The self-medication hypothesis refers to the tendency of individuals to autonomously select substances or specific behaviors to alleviate psychological or emotional distress [11]. According to the self-medication hypothesis, patients experience temporary relief from psychological pain through substances like cocaine or opioids. The rewarding effect of such substances weakens patients’ self-control and increases their dependency on the selected substance. Patients who lose their self-control fail to consider the consequences of addiction, thereby heightening the likelihood of substance use and dependency [12].

In various studies on the causes and motivations behind IGD, the self-medication hypothesis has been discussed [13-17]. During pandemic situations like COVID-19, the prevalence of IGD increased [18,19], alongside a decline in self-control and a rise in depression and anxiety [20-22]. Resilience, defined as the ability to overcome stress, adversity, and psychological distress to return to a stable psychological state, tends to be lower in individuals with IGD, who also exhibit higher levels of depression [23,24]. Patients with posttraumatic stress disorder (PTSD), a representative anxiety disorder, are more likely to experience IGD, providing empirical support for the co-occurrence of these conditions [25,26]. While it remains unclear whether problematic gaming behavior is a cause or a consequence of weakened self-control, depression, and anxiety associated with COVID-19 and PTSD, the self-medication hypothesis is likely applicable to IGD, akin to its role in SUDs.

Research indicates that antidepressants like escitalopram and bupropion improve both IGD symptoms and depressive symptoms [27,28]. Such findings suggest that underlying causes may precede problematic gaming behavior. Previous studies have shown that bupropion is effective in managing attention and impulsivity, while escitalopram is effective in alleviating depressive symptoms. In particular, the findings from most studies suggesting that bupropion is more effective than escitalopram in improving symptoms of IGD [29,30] imply the necessity of managing the adverse effects of self-medication, such as reward effects of maladaptive behaviors and reduced self-control, regardless of the underlying causes driving problematic gaming behavior.

The similarities between IGD and SUD have been explored in various studies. Both conditions exhibit similar impulsivity traits [31], and neurological tests using functional magnetic resonance imaging have identified overlapping features [32]. However, individuals with SUD tend to have experienced more severe past adversities and exhibit more extreme problematic behaviors than those with IGD [33]. This distinction suggests that the two conditions may represent a continuum of self-medication choices, influenced by the severity of underlying causes. The high accessibility and immediate rewards of internet gaming may serve as a gateway, enabling individuals with relatively mild psychological distress, such as depression and anxiety, to easily experience reward effects and opt for gaming as a form of self-medication.

Patients with IGD often hold game-related misconceptions, such as “Only in internet games do people recognize me.” These distorted cognitions about gaming contribute to maladaptive behavioral patterns and cravings related to gaming [34]. CBT plays a role in correcting these erroneous beliefs that drive excessive gaming and managing the negative emotions triggered by game withdrawal [35]. Modifying cognitive distortions about gaming can regulate the severity of IGD symptoms and reduce cravings [36]. The application of CBT, originally developed for depression treatment, to various mental health disorders such as PTSD, anxiety disorders, and IGD highlights the shared and distinct features among these conditions and their connection to CBT elements. Therefore, analyzing IGD through the lens of CBT research [37] may provide new perspectives on traditional therapeutic approaches.

The theoretical background for the interaction between emotions and cognition in CBT is explained through the associative network theory [38]. CBT involves analyzing and treating the process through which individuals interpret current events based on “automatic thoughts” derived from past experiences. As illustrated in Figure 1, emotions and interpretations interact dynamically, with their sequential relationship reinforcing each other and leading to uncontrollable outcomes [39]. CBT addresses the vicious cycle of psychological distress by introducing alternative thoughts. These newly provided pieces of information compete with negative cognitions during the cognitive processing bottleneck, delaying the processing of negative thoughts and replacing them with alternative perspectives [40].

While associative network theory explains the theoretical basis for the activation of “automatic thoughts,” it has limitations in capturing the complexity of human emotions. For instance, discrepancies may arise between rational beliefs and sensory perceptions. Furthermore, according to associative network theory, the emergence of depressive symptoms requires a triggering event that evokes past experiences and emotions. However, patients with depression often exhibit depressive symptoms not only as a result of current mood and stimuli but also due to an inherent cognitive vulnerability [41,42].

