ORIGINAL RESEARCH published: 04 March 2021 doi: 10.3389/fpsyg.2021.621953 A Serious Game to Improve Emotion Regulation in Treatment-Seeking Individuals With Gambling Disorder: A Usability Study Teresa Mena-Moreno 1,2, Fernando Fernández-Aranda 1,2,3, Roser Granero 2,4, Lucero Munguía 1, Trevor Steward 5, Hibai López-González 1, Amparo del Pino-Gutiérrez 2,6, María Lozano-Madrid 1,2, Mónica Gómez-Peña 1, Laura Moragas 1, Isabelle Giroux 7, Marie Grall-Bronnec 8, Anne Sauvaget 9, Bernat Mora-Maltas 1, Eduardo Valenciano-Mendoza 1,10, José M. Menchón 1,3,10 and Susana Jiménez-Murcia 1,2,3* Edited by: 1 Department of Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain, 2 Ciber Fisiopatología Obesidad y Daniela Villani, Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain, 3 Department of Clinical Sciences, School of Medicine and Catholic University of the Sacred Health Sciences, University of Barcelona, Barcelona, Spain, 4 Department of Psychobiology and Methodology, Autonomous Heart, Italy University of Barcelona, Barcelona, Spain, 5 Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Reviewed by: VIC, Australia, 6 Department of Public Health, Mental Health and Perinatal Nursing, School of Nursing, University of Patrizia Velotti, Barcelona, Barcelona, Spain, 7 Centre d’Excellence pour la Prévention et le Traitement du Jeu, Faculté de Sciences Sociales, Sapienza University of Rome, Italy Université Laval, Pavillon Félix-Antoine-Savard, Quebec, QC, Canada, 8 INSERM, SPHERE U1246, University of Nantes, Stefano Triberti, Nantes, France, 9 CHU Nantes, Movement ‐ Interactions ‐ Performance, MIP, University of Nantes, Nantes, France, 10 Ciber University of Milan, Italy Salut Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain *Correspondence: Susana Jiménez-Murcia Background: Serious games have shown positive results in increasing motivation, sjimenez@bellvitgehospital.cat adherence to treatment and strengthening the therapeutic alliance in multiple psychiatric Specialty section: disorders. In particular, patients with impulse control disorders and other disorders in This article was submitted to which the patient suffers from inhibitory control deficits (e.g., behavioral addictions) have Psychology for Clinical Settings, a section of the journal been shown to benefit from serious games. Frontiers in Psychology Aim: The aim of this study was to describe the characteristics and to evaluate the usability Received: 27 October 2020 Accepted: 08 February 2021 of a new serious videogame, e-Estesia. This serious videogame was designed to improve Published: 04 March 2021 emotion regulation in patients with gambling disorder (GD). Preliminary results from a pilot Citation: sample are also reported. Mena-Moreno T, Fernández-Aranda F, Granero R, Method: A pilot sample of 26 patients undergoing treatment for GD was recruited (ranging Munguía L, Steward T, from 22 to 74 years, mean = 41.2 and SD = 12.9; 80.8% men). Participants used e-Estesia López-González H, del Pino-Gutiérrez A, on a tablet, which was connected to a thoracic band that sent heart rate (HR) and heart Lozano-Madrid M, Gómez-Peña M, rate variability (HRV) data to the videogame platform in order to provide biofeedback. The Moragas L, Giroux I, Grall-Bronnec M, Sauvaget A, System Usability Scale was completed by patients to determine the usability of e-Estesia. Mora-Maltas B, Valenciano-Mendoza E, Results and Discussion: e-Estesia performed comparatively well for all the explored Menchón JM and groups (i.e., sex, age, and online vs. offline gambling: mean usability score = 83.8, Jiménez-Murcia S (2021) A Serious SD = 13.1). Around 84.6% of the patients endorsed that it was easy to use. Female Game to Improve Emotion Regulation in Treatment-Seeking Individuals With patients with GD presented higher HRV during the use of the serious videogame Gambling Disorder: A Usability Study. compared to men. Front. Psychol. 12:621953. doi: 10.3389/fpsyg.2021.621953 Keywords: new technologies, serious games, heart rate variability, emotion regulation, gambling disorder Frontiers in Psychology | www.frontiersin.org 1 March 2021 | Volume 12 | Article 621953 Mena-Moreno et al. Serious Games and Emotion Regulation INTRODUCTION pathway model of GD (Blaszczynski and Nower, 2002) describes the existence of two subgroups characterized by significant Gambling disorder (GD) is persistent and recurrent problematic emotional vulnerability and emotional dysregulation (emotionally gambling behavior leading to clinically significant impairment vulnerable subtype and the antisocial impulsive subtype). This or distress (American Psychiatric Association, 2013). The theoretical model has been confirmed by empirical studies, both prevalence of GD has been estimated to range between 0.12 in clinical samples and in non-treatment-seeking individuals and 5.8% (Calado and Griffiths, 2016), and lifetime prevalence with gambling problems (Milosevic and Ledgerwood, 2010; rates for GD have been estimated to be around 0.5% Moon et al., 2017; Kurilla, 2021). (Petry et al., 2005; Kessler et al., 2008). There is no widespread agreement between