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Replay: The Dangers of Excess Screen Time with Dr. Adrian Lopresti and Dr. Nicholas Kardaras

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Replay: The Dangers of Excess Screen Time with Dr. Adrian Lopresti and Dr. Nicholas Kardaras

Dr. Nicholas Kardaras, psychologist, international speaker and author describes the physical and psychological impact excessive screen time has on both adults and children. Together with our ambassador, Dr. Adrian Lopresti, Nicholas describes the addictive nature of excessive screen and the impact this has on dopaminergic function, likening it to substance abuse. 

As a psychologist, Nicholas looks to the behavioural implications of screen use in children, describing the connection between screen time and impulsivity and the longer term consequences. 

While often associated with children, adults are not immune to screen time addiction, with research demonstrating many adults using screens as an escape from reality. Nicholas describes the implications of screen time addiction on the individual’s ability to connect with others and the correlation this has with increased numbers of depression.  

Covered in this episode 

[00:58] Welcoming Dr. Nicholas Kardaras
[01:25] Video game induced psychosis
[05:17] The link between screen time and mental health
[10:21] How COVID has affected screen time
[12:38] How escapism is a major driver of addiction
[16:49] Push-button instant gratification leads to impulsivity in children
[19:30] How video games are designed for addiction
[22:43] Extended gaming and its effects on the HPA axis
[28:09] Technology and its effects on the brain
[33:22] Assessing screen time - what’s your client’s digital diet?
[36:18] Video games and aggression
[41:18] Impacts of gaming on health
[43:30] Nicholas's tips for practitioners treating clients with gaming addictions
[46:48] Additional resources for practitioners
[50:45] Thanking Nicholas and closing remarks

Key takeaways 

  • Screen time or digital technology addiction is ubiquitous with the ICD-11 defining the diagnostic criteria for gaming disorder.  
  • There are similarities between the clinical presentation of substance abuse and digital technology addiction with repercussions of both impacting the physical health of the individual, including their nutritional status.  
  • Game Transfer Phenomenon refers to the transferral of visual or auditory aspects of a game into waking awareness presenting as a transitory-gaming-induced psychosis. 
  • Screen time may reduce positive face to face interaction and engagement, social connection, physical movement and increases the risk of depression. 
  • Gaming isn’t a problem isolated to children and teens. Adults engage in gaming as a form of escapism from challenges in the real world. The Rat Park experiment used to identify the role of social isolation in addiction supports the hypothesis that current unhealthy lifestyles focussing on work, screen use and toxic culture can promote technology addiction. 
  • The instant gratification nature of screen use promotes impulsivity in children and has the capacity to change the structure and function of the brain. Impulsivity has been shown to be a predictor of addiction. 
  • Gaming companies develop their games to maximise the dopaminergic response that promotes an addictive response. Social media companies have been called out for developing algorithms that encourage engagement while increasing the risk of psychological harm and suicide in teenagers. 
  • The raised dopamine production associated with extended game play consequently raises adrenaline, unbalancing the HPA axis and stimulating the fight or flight response for extended periods of time, leading to adrenal fatigue. The hyper-arousal state induced by game play makes all other real-world activities appear mundane. 
  • Excessive screen time use may impact the health of the myelin sheath, in a similar manner to substance abuse. 

Resources discussed in this episode

Dr Nicholas Kardaras
Book: Glow Kids by Dr Nicholas Kardaras
The ICD-10 Classification of Mental and Behavioural
Disorders: Clinical descriptions and diagnostic guidelines
ICD-11 diagnostic criteria for gaming disorders
NY Post Article: It’s ‘digital heroin’: How screens turn kids into psychotic junkies by Dr Nicholas Kardaras
Research: The consequences of compulsion: A 4-year longitudinal study of compulsive internet use and emotion regulation difficulties (Douglas, Ciarrochi & Sahdra, 2020)
Video: Nicholas Kardaras on ABC 20/20
Video: Facebook Whistleblower Frances Haugen: The 60 Minutes Interview
Research: Evidence for striatal dopamine release during a video game (Koepp, et al, 1998)
Research: Short Term Exposure to a Violent Video Game Induces Changes in Frontolimbic Circuitry in Adolescents (Wang, et al., 2009)
Book: How to Reset Your Child's Brain by Dr Victoria Dunkley
Research: Screen Time Activities and Aggressive Behaviors Among Children and Adolescents: A Systematic Review (Keikha, et al., 2020)
Research: The Effect of Online Violent Video Games on Levels of Aggression (Hollingdale & Greitemeyer, 2014)
National Institute of Digital Health and Wellness Training

Additional resources and further readings

Screen time and psychological health 

Research: ‘Adverse physiological and psychological effects of screen time on children and adolescents: Literature review and case study’, Environmental Research, 2018
Research: ‘The relationship between screen time and mental health in young people: A systematic review of longitudinal studies‘, Clinical Psychology Review, 2021
Research: ‘Associations between screen time and lower psychological well-being among children and adolescents: Evidence from a population-based study’, Preventive Medicine Reports, 2018

Screen time and social media 

Research: ‘Not all screen time is created equal: associations with mental health vary by activity and gender’, Social psychiatry and psychiatric epidemiology, 2021

Screen time and children 

Research: ‘Screen time in under-five children’, Indian Paediatrics, 2019
Research: ‘Screen time in children and adolescents: is there evidence to guide parents and policy?’, The Lancet, 2019
Article: ‘Is it time to screen kids for screen time?’, RACGP, 2022
Article: ‘‘Screen time’ for kids is an outdated concept, so let’s ditch it and focus on quality instead’ The Conversation, 2022

Screen time and health behaviours 

Research: ‘Screen Time Associated with Health Behaviors and Outcomes in Adolescents’, American Journal of Health Behaviour, 2013

Screen time and sleep 

Research: ‘Screen time and sleep among school-aged children and adolescents: A systematic literature review’. Sleep Medicine Reviews, 2015