To explain complex emotions and cognitive vulnerability, the ICS theory has been proposed [43,44]. The model comprises nine subsystems—acoustic, visual, body-state, articulatory, limb, morphonolexical, object, propositional, and implicational—each responsible for processing specific types of information. Through their interactions, cognition and emotion emerge. Visual and auditory information are first interpreted semantically in isolation and then integrated into a specific meaning within the propositional subsystem. This general meaning is further integrated with body-state, visual, and auditory information, evolving into implicational meaning [40]. As illustrated in Figure 2, the interaction between cognition and emotion demonstrates that external stimuli and emotions are indirectly connected. Emotions are portrayed not as mere reactions to external stimuli but as outcomes reflecting cognitive characteristics, thereby explaining why individuals exhibit different responses to stressful situations. Figure 3 illustrates the process where specific meaning and general meaning influence and reinforce each other [43].

MBCT, based on the principles of the ICS, integrates the core mechanisms of CBT with stress-reduction techniques derived from mindfulness meditation. Originally developed for the treatment of recurrent depression, MBCT has demonstrated its efficacy over the past several decades [45-48]. Beyond depression, its effectiveness has been reported for other mental health conditions, including anxiety disorders [49-51], insomnia [52,53], bipolar disorder [54], panic disorder [55], chronic pain [56], cancer-related pain [57], and stress [58].

Key components such as mindfulness skills, depressogenic cognition, self-compassion and cognitive reactivity, and meta-awareness and decentering have been identified as factors associated with or mediating symptom reduction following MBCT [59]. In addition, MBCT has received significantly high ratings in patient self-assessments and has been shown to improve subscales such as “concerning danger” and “controllability of thoughts” [60].

The mindfulness meditation component of MBCT aims to stabilize thoughts by fostering a cognitive process of accepting present thoughts as internal experiences while shifting attention to external experiences by recognizing body-state cues rather than reacting to automatic thoughts. This dual focus promotes emotional regulation and cognitive stability [61].

Nevertheless, several studies have reported no statistically significant differences between MBCT and CBT [60,62,63]. MBCT appears to demonstrate distinct therapeutic effects compared with CBT in patients who have experienced three or more episodes of depression recurrence [64]. However, these effects also seem to be short-term [60]. Despite previous research, the theoretical mechanisms underlying MBCT remain unclear [59].

The limitations of CBT and MBCT are particularly evident in newly defined mental health conditions such as IGD. The authors posit that, unlike the passive mental models described in CBT and MBCT, individuals actively adopt strategies like self-medication to alleviate psychological distress. Therefore, this paper introduces a modified ICS that integrates the self-medication hypothesis into existing cognitive models. This framework aims to develop a more realistic cognitive model, and the application of this model, referred to as MBCT-G, is explained in the following sections.

The modified ICS focuses on patients’ coping strategies, which were not emphasized in the original theoretical mechanisms. For example, a student with public speaking anxiety may experience situations where they “go blank,” “cannot think of anything,” or “feel mentally frozen” when required to speak in front of a large audience. While these responses may not be ideal, they can be understood as a form of self-medication strategy to cope with the stress of public speaking. By adopting such a strategy, the student may avert their gaze from the audience, quickly read from their script, or even leave the podium without remembering how they spoke, thereby managing the stress in the short term. However, in the long term, this strategy may reinforce their fear of public speaking, lower their self-esteem, and be perceived as an inadequate coping mechanism.

When discussing the mechanisms of cognition and emotion, it is essential to address not only the generation of emotions triggered by external and internal stimuli but also the resulting “reaction” that follows. In the previous example, the experience of giving a presentation is not limited to the emotions felt during the presentation itself but is significantly influenced by the memories and emotions generated during reflection after the situation has ended. Specifically, if an individual evaluates their coping strategy as sufficient and positive after the event, the previously generated emotions can be influenced and transformed into more positive ones. Therefore, the interpretation of emotions should not be confined to a single moment in time; instead, it must account for the distorted recollections formed through self-evaluation of the appropriateness of coping strategies, influenced by past experiences and emotions, as well as the emotions experienced in the present.

For instance, recalling negative experiences such as “feeling darkness before one’s eyes,” “not being able to think of anything,” or “having a blank mind” during public speaking not only reinforces thoughts of psychological distress but also shapes negative self-assessments of the coping strategies used. These negative evaluations, in turn, intensify the negative emotions associated with the experience.

Figure 4 expands the ICS by incorporating the principles discussed earlier. The additional structure on the right in the modified ICS represents coping strategies and recollections related to emotions.

“Hope” refers to the desired strategy for coping with emotions generated in response to a stimulus. For instance, a student fearful of public speaking might think, “I want to finish my presentation quickly and leave,” “I hope my turn gets skipped,” or “I wish no one pays attention to my presentation.”