which type of Several factors have been associated with severity in GD: intervention is the most appropriate to improve ER, despite psychiatric comorbidity (Pilver et al., 2013; Parhami et al., the fact that the role of this aspect in the development, 2014), early age of onset (Johansson et al., 2009; Jiménez- maintenance, and treatment of psychopathology has been widely Murcia et al., 2016), criminal behavior (Grant and Potenza, shown in the literature (Berking et al., 2008, 2011; Sheppes 2007; Folino and Abait, 2009; Granero et al., 2014), lack of et al., 2015; Jauregui et al., 2016). Different approaches have emotion regulation (ER; Williams et al., 2012; Elmas et al., been proposed to address this issue, the most frequent being 2017; Rogier and Velotti, 2018; Marchica et al., 2020), or specific variations of CBT (Ducharme et al., 2012; Fagundo et al., 2013, personality traits such as, high impulsivity (Álvarez-Moya et al., 2014; Radkovsky et al., 2014), dialectic behavioral therapy 2007; MacLaren et al., 2011; Black et al., 2014). The strong (Geddes et al., 2013; Wallace et al., 2014), and mindfulness- association between impulsivity and problematic gambling based interventions (McIntosh et al., 2016; Sancho et al., 2018). behavior has been extensively studied (Kräplin et al., 2014; For example, Sancho et al. (2018) reported in a systematic Del Prete et al., 2017) and this construct has been described review of the literature that the mindfulness-based intervention as a risk factor for GD (Blaszczynski and Nower, 2002; Johansson in addictions was successful for improving emotion dysregulation et al., 2009; Álvarez-Moya et al., 2011; Schreiber et al., 2012). and mood, as well as others symptoms (dependence, craving, Emotion regulation is the ability to experience and modulate depression, anxiety, and perceived stress). emotions (Gross, 1998). ER allows people to access functional Several new treatment perspectives in ER therapy using resources in stressful situations, and allows for the use of computer-based ER training or serious video-games have appropriate coping strategies (Greenberg et al., 2007). According emerged (Jon Hobbs and Yan, 2008; Jiménez-Murcia et al., to the theoretical framework developed by Gratz and Roemer 2009; Kazdin and Blase, 2011; Ducharme et al., 2012; Fernández- (2004), difficulties in the ER can be divided into six dimensions: Aranda et al., 2012). Although therapies based on cognitive- reactions of non-acceptance of one’s difficulties and the tendency behavioral approaches continue to be the “gold standard” of to experience negative secondary emotions in response to the treatment for GD, the use of technology-based tools experience of negative emotions (non-acceptance); difficulty complements this therapeutic approach with promising results in adopting goal-oriented behaviors and performing a task in for different health and mental conditions (Kato, 2010; the presence of negative emotions (goals); difficulty in controlling Fernández-Aranda et al., 2012; Tárrega et al., 2015; Charlier impulses and behaviors in the presence of negative emotions et al., 2016; Jander et al., 2016). Among them, serious games (impulse); lack of emotional awareness and willingness to pay have gained traction and have begun to be used in a variety attention to your emotions (awareness); difficulty in developing of complementary mental health treatments (Lau et al., 2017; effective emotional regulation strategies once emotions have Barnes and Prescott, 2018). In recent years, a systematic arisen (strategies); and lack of qualitative understanding of the review of usability literature in the context of serious games emotion experienced (clarity). found that health was the second most frequent domain for Gambling can be used as a dysfunctional strategy to alleviate the use of such games only after learning. Within health, negative emotional states (Shead and Hodgins, 2009; Lloyd serious games have been utilized to train patients and et al., 2010). It can serve as a maladaptive mechanism for professionals, to provide education, and for diagnostic purposes regulating positive (e.g., euphoria and empowerment) and (Yáñez-Gómez et al., 2017; Barnes and Prescott, 2018). negative emotions (e.g., stress, boredom, or sadness; Tice and In its broadest conceptualization, a serious game is a tailor- Bratslavsky, 2000). Individuals who suffer from GD present made videogame specifically designed to target pre-defined goals greater ER impairments than individuals without this disorder, (Kato, 2010). In recent years, videogames have moved beyond significantly less use of reappraisal as an adaptive emotional being considered as mere tools for entertainment and are now regulation strategy or a counterproductive use of this strategy, used to deliver complex and rich narratives that can be used for a greater lack of emotional clarity and a greater lack of emotional therapeutic purposes. There is even evidence to suggest that some awareness (Williams et al., 2012; Ruiz de Lara et al., 2019; video games are capable of generating more benefits in ER than Marchica et