Policies relating to screen time 

Article: ‘Too much time on screens? Screen time effects and guidelines for children and young people’ Australian Government, 2021
‘Screen time: Help your child achieve a healthy balance in their online and offline activities’, eSafetyCommissioner
‘Balancing your time online’, eSafetyCommissioner
‘Counselling and support services’, eSafetyCommissioner
Article: ‘Why parents need to stop worrying about screen ‘time’, SBS News, 2019

Nicholas Kardaras on YouTube 

Video: 'Glow Kids: What the Research Shows About Screen Effects on Children and Teens'
Video: Back from the dead | Nicholas Kardaras | TEDxUrsulineCollege


Adrian: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based integrative functional and complementary medicine. I'm Dr Adrian Lopresti, clinical psychologist. And joining us today is Dr Nicholas Kardaras, Ivy League-educated psychologist, internationally renowned speaker, and one of the USA's foremost addiction experts. 

Hi, Nicholas. Thanks for joining us on the line today.

Nicholas: Oh, thank you for having me on the show. It's my pleasure.

Adrian: I wanted to talk to you particularly about your interest in screen use and the dangers of internet use. And you've written a fascinating book on the dangers of excess gaming and screen use called Glow Kids. So can you tell us a bit about how you became interested in gaming addiction and the dangers of excess screen time?

Nicholas: Yeah, I was working as a psychologist, as a clinician with young people with adolescents and young adults. And my primary focus had been mental health and substance addiction. That was what my training had been in and I was also teaching at a university and doing a lot of work at secondary schools at that point, this is about 12, 13 years ago. 

And being trained and tuned into diagnosing the clinical aspects of substance addiction, I started noticing some of the similar behaviours with young people and their devices. If you went through the DSM or the ICD diagnostic criteria for substance addiction, it was almost matching exactly what I was seeing with some of these 14, 17, 18-year-olds.

And my real “aha moment” happened, I wrote about this in Glow Kids, when I had a young man that was sent into my office about 11, 12 years ago, who he was, where he was, blinking. Rather, his eyes were wide and was blinking rather intensely. And I kept asking him if he knew where he was, if he knew...just to give him a sense of bearing and orientation. And after a couple of minutes of sort of looking around my room and trying to get his bearings, he asked me if we were still in the game. And I said, "No, no, we're not in the game anymore." And I found out later that he had been playing World of Warcraft for 10 to 12 hours at night for multiple weeks. And it was the intersection of sleep deprivation and multiple-hour drags of gaming ha led to what we might call “video game psychosis,” where he didn't know where the game ends or where reality began. He was essentially in the matrix.

And that was eye-opening and shocking for me because I was used to seeing substance-induced psychosis with psychoactive, things like crystal meth and cocaine, but I've never seen reality blurred by gaming, or by digital experience. And that was my first time experiencing that, but not my last, and that was sort of the beginning where I started saying, "This is something new and different that's happening here. And I don't think we're all fully aware of what some of these clinical potentials might be." So that was really how I first sort of fell into this.

Adrian: So this is psychosis induced by excess screen time, excess gaming.

Nicholas: Yeah, there are a couple of British psychologists that have come to call it “game transfer phenomenon,” GTP. And game transfer phenomenon is where visual or auditory aspects of the game will transfer into waking awareness. Essentially, you'll have...a gamer will hear or see the game, the game will have visual, arbitrary intrusions into their waking reality. And most gamers experience brief moments of that, they might hear a little gunfire or some aspect of the game intrudes into their awareness, but they're aware that it's a shadow aspect. This young man was fully...we would call it a video game-induced psychosis. 

The problem was, it's not genuine psychosis. If he would have gotten some sleep and unplugged for a couple of days, he would have been fine, but he instead went to psychiatric hospital. And they put them on anti-psychotics and they held him there for three weeks and they didn't treat him, in retrospect, in what would have been the best way to treat him because it wasn't genuine psychosis, it was sort of a transitory gaming-induced psychosis.

Adrian: So when it comes to excess screen time in internet addiction and gaming, how bad is the problem?

Nicholas: I think it's the addiction of our times because I think the ubiquity of it, I think we're all swimming in it. And I think the larger question that I've come to understand over the last five years since I wrote Glow Kids, and I'm working on the follow-up book now, which takes a little bit of a wider societal lens of the issue. 

The uphill climb I had to fight five years ago was to get tech addiction or screen addiction accepted as a real clinical disorder. And back then there was some pushback, really can people be habituated or addicted to their devices? And I like to say that we're mad for our devices as our devices are driving us mad. But that's been accepted now. The ICD-11 has, as a diagnostic criteria, a gaming disorder. But back then, five years ago, I wrote an op-ed for the New York Post called Digital Heroin, where I was really looking at some of the brain imaging and some of the clinical research and saying, "Look, this is very analogous to substance addiction." 

So that was sort of the first step to get that established. But now I think the larger picture of it, in terms of how much we're all swimming in this, is what is our intersection as a species? What is our intersection as human beings with this highly technological way that we're living? What is the mental health impact of that? And I think it's a bit like the frog in the water that's getting warmer, it doesn't realise that the water is reaching a boil until it gets boiled alive. I think we've all been gradually swimming in a very unnatural way of living. We weren't meant to be sedentary screen-staring, overworked, over-stressed, sleep-deprived, meaning-deprived, isolated beings.

And so I think when you look at our record rates of depression, our record rates of suicide, our record rates of anxiety, our record rates of ADHD, our record rates of drug overdoses, I think they're all...I think there's a through-line there. I think they're all connected because I think we're on psychiatric fire. And I think the way that we're living is antithetical to our human genetics, we weren't meant to be like that. We need face-to-face community, we need to be more physically active, we need to be more purpose-driven. And I think the digital landscape has robbed us of all those things. And now with COVID, COVID was just kerosene on an already burning fire.