“Reaction” represents the active coping mechanism employed in response to “Hope.” In the given situation, since the external change (eg, skipping the student’s turn) is beyond the student’s control, they may choose an active strategy like “Let’s finish the presentation quickly and step down.”

“Reaction meaning” reflects the individual’s self-evaluation of their chosen coping strategy. After adopting the strategy of finishing the presentation quickly, the student might evaluate themselves either positively or negatively. The outcome of this self-assessment is interpreted in the context of their fundamental “Hope” (eg, “I want to finish quickly”), which, in turn, influences the preceding emotions.

In simpler terms, if the strategy of speaking quickly satisfies the initial “Hope,” the preceding “Emotion” will also be alleviated. As a result, the student may continue to rely on the “quick speech strategy” in future similar situations. On the other hand, if the strategy fails, the student might explore alternative strategies. For example, they may choose an active coping mechanism like “I want to relieve stress by playing a game.” If the student successfully alleviates stress through gaming, the previously experienced “Emotion” is resolved, making gaming a preferred coping strategy in similar future scenarios.

In summary, these differences arise because the subjective interpretation of the emotional coping strategy referred to as “reaction meaning,” creates a vicious cycle that influences the emotions resulting from preceding situations. In addition, past experiences, coping strategies, and emotions, such as “I can relieve stress through gaming,” serve as materials for interpreting current emotions, as in “If I play games, my current psychological distress will be alleviated.” To reiterate, experiences, emotions, and coping strategies must be understood as part of a unified principle that unfolds across the flow of psychological time. This interpretation is particularly valuable in disorders where symptoms manifest in behavioral forms, such as IGD, gambling disorder, obsessive-compulsive disorder, and SUD. It offers a foundation for developing new therapeutic approaches.

As previously mentioned, the gaming behavior of individuals with IGD can be interpreted as a coping strategy for managing stress resulting from external stimuli. Incorporating the self-medication hypothesis, which is often cited as a cause of SUD, the authors propose the self-prescription hypothesis as a potential explanation for the origins of behavioral addictions like IGD.

In the modified ICS, such coping strategies are effective, at least in the short term, in alleviating psychological distress (commonly referred to as a “reward”), serving as a driving force for the repetition of behavioral addictions. From this perspective, traditional treatments that focus solely on correcting maladaptive thoughts about gaming and reducing gaming time are often ineffective because they fail to provide alternative strategies for managing stress [65].

Treatments that do not offer alternative strategies may lead to symptom relapse or the development of other problematic behaviors, as the underlying cause—stress—remains unresolved. On the other hand, mindfulness meditation can serve as an effective alternative strategy. Activities like meditation and walking can help alleviate stress, reducing the perceived need for internet gaming. However, while these strategies are effective, they may not be sufficient for everyone. Some individuals may lack interest in mindfulness meditation, find it unhelpful in directly addressing their stress, or even perceive it as boring.

To address these limitations, three principles for effective psychological counseling are introduced:

By adhering to these principles, counseling can better address the complexity of individual needs and provide meaningful, sustainable solutions for stress management and mental health improvement.

MBCT-G is a therapeutic approach that incorporates the three principles outlined above. Games serve as a novel medium for experiencing virtual environments that are otherwise unattainable, making them one of the most accessible coping strategies for adolescents and young adults. While the accessibility of games can make even those with mild psychological distress susceptible to addiction, it paradoxically offers an ideal environment for learning healthy coping strategies.

The gaming environment allows individuals to repeatedly practice alternative strategies to address the sources of stress. Because this practice occurs in a virtual setting, it imposes lower cognitive demands. In addition, games can provide diverse scenarios tailored to symptoms and individual needs, while maintaining a consistent therapeutic framework. Furthermore, the gaming environment enables the collection of real-world data during the treatment process and sustains motivation for continued participation in therapy. This combination of features makes MBCT-G a compelling and effective approach to integrating mindfulness and cognitive therapy principles into an engaging and accessible medium.

Several studies have explored the use of games to address conditions such as IGD [66,67], depression [68], anxiety disorders [69], stress [70], attention-deficit/hyperactivity disorder [71], and executive function [72]. However, despite increasing interest in digital therapeutics and game-based treatment methods, few have been recognized by regulatory agencies for their therapeutic efficacy.

In the case of previous research on IGD, most studies have been limited to usability research without control groups [73]. The limitations of previous game-based studies include (1) a lack of understanding of cognition, emotion, and coping strategies, (2) an absence of defined reward mechanisms in games and corresponding alternative strategies, and (3) a poor understanding of game design quality.

