¹University of Hertfordshire, School of Health, Medicine and Life Sciences, Hatfield, United Kingdom, ²University of Southampton, Department of Psychiatry, Southampton, United Kingdom, ³Hampshire and Isle of Wight Healthcare NHS Foundation Trust, Southern Gambling Service, Southampton, United Kingdom, ⁴University of Siegen, Department of General Psychology, Siegen, Germany, ⁵University of Lübeck, Department of Psychiatry and Psychotherapy, Lübeck, Germany, ⁶University Hospitals of Geneva, Department of Psychiatry, Geneva, Switzerland, ⁷Geneva University, Faculty of Medicine, Geneva, Switzerland, ⁸University of Duisburg-Essen, Faculty of Computer Science, Duisburg, Germany, ⁹University Hospital Essen, University of Duisburg-Essen, Center for Translational Neuro- and Behavioral Sciences, Essen, Germany, ¹⁰Hertfordshire Partnership University NHS Foundation Trust, Highly Specialised Service for Obsessive Compulsive and Related Disorders, Hatfield, United Kingdom

Background: Problematic Usage of the Internet (PUI) is an umbrella term for behaviours manifesting online which cause distress or functional impairment. Of these, gambling and gaming disorders are currently recognised in diagnostic manuals and NICE recently published a guideline for the treatment of gambling that harms. There is a growing body of evidence related to the biological and cognitive features of gambling and gaming disorders, which could inform new treatment approaches.

Aims & Objectives: To survey neuroimaging and cognitive markers of gambling and gaming disorders and discuss possible future treatment approaches for PUI informed by these mechanistic insights.

Method: We discuss the findings of recent meta-analyses and review papers.

Results: Neuroimaging and cognitive studies in gambling and gaming disorders demonstrate functional and structural differences (vs. controls) in prefrontal and striatal areas, alongside impaired inhibitory control. Current findings support the conceptualisation of these disorders as compulsive-impulsive-addiction spectrum conditions. The evidence regarding the mechanistic basis of the other forms of PUI (which are not yet recognised in diagnostic manuals) is smaller but growing.

Discussion & Conclusions: The largest body of evidence for interventions to treat PUI relates to psychotherapy. Cognitive and imaging data suggest that it would be valuable to conduct well-powered clinical trials to explore pharmacological and neurostimulation approaches which target impulse control and/or activity of the fronto-striatal loops. Further research is required to determine the mechanistic differences between different forms of PUI. Looking to the future, trials considering combined treatments or stepped care approaches will be essential to inform high-quality guidelines and service implementation.