So it's really, I think, the main driver of what I would call our mental health crisis. So it's less about “Are we addicted to our devices?” that's sort of a given that we're all, to some degree...whether you want to call it full-blown tech addiction, but to some degree, we're all impacted by our devices. And that's where I think the paradigm, because we know that the more screen time robs us of two things that are the drivers of depression, it robs us of our physical movement, we're more sedentary because of screen time, and it robs us of face-to-face interactions.

Adrian: Yes

Nicholas: So those two things alone, physical activity and face-to-face interactions are the two best non-pharmaceutical antidotes to depression. But screen time is a nuclear bomb on those two things. Screen time has made us a more sedentary and less face-to-face species. And we know genetically, we're hardwired for community. The tribe survived. We know that our species was evolved over many couple of aeons to be tribal, in the sense that we needed each other for support because we weren't the strongest and we weren't the most...we weren't the biggest but we had strength in numbers. And that was an evolutionary adaptation that's hardwired into our psychological DNA. And we also needed physical activity. And so we know that without physical activity and without face-to-face community, those are the two main drivers of depression. And what we're seeing is a huge depression epidemic, a global depression pandemic, where depression rates, by some estimates, have tripled as we're throwing more and more antidepressants at the problem.

So if the endogenous theory of...the brain chemistry theory of depression was accurate, if depression was simply about neurotransmitters and depleted serotonin, then the more prescriptions of antidepressants should be solving that problem. But what we've seen, if you look at the depression, the bar graph of depression and if you were to overlay a bar graph of our antidepressant prescriptions, we've given increasingly, increasingly, increasingly more antidepressant medication, and that depression was still spiking. 

Adrian: Yeah.

Nicholas: So then we have to say, "Well, it's not just a brain chemistry issue, it has to be a lifestyle issue. That's an environment issue." And what's changed in our environment and our landscape over the last 20 years, except the digital piece. We've become a different species over the last 15 to 20 years because of our high-tech capabilities.

Adrian: Yeah, absolutely. And certainly, the neurotransmitter deficiency hypothesis is certainly limited. And we need to look at a whole range of lifestyle factors that might be contributing to the epidemic of mental health, and certainly reading your book, I’m just amazed by some of the statistics with regards to how often people are texting and using social media and gaming. And I know even a study that was done here in Australia on about 3000 people, 3000 high school students, 10% of them reported themselves as being highly or very highly addicted to the internet. So I know that our statistics are probably similar to what's going on in the U.S.

Nicholas: Right. What's interesting is that COVID has acted as sort of a...well, it's sort of in the proof of the hypothesis that too much of what we're talking about is problematic for our mental health because what we saw, what we've seen, what we're seeing during COVID has been a doubling of screen time and a tripling of depression rates. 

Adrian: Wow, yeah.

Nicholas: So the quarantines, the isolation, the more and more dependence on...it's by necessity, we've got to be Zooming and remote working and remote schooling and remote all these other things, remote, remote, remote. But too much remote makes Johnny a depressed and suicidal boy.

And so that amplification of all those dynamics that were problematic before COVID has been a confirmation of the hypothesis that something was amiss because, like you said, it wasn't just brain chemistry. And it is brain chemistry in the sense that you can...as we know, environment can impact brain chemistry. Trauma can change brain chemistry, but so can lifestyle. So toxic lifestyle can create toxic brain chemistry. And we can't just throw the pharmaceutical sink at it and think that we're going to fix the problem unless we address the underlying societal shift that's happened that's how we live and how we interact as a species.

Adrian: Yeah, absolutely. So really, then if that neurotransmitter deficiency or imbalance hypothesis is correct, and then we really need to go, "Well, what is it that's going on that might be contributing to that?" And we know that certainly from reading your book that a lot of the gaming and the effect that that has on brain chemistry is significant. 

So is gaming a problem just for children and teens, or is it also a problem for adults?

Nicholas: Well, I did a pretty high profile intervention for one of the national news shows here, ABC's 20/20, but I did a televised intervention for a 42-year-old IT executive in Ohio who was escaping his… This was a man who had four children and an attorney as a wife, and he would come home from work and he would just go down to the man cave and escape his reality. I think at the end of the day, those of us that work with addiction, we know that a lot of addiction is about escaping, it's a great escape, the great escape artists, the Houdinis of the mental health world. And so whether you're escaping emotional pain or you're escaping an existential crisis, or you're escaping a relationship that you feel trapped in, and that's the other word that we use a lot with addiction, right? It's if you feel trapped.

There was the famous research by the Canadian Professor Bruce Alexander who did Rat Park, he did the...I'm not sure if you're familiar, but it was great research where back in the '50s, they did addiction research where they would put the rat alone in a Skinner cage, and the rat had the opportunity to hit the lever. And one lever would give the rat morphine water and the other lever would give the rat food, and invariably the rat alone in the Skinner cage would hit the lever for morphine water to the point of overdose. 

And so the conclusions by the clinical society back then, the community, the clinical community back then was okay, this speaks to very highly… It was a sort of a substance-based perspective on addiction that okay, addiction is all about how addicting the substances are. Here, look at these rats, these rats would rather get high than eat to the point of self-destruction. And Bruce Alexander came along and said, "Well, no effects of experiments about that. Rather, is it an experiment about isolation?"

Adrian: Yes.

Nicholas: And maybe if these rats were in community and maybe if it weren't isolated, maybe the morphine water would be less attractive to them. And so that's when he did his famous Rat Park experiment where he created a rat playland of rats that were in community, they were able to play with one another, and they had wheels that they could frolic in and they could have sex with one another. They had access to morphine water. And the rats that were in community and had more connection, there were no rates of morphine water abuse or overdose, and was simply by changing their environment into a healthy, less toxic environment, eliminated the addiction problem, even though they had the same access to the morphine water.