A notable previous study using games to treat IGD is Room2Respawn, developed based on mindfulness-oriented recovery enhancement (MORE) [66]. MORE is a therapeutic approach that integrates three psychological counseling techniques: mindfulness, CBT, and positive psychology. It was originally designed for patients with chronic pain who are prescribed opioid analgesics [74]. The same research team investigated the efficacy of MORE in individuals with IGD. In a randomized controlled trial targeting patients with IGD, MORE was found to reduce the severity of the disorder indirectly by correcting maladaptive gaming-related cognitions [36]. However, while Room2Respawn, developed using MORE, assessed the subjective usability of the intervention, it did not demonstrate the efficacy of implementing MORE techniques through gamified software.

In this paper, MBCT-G does not focus on a single game scenario or production method but addresses the overall factors to consider when using games for the treatment of mental health disorders. Therefore, the components of MBCT-G may differ from those of traditional MBCT.

For instance, MBCT for Life, an adaptation of MBCT designed for practical use in everyday life over an 8-week program, comprises the following sessions: (1) waking up from autopilot, (2) another way of being, (3) gathering the scattered mind, (4) recognizing reactivity, (5) allowing and letting be, (6) responding skillfully, (7) how can I best take care of myself? and (8) mindfulness for life [75]. While MBCT is a highly effective tool for alleviating stress, it requires the patient’s active commitment to treatment. As a result, adherence may decrease in patients with cognitive impairments or low motivation for therapy.

The primary focus when designing game-based therapeutic interventions is to improve treatment adherence and provide opportunities for practicing alternative strategies. The key principles to consider when developing specific MBCT-G programs are outlined below.

Internet games, in themselves, cannot be universally labeled as harmful, and merely reducing the time spent playing games may not correlate strongly with the disease’s pathology [89]. Therefore, the primary goal of MBCT-G is to restore significant impairments in daily life, as subjectively perceived by patients and their surrounding individuals.

This goal can be assessed using various methods, including the widely adopted “IGD-20 Test” and other established research tools [90]. In addition, comorbid conditions frequently associated with IGD, such as depression [91], anxiety disorders [92], and attention-deficit/hyperactivity disorder [93], should also be evaluated. Since MBCT-G focuses on the alleviation of subjective symptoms, assessments based on the patient’s counseling history are particularly important.

Advances in AI offer the potential to evaluate disorders using both verbal and nonverbal information [94-96]. AI-based analytic insights should be provided to psychological counselors to facilitate a complementary relationship between technology and human expertise. Furthermore, measuring the frequency and duration of MBCT-G usage is essential for assessing treatment adherence.

Finally, evaluations should include attempts and applications of alternative strategies. These evaluations should be approached from two perspectives:

Critically, assessing whether patients are adopting healthy coping strategies outside the game environment is the most important therapeutic goal of MBCT-G.

Finally, the 5 stages of MBCT-G are explained. With technological advancements, new technologies such as autonomous driving, AI, and virtual reality are emerging. MBCT-G aims to create scenarios where patients can practice alternative strategies in a virtual environment, tailored to their treatment motivation and the causes of their condition. However, technological complexity and legal regulations pose obstacles to realizing these strategies. Nonetheless, to advance MBCT-G, it is important to start small and progressively implement these strategies according to the current level of technology (see Figure 6).

In the first stage of MBCT-G, the patient visits a hospital, receives a prescription from a psychiatrist, and begins treatment. While clinical data are collected through the MBCT-G program, the program’s difficulty level and scenarios are adjusted by the specialist during the hospital visit.

In the second stage, the MBCT-G program generates personalized questions based on the clinical data collected in stage 1 and asks the patient these questions. Although all patients collect the same clinical data in stage 1, from stage 2 onward, the program gathers tailored clinical data specific to each patient.

In the third stage, the MBCT-G program diagnoses the severity of the condition in a limited capacity and modifies the game scenarios based on the patient's choices to a restricted extent.

In the fourth stage, the MBCT-G program independently diagnoses the severity of the condition and adjusts the intensity of the program and the frequency of sessions. Patients can observe significant changes in the game scenarios based on their choices, allowing them to immerse themselves more realistically and practice alternative strategies.

In the final stage, the MBCT-G program autonomously creates or reconstructs scenarios based on the clinical data collected from the patient. The patient repeatedly trains in virtual reality to address the situations that cause gaming disorder. In stage 5, both diagnosis and treatment are autonomously conducted by the program, with the psychiatrist intervening only in exceptional situations.