of extraversion and openness in the relationship between life satisfaction and IUD symptoms at follow-up. For both traits analyses confirmed that negative scores were significantly influencing this association in terms of e.g. low extraversion lowering the buffering effect of life satisfaction on IUD symptoms. Associations between extraversion and life satisfaction have been documented before (Bucher et al., 2019; DeNeve & Cooper, 1998; Ruini et al., 2003). However, empirical insights explaining the more complex interplay as found here are missing. Generally, low extraversion has been discussed as a risk factor for IUD (Kayis¸ et al., 2016). Extraversion represents a somewhat heterogeneous factor covering facets like assertiveness, optimism but also gregariousness and social dominance. In terms of the social aspects of life satisfaction one could argue that low extraversion might complicate social interactions because individuals are lacking social confidence and trust (Costa & McCrae, 1992). In those IUD patients, the subjective conviction might prevail that - in contrast to virtual social contacts – offline relationships are less appealing or unreliable. This in turn might negatively influence the connection between life satisfaction and treatment outcome. The finding that higher life satisfaction at post-treatment was predicted by high extraversion is supporting that idea. Similarly low openness is related to rather avoid than actively seek for new experiences. Such experiences can also include establishing new social contacts or novel (social) activities. In that respect, low openness might also impair the beneficial effects of life satisfaction on IUD symptoms.
Our study has some limitations that should be noted. The sample size is small and there was an additional number of patients dropping out from treatment or getting lost to follow up. Thus, the follow-up analyses were based on a reduced sample size of n 5 36 which is limiting the interpretation and generalization of the findings. However, we tried to reduce the confounding effect of this circumstance. We analyzed systematic differences in crucial study variables between patients completing treatment and follow-up versus and dropping out or getting lost to follow-up and found no significant differences. Secondly, life satisfaction was assessed by self-reports; an additional external rating of this construct possibly would have yielded additional validity. Lastly, our analyses were restricted to males, which is a general issue in investigations on IUD. There is growing evidence that IUD are related to gender-specific mechanisms in phenomenology and underlying clinical and sub-clinical correlates, i.e. psychopathological symptoms, comorbid disorders, and personality traits (Scherer et al., 2022; Shen et al., 2021; Su, Han, Yu, Wu, & Potenza, 2020). Thus, gender-specific clinical research is needed.
We recommend evaluating our findings in terms of gender-sensitive analyses. Further, a significant difference in health satisfaction was reported regarding the STICA and WLC group at t0. Nonetheless, this can be neglected since the development over the course of the treatment process and beyond was focus of this study. Finally, GAF was included as the single indicator of psychosocial functioning. In the DSM-5, GAF has been eliminated and future studies should rather refer to more recently developed indices. Yet, it should be noted that GAF still represents a widely used instrument for the assessment of psychosocial functioning.
As a future research direction, we recommend also investigating the influence of neuroticism and agreeableness on treatment outcomes. We did not include these two traits because we decided in mainly focusing on primary treatment variables. Since we were concerned that having to many questionnaires included in our trial might impair patients in entering the treatment.
Yet, our study has methodological strengths (e.g. randomized controlled design, external data monitoring, clinical diagnostics etc.) and provided novel and relevant insights into causal relationships between predisposing factors and changes in IUD symptoms. Most importantly, we found that life satisfaction is a needful concept to be addressed in psychotherapeutic treatment of IUD. It can serve as an independent treatment goal and is also predictive of the later IUD status. In life satisfaction we can assume a potential resilience factor against relapse in IUD. For future treatment concepts it might be useful to adapt elements of third wave CBT strategies related to wellbeing and life satisfaction. One example for this is the so-called Wellbeing Therapy (Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998) that is centered on the patient’s awareness of positive life changes and that has proven first promising effects in the treatment of mental disorders (Moeenizadeh & Salagame, 2010). Another example of the benefits of improving life satisfaction was shown in adolescents treated for depression. Raj et al. (2019) applied a mindfulness-based CBT that effectively enhanced psychological functioning and reduced depressive symptoms. Thus, mindfulness-based approaches might also be valuable amendments to existing treatment strategies for IUD.
As a future research direction we recommend investigating the effects of such intervention strategies. In the past years, clinical research on IUD has improved a lot and a growing number of intervention concepts, for instance covering adolescence-specific CBT-programs (Szász-Janocha, Vonderlin, & Lindenberg, 2021) or family-based interventions (Nielsen et al., 2021) have been developed and even been evaluated in pilot trials (Goslar, Leibetseder, Muench, Hofmann, & Laireiter, 2020). This is a positive development and should be extended to further optimize help services for patients suffering from IUD.