And I think that's sort of where we're at right now. I think we're sort of, to some degree, very toxic lifestyles, again, overworked, overstressed, we're never really unplugged. Those of us that have careers and work, we thought...20 years ago, everybody thought having emails would be a wonderful thing and smartphones that could keep us perpetually plugged in. But now nobody ever really can unplug and really complement us and have purely restorative recreational time because to some degree, we're all tethered to… We're all sort of on high alert and what that does to our adrenal system.

So we've created this sort of toxic environment and, like any other addiction, it's about escapism. Those of us, and especially young people because I work a lot with young people, who are feeling trapped and disempowered and stuck in realities that they can't handle, well, there's a much more available alternative to escape than drugs and alcohol because to be a drug addict, it takes some effort. You've got to find a drug dealer, and you've got to purchase whatever your drug of choices. But the ubiquity of digital makes it a push-button escape. 

So, talk about gaming escapism. So that executive that he did the intervention on, he couldn't stand the reality, the pressure of being married with four children, and he hated his job, and he was an office worker slaving away in a cubicle. So he would go home and he would play Grand Theft Auto, and he was a want-to-be gangster in a fantasy world of an avatar that he lived a vicarious life through. And that worked better for him than drinking a fifth of vodka every night.

Adrian: Yeah, so we really need to then, rather than just look at the addiction, we need to also look at what's going on in that person's life that might be contributing to that addiction. And obviously, as you mentioned, escapism is one of those things that could be occurring for them. It sounds like the problem is that it's widely available, it's something that we can just go into, we don't even need to leave the room, do we? We can just use our phones to go on a screen and it's freely available 24 hours, 7 days a week.

Nicholas: So it's readily available for adults in terms of push-button escapism, but the problem for children developmentally that I write about in Glow Kids quite a bit, is that instant gratification aspect of it really primes the pump for impulsivity. And really, the interesting part is neurophysiologically, and they've looked at this...and Dr Christakis, who does a lot of the ADHD research here with screens in the United States, University of Washington, he's looked at a lot of this. 

So not only is it readily available, but if you're a child who hasn't really developed your prefrontal cortex and your executive functioning and your impulse control, and we know that the things that nurture that the most are delayed gratification. The old marshmallow test, one marshmallow today, but if I don't have it today, I'll have two tomorrow. 

If I can cultivate the skills of patience and delayed gratification, those bode well for long-term outcomes of children as young adults. But push-button instant gratification now is priming the pump towards impulsivity and what they were finding on the brain imaging research is the part of the brain devoted to that in the same way that it atrophies, in the same way that it gets compromised with substance addiction is happening with screen time.

I think that was the biggest shock for a lot of people because people can...I think they were able to conceptualise that substances, you ingest something and that can change your physiology and neurophysiology. But I think people were really shocked to find out that something that you're not actually putting into your body can change your brain, can change your neurophysiology, and that's what we were seeing. So you were seeing the DGM, the dense grey matter of the prefrontal cortex was actually shrinking and being compromised, thus leading to more impulsivity with excessive screen time. 

So if you give a 5-year-old too much screen time, they're never going to develop their attentional muscles, their ability to delay gratification, they're going to be wired and primed for impulsivity across a lifetime. And impulsivity is also a predictor for substance abuse and all sorts of other not great outcomes long term.

Adrian: I remember reading in your book, you talked about how gaming companies hire the best neurobiologists and neuroscientists to elicit a physical response, so they certainly know what they're doing and the outcomes they're trying to achieve.

Nicholas: Yeah, yeah, the whole dopaminergic response and the whole levelling up, they're very...you've got to give the devil their due, they're very efficient in terms of creating highly habituating, dopamine-activating platforms that really prime an addictive response. 

And it's interesting how...I don't know if it's in the news yet there in Australia, but it was big news here about a week ago, and it was on our local 60 Minutes about the Facebook whistleblower and how some of the big tech companies, they knew...The story was that with Instagram that they had their own internal clinical research showing that excessive engagement with Instagram was increasing suicide rates, 13% higher suicide rates amongst teenage girls the more that they were on Instagram. They know not only was the blueprint for big tech and some of these gaming companies habituation because that drives engagement and drive sales and profitability, but I think the really shocking part that I think a lot of people found offensive was, okay, so we get it, a lot of toy manufacturers and food manufacturers, they try to sell their product, they use marketing techniques.

But now they knew from their own internal emails that their marketing strategies and their habit-forming strategies were leading to psychological harm. And they ignored the data, they ignored...by their own internal emails, let's change the algorithm. Because the algorithm, at least with Instagram, was about...it created self-loathing, created negative self-concept. And they refused. Well, it was almost collateral damage, we're going to accept that some young girls are going to commit suicide, but if we change the algorithm to make it...because we know that the lizard brain is going to respond to things like hate and self-loathing and adrenaline in gaming. 

So it's all about activating the lizard brain, but whether it's adrenaline or self-loathing, as I said. And similarly to the tobacco industry, and here in the congressional hearings that big tech was in front of, they call it the “big tobacco moment” because similarly, here in the tobacco industry, there was an understanding when big tobacco in the 1970s went under the magnifying glass that they knew that their product was a carcinogen, and they sold it to children anyway, and they marketed it to children with Joe Camel and techniques anyway.

Adrian: Yes.

Nicholas: It'd be one thing if they didn't realise that, “So, okay, I didn't realise that my product is harmful, and I'm just doing my best to sell a product. I sell encyclopaedias door-to-door, I didn't know that they were harmful.” But here you have email trails that are documenting that they know. That, by design, addicting platforms are harmful. And they're ignoring that, and they're saying, “So what?” And that's the part that I think is sort of eye-opening for a lot of people right now and that they want to have some accountability for that.