al., 2020). the serious game specifically designed for this purpose, because Different studies indicate that difficulties in ER are associated the fictional properties that can be achieved are better, as they with greater severity in GD (Álvarez-Moya et al., 2010; Lobo do not have to focus on another goal beyond the fun of the et al., 2014; Suomi et al., 2014). GD is a heterogeneous condition, user (Villani et al., 2018). Among the frequently mentioned positive and it is possible to identify differentiated subtypes, which share outcomes of playing videogames are the development of cognitive similar risk factors, phenotypes and symptoms. The prevalent and social abilities, the inducement of positive emotions, Frontiers in Psychology | www.frontiersin.org 2 March 2021 | Volume 12 | Article 621953 Mena-Moreno et al. Serious Games and Emotion Regulation improvements in mood, the promotion of engagement, and the increased their emotional awareness and improved their decision- achievement of self-actualizing experiences (Fernandez-Aranda making by refining reward processing through the biofeedback et al., 2015; Tárrega et al., 2015; Osmanovic and Pecchioni, 2016; mechanism of the game (Astor et al., 2013). Heart rate variability Mack et al., 2017; Russoniello et al., 2009). (HRV) is an accessible research tool that can increase the The proliferation of serious games in health-related contexts understanding of emotion in social and psychopathological has been explained as the consequence of three factors. First, processes (Porges, 1986, 1997, 2001). HRV analysis is emerging serious games appeal to a wide audience that otherwise would as an objective measure of regulated emotional responding not seek treatment; second, it is easier to engage in and enjoy (generating emotional responses of appropriate timing and the therapeutic process; and third, the immersive experiences magnitude). The measurement of HRV responds to autonomic on a sensory level (at the visual, auditory level, etc.) depicted flexibility and, therefore, an increased HRV correlates with greater in serious games have been shown to improve effectiveness emotional control (Appelhans and Luecken, 2006). (Fleming et al., 2017). Also, as self-training methods, these In an experiment using a breathing-strategy-game for ER therapeutic aids can be easily accessible and affordable for those in youths, in which a frustration-inducing phase was added, who face financial barriers in obtaining professional help for participants did not behave differently when using mobile mental disorders (Clarke, 2007). A review of 15 studies reporting devices as compared to using a computer, signaling the adequacy uses of serious games in psychotherapy concluded that all of tablets for this purpose (Vara et al., 2016). However, that interventions showed positive results with improvements in the experiment was carried out among high school students and outcome variable, and were particularly effective in increasing caution must be exerted to generalize these conclusions into motivation, adherence to treatment and strengthening the a treatment-seeking setting. In fact, a systematic review revealed therapeutic alliance (Eichenberg and Schott, 2017). This final that 87% of health-oriented serious games usability studies point is important, since the relationship between the therapeutic were conducted on healthy users, whereas only 13% recruited alliance and the response to treatment, regardless of the specific a clinical sample (Yáñez-Gómez et al., 2017). treatment modality used, has been demonstrated. Characteristics Since available empirical evidence in the scientific literature such as sex, age, or the type of problem presented by the patient has indicated that sex and age play an important moderating influence the therapeutic alliance, in addition to the characteristics role in gambling (Valero-Solís et al., 2018; Granero et al., 2020; of the therapist and the interaction with the patient themselves Jiménez-Murcia et al., 2020), these two sociodemographic (Martin et al., 2000; De Weert-Van Oene et al., 2001; Norcross, variables were considered. 2002; Arnow et al., 2013; Bucci et al., 2016; Kallergis, 2019). Here, we present a new serious videogame, e-Estesia. Thus, Another study by Tárrega et al. (2015) found that obtained the aims of this study are to first present a description of the patients had a lower dropout rate when using serious games serious videogame e-Estesia and then to assess its usability in compared to patients who did not. patients undergoing treatment for GD. Differences in the usability Self-training of people experiencing GD via serious games scores based on the participants’ gender and age, as well as with biofeedback sensors has been proven to reduce arousal on gambling preferences, are also explored due the strong and general impulsive behaviors while enhancing self-control contribution of these features to gambling behavior. (Jiménez-Murcia et al., 2009; Fernandez-Aranda et al., 2015; Tárrega et al., 2015). In the specific context of the use of serious games to channel ER interventions, some experiments have MATERIALS AND METHODS shown that participants prefer these over paper-based interventions, and that they find serious games more apt to generate, first Introducing e-Estesia frustration and then effective ER (Rodriguez et al., 2015). e-Estesia is an app-based serious videogame designed to improve The underlying mechanism of serious games for therapy is ER in patients with impulse control disorders and other disorders simple. Individuals become more aware of their emotions as characterized by inhibitory control deficits. In its current format, measured by biosensors through a visual and audio representation e-Estesia runs on password-protected Android portable devices of them on screen. The biofeedback connects the emotional (tablets) and is connected via Bluetooth to a sensor that reaction to the media display, helping individuals to learn how transmits physiological data [heart rate (HR) and HRV] from to regulate their emotions and visually rewarding them when the participant to the device. doing adequately (Jerčić and Sundstedt, 2019). Serious games The game is based on a previous serious game, developed allow real situations to be recreated in virtual settings, while by our group and the PlayMancer Consortium (Jiménez-Murcia provoking a series of cognitive, emotional and behavioral responses et al., 2009; Fernández-Aranda et al., 2012). PlayMancer is in individuals. This allows for the training of specific skills in a more complex serious videogame that retrieves scores from a motivating and entertaining way that can be more difficult multiple biofeedback sensors including galvanic skin response, to achieve with traditional therapies. For example, in the concrete oxygen saturation, HR and HRV, breathing frequency and task of uniting stars from the constellations in Playmancer, the skin temperature. This intervention has been demonstrated core objective is training in relaxation, increased self-awareness to improve treatment outcomes in eating and GD patients and self-regulation. (Fernández-Aranda et al., 2012). (Fagundo et al., 2013; Fernandez-Aranda et al., 2015; Tárrega Bespoke games using biosignals to improve ER have been et al., 2015). However, PlayMancer needed patients to play tested in laboratory conditions. One study reported that individuals the game within the premises of the hospital due to the Frontiers in Psychology | www.frontiersin.org 3 March 2021 | Volume 12 | Article 621953 Mena-Moreno et al. Serious Games and Emotion Regulation multiple required biosensors. In contrast, e-Estesia is a much Participants more convenient solution that facilitates treatment by (a) A pilot sample of 26 patients seeking treatment for GD was transforming the desktop computer-based experience into an obtained for the present study. Data from participants were app-based interface, making it fully portable and allowing collected from December 2018 to May 2019 by means of a treatment delivery at home, (b) reducing the outcome measures purposive sample recruitment procedure. Consecutive patients and the equipment needed to a single biosensor and a tablet, who began cognitive-behavioral treatment for GD were offered and (c) streamlining the game design and the human-media the opportunity to participate in the study, and all participants interactions to its core, most therapy-relevant components. who agreed were selected and provided that they met the e-Estesia starts by asking participants about their mood. inclusion and exclusion criteria. Due to the observational nature The question can be answered by selecting one of five face of this pilot study, self-selection bias and lack of randomization icons ranging from sadness to happiness (graphics validated in were not deemed significant as the results at this stage were previous studies and in different samples; (Diana et al., 2012; not to be compared to a control group. Garcia-Palacios et al., 2014). In order to participate, the following exclusion criteria were Next, a voice-over trains participants on how to become considered: (a) the presence of a psychiatric or neurological aware of their breathing and sitting posture. The game is set disorder such as schizophrenia or other psychotic disorders on a tropical island. The gamer’s point of view is located a that might impact game performance, (b) an intellectual disability, few feet inland and moves alongside the coastline in a single, and (c) active pharmacological therapy that might interfere uninterrupted tracking shot (see Figure 1). The game depicts with game performance. Inclusion criteria included being tropical vegetation, sea, horizon, sun, clouds, and rain. The diagnosed with GD, which was assessed prior to the study game follows an A-B-A design pattern consisting of (a) an both via screening methods (SOGS, DSM-IV criteria and other initial 3-min period in which the landscape is sunny, (b) a relevant measures to identify psychopathological symptoms) subsequent 4-min period in which rain clouds and eventually and individual structured interviews by experienced psychologists. a storm appear, and (c) a final 3-min period identical to the