Adrian: Yeah, absolutely. Obviously, they're in the business of selling and they have great scientists who know what they're doing to be able to make us more addicted. I know that you use the term it's like “electronic cocaine,” and I know in one study you mentioned that video games can increase dopamine as much as sex and this was, I think it was a 1998 game or something.

Nicholas: Yeah, it was a 1998 study by Dr Koepp in the Nature magazine. And so they were looking at different substances and experiences and how much they raised dopamine levels. And that 1998 study where they used a 1998 game, which wasn't quite Pong, but it wasn't the highly-arousing dopamine-activated games of today like Grand Theft Auto or some of the other more intense games. Right, it was as dopaminergic as sex, 100% dopamine-activated. 

So food was raising dopamine 50%, but sex and video games were raising dopamine 100%. And the difference when I...sometimes I speak at conferences about this. It's even worse than that because, without being crude, sex...and we know that the dopaminergic response was an evolutionary adaptation for survival. That two primary survival functions were incentivised by a dopamine response, and that was eating...So eating food feels good, so dopamine gets released when we eat so that kept us alive. And also procreation released dopamine, and that felt good, so we continue to do that.

But there is no benefit to cocaine use, which spikes dopamine, or crystal meth use, which spikes dopamine, or video game use. But the problem with that is that you can play a video game for...I mean, I've had clients who have played video games for two or three days straight. Where typically the sexual experience is short-lived. And so you're creating this dopamine spike for a much longer plateau period. 

So you're releasing dopamine hour after hour after hour, and you're also raising the adrenaline. So you're raising the HPA axis, the fight-or-flight response, the hypothalamus-pituitary-adrenal axis is activated. And so now you're going through extended fight-or-flight for multiple hours and we're not meant to go into fight-or-flight for multiple hours because then you go through adrenal fatigue.

Adrian: Yes.

Nicholas: And now you've gone through this extended dopaminergic response and extended adrenal period. We're just not wired for that. And so that leads to all sorts of other issues with young people where… and the ones that I've worked with that have this adrenal fatigue, it looks a lot like PTSD and anxiety. They're shot, their nerves are shot. They're sleep-deprived, and they're wired and tired, and they're not really...they can't focus, and they're very jittery and they're very jumpy, that kind of thing.

Adrian: I know a lot of practitioners who will be listening to this podcast use the term adrenal fatigue and obviously look at lifestyle factors and stress and so forth. And from what you're saying, they really need to ask about screen time and gaming use because that can also really activate that HPA axis, that stress response that's going on for them.

Nicholas: At the end of the day, that's what it is. It's a stimulant, it's a stimulant stress response. That's where the engagement and activation comes in. If it wasn't, people would just get off their devices after 10 minutes. But I wrote about in Glow Kids, the gaming companies, they know that when they beta test their games, they're looking for that blood pressure spike, they're looking for that arousal because arousal drives engagement, which drives habituation. So the intersection of adrenaline and dopamine is the sweet spot for habituation and addiction.

So whether it's a social media platform, whether it's TikTok, Instagram, or Grand Theft Auto, the name of the game is arousal. And continual arousal hour after hour, not only does that create the adrenal fatigue profile, but even worse, I think, in a very real way, and I see this a lot with adolescents that I work with, it desensitises them to the real world because you get so habituated to these hyper-immersive, arousing screen experiences that everything in the real world pales in comparison. Good luck listening to your math teacher drone on in school, or good luck trying to have a conversation with a friend, or reading a book,

God forbid. All those mundane day-to-day activities now become pale, pale experiences compared to these other really stimulating experiences that they get from screen time.

Adrian: Yes.

Nicholas: That's almost a bigger problem. So you get these kids that look bored. They look bored with life, like, yeah, shoulder shrugging and sort of apathetic and not passionate about anything and sort of ennui, a lack of passion because their dopamine receptors have just been burned out.

Adrian: Well, people these days, they can't even go to the toilet without having an electronic device with them. So obviously, they need that stimulation even in the toilet.

Nicholas: That’s it. I think there's a form of anxiety for us adults when we're without our phone if our battery runs low. I think...what's the word? Nomophobia. Nomophobia is this anxiety when we...the fear that our battery might die and we might be without a phone in our car, or God forbid, we've all become so dependent on it, except just children are more affected.

Adrian: What's it called? Nomophobia.

Nicholas: Nomophobia, and it's sort of a combination of...yeah.

Adrian: Wow. All right. So you got then, obviously, the effect that's gaming and screens have on dopamine, and then you've mentioned the HPA axis that occurs. Obviously, and then the concern is that we've got young children who are being exposed to screens, and the impact that has on the developing brain. So we're obviously seeing some significant changes in the brain as a result of excess screen time.

Nicholas: Yeah, the one study that I mentioned in Glow Kids that I like most, the one brain imaging study that I think shows the brain changes, I think it's the best study because it's a pre and post-MRI study. Because one of the arguments used to be because some of the brain imaging research was clearly showing that the brains of gamers were different. And one of the counter-arguments were, well, maybe folks, maybe kids or teenagers that had already compromised prefrontal cortex gravitated towards gaming, so maybe it wasn't the gaming. A little bit of a chicken or the egg argument, maybe wasn't the gaming that created the deficit in the prefrontal cortex, maybe kids with a deficit in the prefrontal cortex gravitate towards gaming.

But this study at Indiana University Medical School, they took a group of young men who were not gamers, and they did an fMRI before the study, and then they had them play violent video games for 10 hours a week for 2 weeks. And by the way, 10 hours a week is a walk in the park for most gamers. A lot of the gamers that I've worked with, 10 hours is a night's play. But anyway, they made them play for 10 hours a week for 2 weeks, and then they took an MRI scan at the end of the 2 weeks and you saw a significant impact on their prefrontal lobe, on the prefrontal cortex, you saw less activation, especially in the part of the brain related to impulsivity and progression. And so that was just after two weeks. 

Now, the bigger question is, well, is that permanent? Is there neuroplasticity? So will that fix it, correct itself if a person stops ingesting that? And they did another follow-up fMRI on those same people in that study a few weeks later, and the ones who had stopped gaming, they did see a reversal of some of those effects. So I do think the hope is that some of these effects, because of the powerful aspects of neuroplasticity, can be reversible. 

But the impacts that are developmental, I don't see as being reversible. We know that ADHD types of developmental stages...if you're adversely impacting infants and children when they're 3, 4, 5, 6, 7 years old, that's the most impressionable time of development for a child's brain if you're adversely doing things there. The one study that was just most recently in the New England Journal of Medicine, and it looked at infants that were 2 years old and screen time and looked at cognitive deficits that were happening with over an hour of screen time as opposed to no screen time.

Adrian: Yes.

Nicholas: So we're changing the brains of our children. The big question is, how permanent will some of this be? And how long-term and what will it look like 10, 20 years down the road when some of these kids grow up? And we're beginning to see that now because what we're seeing the graduating class from 15 years ago stretch into young adulthood today, and I think we are seeing some of those psychiatric red flags.

Adrian: Yeah. And obviously, as time goes on, we'll be able to see that longitudinal data where what happens when young children are exposed to screens and what happens when they're adults? 
Or even the concern is, what happens in terms of increasing their susceptibility to cognitive decline and Alzheimer's disease? And have you seen any research about that yet?

Nicholas: Yeah, there's a lot of research that looked at the myelination and the white matter, so the myelin sheath. And so there was a UCLA researcher, Dr Bartzokis that did all of myelination research with substance addictions and he died four, five years ago, but he showed that chronic substance abusers had white matter or myelin sheath abnormalities that really mirrored dementia or Alzheimer's. The myelin sheath is a white lipid insulation of the axon cable, looks like the insulation cable, it's sort of porous, brittle, compromised, like a Swiss cheese effect, and that was from drug use. 

Now, they did similar studies, Dr Bartzokis did, with substances with screen time and they found the same effect. The myelin sheath is extremely fragile and excessive screen time was compromising the myelin sheath in the same way that substance abuse was, which was doing it the same way that Alzheimer's and dementia does. And if you have a brittle or compromised myelin sheath, the rapidity, how optimally your brain functions is a byproduct of how robust your myelin sheath is.

And now substance abuse and screen time and, as we know, certain dietary things can really compromise your myelin sheath, we know that certain foods and prions with some of the meats can create some of these issues. So yeah, we're going to be seeing more and more these issues, I think, as we move forward down the road and they continue to unfold in a very problematic way.

Adrian: So when we're doing our assessment these days, we really need to ask about a history of computer use, gaming, screen time, when it began, how often it began, how often children were exposed to it and really using that information as part of our assessment because it obviously, from what you're saying, it has a significant effect on our neurology and our biology.

Nicholas: Absolutely, we're doing it here more and more in the United States where part of the biopsychosocial assessment has to include a piece about a screen time assessment. How much time is your child, teenager, young adult on the screen, what type of screen usage because it also impacts their sleep patterns, right? So we know...I was at a committee on social education for a young person, they were ordering a sleep study on this person because we thought...he kept falling asleep in class and we thought he had a sleep disorder. And the simple question that was asked at the meeting of the parents were, "What are his digital habits?" "Well, he does stay up gaming until 3:00 in the morning. Do you think that has something to do with why he falls asleep in class? Because we thought he just had narcolepsy." Well, if your son is staying up until 3 or 4 in the morning, you don't have to be a rocket scientist to perhaps infer that there might be a correlation. So why don't you try first eliminating the screen time or at least cutting it back to...we talked about sleep hygiene because we know that the screen also disrupts the circadian sleep cycle and that begins to look like ADHD in school in the morning.

So a lot of various impacts that I think are often getting misdiagnosed as other things...One of my friends and colleagues, Dr Victoria Dunkley, she's an adolescent psychiatrist, she wrote a book called How to Reset Your Child's Brain, and she works out of Los Angeles. And she won't diagnose or prescribe any medication for any child or adolescent until after they've done a four-week digital detox, until they've unplugged for four weeks. And what she's found in the thousand kids that she's seen over the last 10 years is that fully up to 70% of them become symptom-free by just through a digital detox, whether they're coming in there for ADHD, or mood disorder, even spectrum types of autism issues, she's seeing greatly...either it totally go away or greatly improved by just taking away the stimulant of screen time.

Adrian: I know that a lot of practitioners listening today, obviously, are aware of the importance of diets and the importance of improving somebody's diet and the relationship that has on mental health. But obviously, now we've really just got to be aware of screen time. And maybe it's a detox like you mentioned before you really get a good baseline assessment to say what's actually really going on for the individual. Is there anything going on biologically other than the effect of screen time and gaming and all that? And you've mentioned here that the effect it has on depression and ADHD and obviously sleep hygiene. 

And what about the research with the link between video games in violence and aggression, what's the research say about that?

Nicholas: And by the way, I just wanted to quickly comment on what you had said about that. And I think a good way to look at it if you're a clinician is if you're going to do a nutritional assessment, you should just...for a nutritional diet, you should also do a digital diet assessment.

Adrian: Yeah.

Nicholas: What is your client's digital diet? Because that's going to tell you a lot. 

The aggression research was voluminous. Craig Anderson and Iowa State were the main folks, but there's been a lot of other international research around this as well. Well, if we go back to the thesis that a lot of screen time, especially gaming, if we look at screen time as digital drugs and if there's a continuum of drugs at one end of the spectrum, you have something like crystal meth and the other end you have maybe cannabis so not all screen time is as toxic just like not all substances are toxic. 