The sample included 21 men (80.8%) and five women (19.2%), first one. Gamers are instructed at the beginning of the game with ages ranging from 22 to 74 years (M = 41.2, SD = 12.9). to try and breathe calmly (diaphragmatic breathing instructions). All participants received information regarding the aims of The initial and final periods are used as baseline to practice the research and they provided signed informed consent for this breathing technique. The intermediate period is designed participating. There was no financial or other compensation for the subjects to learn how to manage their breathing through for being part of the study sample. Participants who agreed a HRV biofeedback mechanism. This mechanism gives the to take part in the study were briefed on the purpose of the user information about their breathing thanks to a visual system study and were reassured of the voluntary nature of their with animations (e.g., clear sky vs. rainy clouds). In this way, participation and their rights to stop at any time. The study e-Estesia reports feedback (clouds appear more or less frequently) was approved by the Ethics Committee of the first author’s based on participants’ breathing while using the device. When hospital (ref. number PR286/14), adhering to the principles participants succeed in regulating their emotions by breathing outlined in the latest version of the Declaration of Helsinki. properly, the biosensor utilizes this physiological information to reinforce this behavior by dissipating the storm; if breathing does not improve, the rain becomes more intense. This Procedure intermediate period adds stressors. During the game, simple After providing informed and signed consent, participants were instructions are given regarding how to modulate poor weather scheduled for an individual appointment in a week’s time. conditions. The patient must be an active participant in the This appointment was used to (a) brief the participants about process as they interact with the application and consolidate the study procedure; (b) explain how to use the device this learning via breathing techniques. and sensor strap; (c) train participants how to “beat” the app FIGURE 1 | Screenshots from e-Estesia depicting the different phases of the Serious Game. Frontiers in Psychology | www.frontiersin.org 4 March 2021 | Volume 12 | Article 621953 Mena-Moreno et al. Serious Games and Emotion Regulation (i.e., breathing calmly, regulating one’s emotions, etc.), and (d) Litchfield, 2003; Lehrer et al., 2010; Lehrer and Gevirtz, 2014; conduct an initial supervised session using e-Estesia. After Russell et al., 2014; Nazarewicz et al., 2015). conducting the initial intervention session with the application, the usability scale described below was administered to Sociodemographic Variables the participants. Additional data were obtained through a semi-structured interview, which assessed sociodemographic features (e.g., Measures education, marital status, socio-economic, and employment The System Usability Scale (SUS; Brooke, 1996) was used to status). However, for the purpose of the present study, only gauge how usable participants perceived the app to be. This age, gender, and gambling platform preference (i.e., offline vs. scale is context-specific and does not measure usability in online) were reported. isolation but as a product of the user-interface interaction and the specific goals that users expect to accomplish with its use Statistical Procedure (Schmidt and De Marchi, 2017). The instrument was conceived Statistical analysis was done with Stata16 for Windows. Means after the international standard ISO 9241-11, which identifies on the SUS were compared between the groups defined by effectiveness, efficiency, and satisfaction as the key components the patients’ sex and age, through nonparametric Mann-Whitney of usability assessment. The instrument comprises 10 items tests, and effect size for the mean differences was estimated and each item is placed on a 5-point Likert scale (from 1 to through Cohen’s-d coefficient (|d| < 0.20 was considered null 5; 1 = strongly disagree; 3 = neither agree nor disagree; 5 = in effect size, |d| < 0.50 low, |d| > 0.50 moderate and |d| > 0.80 large). complete agreement). Final scores for SUS range from 0 to 100, with higher scores indicating greater usability. Internal consistency of the scale calculated in the study was adequate RESULTS (Cronbach-alpha, α = 0.75). The sample included 21 men (80.8%) and five women (19.2%), Psychophysiological Variables with ages in the range of 22–74 years-old (M = 41.2, SD = 12.9). Two physiological variables were measured: heart rate (HR) The number of participants who reported to prefer offline and HRV (defined as the variation in the time between successive gambling was 21, whereas five preferred online gambling. heartbeats). These measurements were recorded via a Polar Table 1 includes the frequency distribution of the items in TM H7 Bluetooth Heart Rate Sensor by Polar Electro Oy . HR the study. Total raw score for the SUS ranged from 53 to 98 (beats per minute) scores were used. The rationale for these (mean = 83.8, SD = 13.1; Normality test: Kolmogorov-Smirnov- measures derives from previous studies pointing out that Statistic = 0.13, df = 26, p = 0.200). Table 2 contains the deviations higher than baseline HR scores are typically associated results of the comparison of mean scores based on the patients’ with emotions of anger and joy, whereas lower values of sex, gambling preferences, and age groups [defined by the excitement (i.e., below baseline) usually indicate neutral condition median (percentile 50) in the sample]. Although no statistical and boredom (Eddie et al., 2014, 2015). HRV, which usually differences were obtained in the comparison between the groups, ranges from 30 to 39, is a variation in the beat-to-beat time a moderate effect size was related to participants’ age (lower interval (time between two successive R-waves) that occurs mean score in the younger age group; |d| = 0.59). spontaneously and naturally and that is positively associated Regarding the preliminary results of the pilot study carried with self-regulation, heart health, autonomous balance, and out using e-Estesia, Figure 2 shows the changes in HR and task performance. In turn, it is negatively associated with HRV during the initial 3-min period pre-game, the subsequent anxiety, depression, stress, hypertension, chronic muscle pain, 4-min period game play, and the 3-min period post-game, and nausea (Porges, 1995; Malik, 1996; Sargunaraj et al., 1996; obtained in the sample (n = 26). As expected, the measures TABLE 1 | Frequency distribution for the System Usability Scale (SUS) items. Strongly disagree Strongly agree Option 1 Option 2 Option 3 Option 4 Option 5 n % n % n % n % n % 1. I would like to use this system 1 3.8% 3 11.5% 9 34.6% 8 30.8% 5 19.2% 2. System unnecessarily complex 19 73.1% 1 3.8% 4 15.4% 1 3.8% 1 3.8% 3. System easy to use 1 3.8% 0 0% 3 11.5% 4 15.4% 18 69.2% 4. I would need technical support 21 80.8% 5 19.2% 0 0% 0 0% 0 0% 5. Various functions well integrated 0 0% 3 11.5% 7 26.9% 9 34.6% 7 26.9% 6. Too much inconsistency 11 42.3% 10 38.5% 4 15.4% 1 3.8% 0 0% 7. Most people would learn 0 0% 1 3.8% 2 7.7% 6 23.1% 17 65.4% 8. Very cumbersome to use 22 84.6% 1 3.8% 2 7.7% 0 0% 1 3.8% 9. Very confident using the system 1 3.8% 2 7.7% 4 15.4% 8 30.8% 11 42.3% 10. I need a lot of learn before use 22 84.6% 2 7.7% 1 3.8% 0 0% 1 3.8% Frontiers in Psychology | www.frontiersin.org 5 March 2021 | Volume 12 | Article 621953 Mena-Moreno et al. Serious Games and Emotion Regulation TABLE 2 | Comparison of the SUS raw scores divided by sex, gambling preference and groups of age. Sex Gambling preference Age groups Women Men Offline Online Age 22–35 Age 36–74 n=5 n = 21 n = 21 n=5 n = 12 n = 14 Mean SD Mean SD p d Mean SD Mean SD p d Mean SD Mean SD p d 86.5 8.8 81.4 13.9 0.447 0.44 81.8 11.7 85.0 19.2 0.631 0.20 78.3 13.7 85.9 11.9 0.145 0.59† SD, standard deviation. Groups of age defined for the median (percentile 50) in the sample. † Bold: effect size in the medium (|d| > 0.50) to large (|d| > 0.80) range. FIGURE 2 | Line-plot for heart rate (HR) and heart rate variability (HRV) means within the entire sample. varied as a function of time in the session, with increased (ranging from 0 to 100), which indicates a high levels of activity during the start of the game (differences are more endorsed usability. Mean scores were somewhat lower in the evident for HR comparing the period of game play vs. the younger group (between 22 and 35 years). period of pre-game). Figure 3 includes the line-plot stratified The main reasons for using this specific type of technology by the patients’ sex, which shows greater activation in HR are the internal characteristics of serious games, such as the among men compared to women for all the session, but greater intensity with which they capture the attention of the individual, HRV among women. Particularly, women showed a decrease the ease with which they disconnect from the outside world, in the HR during the period of game play compared with their ability to immerse, the low resistance on the part of the pre-game phase, while men showed an increase in the most individuals to use them and the motivation that they HR levels during the game playing phase. tend to generate in many people (Eichenberg and Schott, 2017). With e-Estesia, aspects as the easy use, easy learning, and the no expert support was needed in it use were highly scored DISCUSSION (84, 88, and 100% of agreement, respectively). This is an important aspect considered that one of the aims of the The present study aimed to assess the usability of a new development of e-Estesia were to provide independence to their emotion-regulation training app for GD, based on previous users, as an improvement of other similar serious games that studies carried out in eating disorders and GD (Fernández- have been used to improve emotional regulation, such as Aranda et al., 2012). In the study participated 26 patients Playmancer, this serious game is useful for improving emotional undergoing treatment for GD, giving high scores in effectiveness, regulation, but requires the support