The most...let's call it some of the most toxic to being violence, first-person shooter game, Grand Theft Auto and those types of games. Well, of course, whether you're looking through the lens of social learning theory, or from just desensitisation, or just from a genealogic standpoint, you're raising the thermostat of aggression in some of these kids. So the research has been pretty voluminous, and it wasn't...And they were clear to say that the conclusions...and the one study, in particular, was a meta study that looked at over 40,000 young people, and it looked at, I think it was, over 30 different studies. And the conclusion was that the results were causal, not just correlational, that screen time does lead to increased aggression

Now the caveat with that is that increased aggression doesn't always mean violence. Just because I'm more aggressive...if you drink two cups of coffee, you may be a little bit more aggressive, doesn't mean you're going to assault someone, but you're more primed. The pump is primed for violence if you raise the aggression temperature. And so there's been quite a bit of research that shows… they’ve even manipulated the extreme experiences of things like playing the same video game, one has blood, the other doesn't have blood, one has sound, the other one doesn't have sound, adding violent sound effects, people screaming, things like that. And they all have an impact, so the more immersive and the more realistic the violence, the more impactful it is on shaping aggression.

They used to say back in...I don't know how old you are. If you're of a certain age, you remember back in the day, they used to say, "Well, cartoons, like Bugs Bunny and the Road Runner, they're pretty violent, and maybe they raise violence levels." But the difference was twofold. There's two major differences with let's call it television violence of the 1970s. Whether it was cartoon violence or a police drama like… I'm trying to be culturally relevant with what might have been a police show in Australia in the 1970s. But let's call it, I'm thinking about Starsky and Hutch, any kind of police show here. The violence was non-realistic, right? You shot somebody in television, there was no blood, it was pop-pop, bang-bang. Same thing with some of the cartoons with the Road Runner or Wile E. Coyote and Bugs Bunny. There was no realism to it.

Adrian: Yes.

Nicholas: So now, fast forward to the main difference is the player is not a passive viewer of the experience, they're an immersed active participant in the experience and there's a lot of blurring of the lines, especially with younger children who haven't fully developed their reality testing yet. 

So for some young children, if you're 5 or 6 or 7 and you're playing some immersive video game on a 50-inch plasma TV, you are going to have a difficult time saying where reality ends and the game begins. But then also the realism of it, like in Grand Theft Auto, I remember one of the iterations of Grand Theft Auto, I think it was Grand Theft Auto 4, I mean, you were beating the prostitute and they added the sound effects of the bat thumping on the head of the person. Those kind of ugly details matter because they add to the realism, which I think adds to the disruptive and aggression-increasing effect of what we're talking about.

Adrian: And if it's part of your world and you're exposed to these scenes and images, then it's certainly going to have an effect on how you see the world and then your belief systems and all of that. So there's no doubt that it's going to happen. 

Also, I wrote down here an interesting study that you mentioned in your book. Children were exposed to a Call of Duty game and then they were required to season food with hot chili sauce for a taste tester who couldn't stand hot chili sauce, and those who just played Call of Duty added significantly more chili sauce than those who didn't. I remember that, so I had a good laugh on that one. It's amazing. Wow.

Nicholas: Yeah, they have pretty ingenious ways of how they measure increased aggression, right? So it's just like how...Yeah, so I thought that was pretty, like you, I thought that was pretty humorous how they quantified that.

Adrian: Absolutely. So we've got then obviously the links with the impact it has on our biology, seems as though there's strong evidence to indicate that it increases...and it's obviously a bidirectional relationship, but it certainly increases the risk of depression and ADHD and other mental health disorders. You’ve mentioned the impact effect that has on our sleep and obviously it's going to...and our social connections. And obviously, it's also going to affect what we eat in our diets and things like that too, isn't it?

Nicholas: Yeah, it's the stereotype of the gamer is they're just surviving on energy drinks, toxic energy drinks. And they're not notorious for their balanced, vegetable-laden diets. They're notorious for their high-sugar, high-octane diet so they can stay up longer. Because again, we have to always remind ourselves at the end of the day, these are stimulants. And to be a successful gamer in so many of these young kids, and I can't believe it's the fastest-growing “sport."

And it nauseates me that eSports or gaming is now considered a sport and that eSports are the fastest-growing both participant and entertainment sport in the world. But these athletes who are training...And then again, excuse me if I vomit, but these quasi-athletes who are training for their eSports, their training requires energy drinks, Red Bull, and sugar to stay awake for multiple hours and days. So yeah, they're not really...so typically...And I run one of the few clinics in the United States that has an expertise and we have a track for treating gamers and tech addiction.

So in the last two years, we've been residentially treating young, 17 to 25, 30-year-old gamers for the last few years in an 8-week residential program, and the vast majority of them are coming in...well, it's one of two things, right? They're either malnourished, they're coming in underweight, malnourished, the worst dietary habits, the worst hygiene, and terrible sleep habits, or they're coming in significantly overweight and obese. But they're typically not coming in healthy, physically exercising and getting good restorative sleep, it's one extreme or the other of underweight or overweight.

Adrian: Sounds very much like your addictions to your illicit substances, they're presenting very similar in similar ways. So if a practitioner's seeing somebody who they're concerned they're excessively playing games, or using social media, can you just give some...briefly just some recommendations that they can do in terms of how they can treat such an individual?

Nicholas: Yeah, it's interesting because the long-term process really mirrors treating an eating disorder because if you're treating a substance addiction, abstinence tends to be the goal. And so we can live a very happy and fulfilling life without drugs and alcohol. So abstinence can be a treatment goal for that. 

But you really can't be digitally abstinent in 21st-century society today. So first, you have to assess the severity of the problem. If the person is...let's call it tech overuse and they haven't crossed that fine line into what we might call addiction. Because I've worked with some clients who were entirely dysfunctional and they couldn't function, they couldn't...entirely, entirely dysfunctional and they needed residential treatment. And there was no way that they were going to see a therapist once a week and change the course of the trajectory of their lives. That might be a minority of the cases. So let's call it...So the vast majority are maybe some degree of excessive use.