of an expert to be able efficiency, and satisfaction with the use of the tablet-based to use it (Fernández-Aranda et al., 2012). serious game e-Estesia (according to the SUS; Brooke, 1996). Some studies have shown that the use of video games could This is one of the few studies conducted in order to evaluate improve motivation and adherence to treatment (Kato et al., usability of a serious game in clinical population (Yáñez-Gómez 2008; Coyle et al., 2009). The study results showed that a high et al., 2017). The app performed comparatively well in all percentage of participants believed the app was coherent, groups. The average score, both in men and women, and with consistent, not confusing (61.5, 80, and 88.4% of agreement different gambling preferences (online vs. offline) was over 80 respectively) and that its features were adequately merged into Frontiers in Psychology | www.frontiersin.org 6 March 2021 | Volume 12 | Article 621953 Mena-Moreno et al. Serious Games and Emotion Regulation FIGURE 3 | Line-plot for HR and HRV means stratified by sex. the overall app design and content. This aspect is important difficulties in ER compared to women (specifically, men had considering that the benefits of the use of serious games in poorer performance in the non-acceptance of emotions domain; health contexts are related with their capacity to capture the Sancho et al., 2019). Other studies in laboratory conditions attention of the user, which can help the motivation to continue and with healthy populations show results contrary to the using it (Fagundo et al., 2013). Also, in the context of GD study, suggesting that women could react to laboratory stressors patients, this could be an important auxiliary treatment strategy, with higher HR responses, whereas men have greater blood if it is considered that different personality traits (Tárrega pressure (Carrillo et al., 2001; Abad-Tortosa et al., 2017). et al., 2015), such as low self-directedness (Janiri et al., 2007), This application aims to improve the management of ER have been associated with lack of adherence to the treatment through a biofeedback mechanism, mediated by instructions in (Del Pino-Gutiérrez et al., 2017). diaphragmatic breathing. It is possible that in the first sessions, Finally, comfort and desire to use the app were inextricably in which patients are learning the management of their linked. All the patients who responded that they agreed that psychophysiological state and the establishment of new breathing they would like to use the application frequently also agreed patterns, they would not feel entirely comfortable with this that they were comfortable using it. This is consistent with intervention. Levels of stress and anxiety might even be expected the preexisting literature that affirms that for serious game to increase during the first sessions. Other serious game studies users, it is easier to engage in the therapeutic process if it is have shown similar results on this point, such as the “Zen Cat,” enjoyable (Fleming et al., 2017). a brain-computer interface that allow any person to control Using e-Estesia during a session with 26 GD patients revealed applications using only their brain waves. The majority of players, that women had a lower mean HR and a higher HRV during in the first sessions of the evaluation, thought that the game the use of the serious game compared to men. This could was hard, even on the easy mode. Although this opinion persisted indicate that for this first session, women show a greater for some subjects in the later sessions as they were still trying capacity to self-regulate their psychophysiological state through to find a good strategy, most of them thought that the game biofeedback and breathing instructions (Appelhans and Luecken, became easier with each session, as they were able to reach 2006). During the interaction phase of the serious game, this higher scores and maintain the average meditation higher for difference between men and women increased, with women longer periods of time. showing a higher HRV. Therefore, future research is needed that measures more These results should be careful lighted through the differences than one e-Estesia session in contexts that differ from the in emotional regulation difficulties that both genders present laboratory. In conclusion, the usability scores and the biofeedback in GD patients. While higher rates of arousal-seeking behavior information provide promising evidence of using e-Estesia to have been described in men, women’s gambling activities may assist in the treatment of GD. be related with the aim of avoid negative emotion states (Ledgerwood and Petry, 2006; Liu et al., 2009), for which it is possible to hypothesized that men GD patients could have LIMITATIONS AND FUTURE LINES OF higher difficulties at the beginning in self-regulation of them RESEARCH psychophysiological state. However, other aspects as the conditions of the evaluation, may influenced these results. A This study should be interpreted in the basis on some limitations. study comprising 484 GD patients showed that men had more First, the usability of the app was assessed through a scale Frontiers in Psychology | www.frontiersin.org 7 March 2021 | Volume 12 | Article 621953 Mena-Moreno et al. Serious Games and Emotion Regulation focused on the key components of this type of systems, and, AUTHOR CONTRIBUTIONS therefore, no reference benchmarks or norms are available for comparing our results. In addition, only one scale was used SJ-M, FF-A, TM-M, RG, LM, and TS contributed to the development to measure usability, without specific additional methods such of the study concept and design. SJ-M, FF-A, RG, LM, AP-G, as usability testing, cognitive walkthrough, heuristics analysis ML-M, MG-P, LM, and JM had previous experience in the design or other instruments. Second, the low sample size: statistical and use of SG for the treatment of impulsive spectrum disorders analysis was not adequately powered to examine associations and their experience and advice were decisive in the design of between background variables with the usability measures. It the present device. RG performed the statistical analysis, wrote should be outlined that many feasibility studies are carried the results and made the tables and Figures. SJ-M, TM-M, LM, out within small samples, which should accurately reflect the TS, and HL-G aided with interpretation of data and the writing characteristics of the larger target population of users. We tried of the manuscript. TM-M, LM, AP-G, ML-M, BM-M, EV-M, to choose a representative group of GD patients that closely MG-P, and LM collected the data. FF-A, JM, IG, TS, MG-B, matched the distribution of age, sex, and gambling preference and AS revised the manuscript and provided substantial comments. of the whole population candidate to use the e-Estesia. In SJ-M, FF-A and JM obtained funding. All authors contributed Spain, the odds men/women and offline/online preference to the article and approved the submitted version. among GD patients are around 4/1, and these ratios have been reflected in this pilot analysis. Future studies could test additional relationships, and try to identify potential predictors FUNDING of usability in the GD area (such as the presence of comorbid mental health conditions, sociodemographic profile or confidence This research was supported by grants from the CERCA Programme/ in using technology). Generalitat de Catalunya for institutional support. It was additionally supported by grants from the Ministerio de Economía y Competitividad (PSI2015-68701-R), and from the Ministerio de DATA AVAILABILITY STATEMENT Ciencia, Innovación y Universidades (grant RTI2018-101837-B-100). The research was funded by the Delegación del Gobierno para The raw data supporting the conclusions of this article will el Plan Nacional sobre Drogas (2017I067 and 2019I47), Instituto be made available by the authors, without undue reservation. de Salud Carlos III (ISCIII; PI17/01167) and co-funded by FEDER funds/European Regional Development Fund (ERDF), a way to build Europe. CIBERObn and CIBERSAM are both initiatives of ETHICS STATEMENT ISCIII. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The studies involving human participants were reviewed and TM-M and ML-M are supported by a predoctoral Grant of the approved by Ethics Committee of the first author’s hospital Ministerio de Educación, Cultura y Deporte (FPU16/02087 and (ref. number PR286/14), adhering to the principles outlined FPU15/02911). HL-G is supported by a Generalitat de Catalunya in the latest version of the Declaration of Helsinki. The patients/ Grant (2017 BP 00035). LM was supported by a postdoctoral participants provided their written informed consent to Grant of the Mexican Institution Consejo Nacional de Ciencia y participate in this study. Tecnología-CONACYT (Science and Technology National Counsel). REFERENCES Appelhans, B. M., and Luecken, L. J. (2006). Heart rate variability as an index of regulated emotional responding. Rev. Gen. Psychol. 10, 229–240. doi: Abad-Tortosa, D., Alacreu-Crespo, A., Costa, R., Salvador, A., and Serrano, M. Á. 10.1037/1089-2680.10.3.229 (2017). 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Psychol. 11, 379–405. doi: 10.1146/annurev- López-González, del Pino-Gutiérrez, Lozano-Madrid, Gómez-Peña, Moragas, Giroux, clinpsy-032814-112739 Grall-Bronnec, Sauvaget, Mora-Maltas, Valenciano-Mendoza, Menchón and Suomi, A., Dowling, N. A., and Jackson, A. C. (2014). Problem gambling Jiménez-Murcia. This is an open-access article distributed under the terms of the subtypes based on psychological distress, alcohol abuse and impulsivity. Creative Commons Attribution License (CC BY). The use, distribution or reproduction Addict. Behav. 39, 1741–1745. doi: 10.1016/j.addbeh.2014.07.023 in other forums is permitted, provided the original author(s) and the copyright Tárrega, S., Castro-Carreras, L., Fernández-Aranda, F., Granero, R., owner(s) are credited and that the original publication in this journal is cited, in Giner-Bartolomé, C., Aymamí, N., et al. (2015). A serious videogame as accordance with accepted academic practice. 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