So, ideally, what you would do is you would begin to identify what the problematic digital usage is, and we start talking about identifying digital vegetables versus digital candy. If you're a student and you're researching a paper for school, that's a healthy use of technology, but if you're just mindlessly gaming or doing some other kind of activity that has no conceivable benefit to your life, and that's digital candy. So you would start creating a diet plan that cuts down the candy and increases the healthy usage. So the goal being towards mindful digital usage, mindful and balanced digital usage. And if you could do that in a therapy once-a-week setting or in an outpatient setting, then wonderful, if a person could be given some tools to do that.

And a very helpful tool to do that is for the client...and I do this myself, I think it's healthy for all of us to do this is to do a once-a-week digital fast where one day a week, you're just off of your devices entirely. And whether this is a family, whether this is a child, whether this is a college student, I find it extremely helpful in my own life. One day a week, it's just you're going to be present, you're going to be not on a TV and not a smartphone. You're just going to be fully present, and that really helps recalibrate your adrenal system in kind of a nice way.

Adrian: Yes.

Nicholas: So things like that, of course, nature is a big part of it, like an antidote to some immersive screen time. So encouraging people to participate in some of those types of activities, reclaiming some hobbies. A lot of the screen folks that I work with used to have pretty full and robust hobby lives or recreational lives where they used to play sports or other activities. And if the screen time takes over, you see that all those things go by the wayside. So encouraging them to start playing the piano again, or playing soccer again, or reconnecting with things that used to have more balance in their lives.

Adrian: Where can practitioners find more information about gaming and excess screen time so that they can improve their own clinical skills in being able to treat this problem?
Nicholas: Yeah, there's a training that we do here in the United States, I'm involved in this. It's the National Institute of Digital Health and Wellness, the NIDHW. And we do, it’s a one-day, six-hour certification course. It's for clinicians and educators to be able to identify and work with technology issues, tech overuse. And that's through an organisation called they offer the training like three, four times a year. In fact, our next training I believe that I'm doing is in January. 

My book is out there. I do highly recommend Victoria Dunkley's book that's kind of...she walks through a little bit more of a how to do the digital detox the digital fast with children. She gives a little bit more of a prescriptive step-by-step piece about that. And again, her book is How To Reset Your Child's Brain, and it's Dr Victoria Dunkley, D-U-N-K-L-E-Y. 

And it's growing. I mean, there's a growing awareness that this is a problem. I was going to say when working with young people, at the end of the day, it's also finding out, kind of like with an eating disorder, helping them find a strong sense of self, a strong core identity because that is where a lot of the social media, shaping young females sense of body image, and sort of the mean girl thing, and also with young boys escaping in gaming avatars, they don't love who they are and they're escaping into these fantasy realms. So part of the therapeutic clinical work is helping them get to a place where they accept and like themselves, and don't need to live in a fantasy world, essentially.

Adrian: So it's not just about looking at strategies to reduce screen time on gaming use, but also looking at the wider picture and what's going on for them, or how they see themselves, how they see the world, and so forth.

Nicholas: I find those strategies to be somewhat ineffective. If you're just focusing on... everybody asks, "Well, how much screen time is enough?" And if your child has really crossed a line, and you're trying to just moderate their screen time, and you say, "Well, you can do two hours of gaming once you've done your homework, and cleaned your room, and helped with dinner," the child, if they're still addicted to gaming and gaming is still the carrot that they're going to receive, everything else gets rushed through and it's not done mindfully. Everything else is sort of just bulldozed. And so until a young person can sort of re-calibrate themselves and, like you said, address the bigger picture,  moderating screen time is changing seats on the Titanic, it's not ultimately that effective at the end of the day.

Adrian: Now, you've also got a book that you're finishing up and publishing sometime soon.

Nicholas: Yeah, it's same publisher, St. Martin's Press, and it's really looking at a 30,000-foot view of social-political aspects of how technology is not only driving our mental health pandemic but big tech's role in some of these things. And what my hypothesis, in this book, is that social media and our immersion, now that social media has swallowed up the globe, it's shaping the architecture of our brains and how we process information.

Adrian: Yes.

Nicholas: So in effect what you have is you have algorithms that are fuelling polarity, which are then increasing the experience polarity, the person's polarity in the way that they process information moving forward. So now things are black or white, love or hate, all or nothing in these extreme types of ways that I've never seen before. And I do think that that's at the feet of social media.

Adrian: All right. Well, Nicholas, thank you so much for spending time with us today. And thank you for the great work you're doing in the area. I think it's something that we all need to be aware of for both ourselves and our patients. And I think you've given some really useful insights for practitioners to really consider when they're working with people with excessively using screens, and obviously just making sure that we do a good assessment and ask about what's going on for them. So absolutely, thank you very much for spending time with us today.

Nicholas: Oh, thank you for having me on the show. It's been my pleasure.

Adrian: Thanks, everyone for listening today. And don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Dr Adrian Lopresti, and thanks for joining us.


Dr. Kardaras is an Ivy League educated psychologist, best-selling author, internationally renowned speaker and considered one of the world's top thought leaders on mental health, addiction and the impacts of our digital age. He's the CEO and Chief Clinical Officer of Maui Recovery in Hawaii and Omega Recovery in Austin, Texas, and a former Clinical Professor at Stony Brook Medicine in NY where he specialized in teaching the neurophysiology and treatment of addiction and mental health. 

Dr. Kardaras is the author of the best-selling book "Glow Kids", which has been translated into 10 languages and is considered the seminal book on the clinical, neurological and sociological aspects of tech addiction. He's written for TIME MagazineScientific AmericanPsychology TodaySalon, and the NY Daily News and has appeared on ABC's 20/20, Good Morning America, the CBS Evening News, FOX & Friends, NPR, Good Day New York and in EsquireNew York Magazine and Vanity Fair


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