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Welcome to CombatCounselor Chronicle, an E-zine dedicated to giving you the most current, pertinent information on cognitive behavioral therapy (CBT) and mindfulness-based CBT available.

Chris Sorrentino, a.k.a CombatCounselor, is a leader and expert in cognitive behavioral therapy. He combines 30 years of experience in psychology with the discipline from having served as a U.S. Air Force officer for 20 years, 4 of those in combat zones, retiring as a lieutenant colonel in 2005.

The Leader in Military and Veteran Psychology ... Follow Me to Mental Health!

CombatCounselor Q&A



PenePan @PenePan
11/13/13 Once immersed in therapy how to judge if ur pain and anguish is therapeutic or just painful/therapist not a good fit?

ANSWER: Facing and enduring painful #thoughts and #emotions is part of #therapy. If you continue to get worse, something's wrong.  There's normally a #HoneymoonEffect followed by a short downturn, then gradual improvement with minor set-backs from time to time. If you don't see gradual improvement over 3-4 consecutive sessions, it may be time to find a new therapist !

Here's an article on finding a good therapist: 

This article tells you everything you need to know AND ASK when looking for a TRUE COGNITIVE BEHAVIORAL THERAPIST:

C.T. Sorrentino, LtCol, USAF (Ret)
aka CombatCounselor

Key Words: The rap question answer pain anguish twitter Facebook combat counselor CombatCounselor psychology psychotherapy blogger emotion thought mindfulness

Question ("Anonymous" on Tumblr):  I'm looking to find studies or research which show a link between diet and nutrition and mental health especially depression, I know that research exists on this topic but I honestly don't know where to start because there's a lot of inaccurate information about on the internet. Do you know of any accredited studies or research on this topic? Thanks!

Answer:  There are tons of research linking diet, exercise, sleep, and many other things with depression, so you may want to be more specific.

Perceived body image problems have been linked to anxiety and depression and so has poor nutrition among many others. Depression is one of the most heavily studied mental health issues, so if you don't narrow it down, you will waste a great deal if time.

There are numerous scholarly journals and reputable studies out there and a keyword search on Google or other search engine should bring up hundreds, if not thousands, of options. You want to look for studies published in large journals or by prestigious institutions, involving large numbers of subjects, a control group, and realistic expectations (results). If it sounds too good to be true, it probably is not (true). Statistics can be distorted to "prove" practically anything, so look for multiple studies measuring the same things (variables) or what we call meta-analyses, or study of several studies.

My proprietary therapy, discussed at length on my website,, blog,, and YouTube channel, offers an easily understandable synopsis of my extensive review of the literature, so feel free to start there. If you have specific questions, I would be happynto try to answer them for you.

Good luck, StayPresent, BeResilient. and StayTheCourse...CombatCounselor



Justin Iiams wrote on Twitter:

Question: @CombatCounselor what's the % of vets from oif/oef who have PTSD or have committed suicide? -- @justiniiams

Answer: Recent studies say UP TO 50% of OIF/EF #Vets return with PTSD-like symptoms & suicide rates are slightly higher than national average. #AFTimes recently reported a study claiming over 90% of OIF/EF #Vets have PTSD & 70% attempted suicide, but I'm suspicious.

C.T. Sorrentino, LtCol, USAF (Ret)

Question:  I've heard that therapy can last for years and I can't afford to spend so much time or money.  What kind of commitment are we talking about here?

Answer: Cognitive behavioral therapy is a structured, time-limited approach, so therapy can be very short (2-3 sessions) or a bit longer (10-14 sessions).  On average, CBT takes between 8 and 12 (1 hour) sessions.

Question:  Why don't you accept insurance?

Answer:  We can offer lower prices because we do not accept insurance.  Insurance has many limiting factors with potential negative ramifications for you and for us.  If we were to accept insurance, the insurance company has many requirements that are beneficial to them, but not necessarily to you.  To avoid those pitfalls and potential ethical dilemmas, including the requirement to assign a diagnosis which may follow you for the rest of your life, we choose to charge our clients less so they can afford to utilize our services.

Question:  What do you mean by "mindfulness-based" CBT and a "holistic" approach?

Answer:  The latest research indicates that mindful "acceptance" of things as they are in the here-and-now is a powerful approach to living a happy and rewarding life.  At KCCBT, we incorporate mindfulness training (acceptance) into therapy and offer additional low-cost training (for those who need it) from a certified Yoga/Tai Chi instructor.  From a holistic perspective, we focus on your unique situation multi-dimensionally, analyzing in detail your cognitive (thoughts), behavioral (habits), physiological (diet, sleep, exercise), and emotional (anxiety, depression, shame) make-up, developing a therapeutic plan with you that will break the vicious cycle which brought you to therapy in the first place.  We have a licensed nutritionist available for those requiring more in depth dietary analysis and intervention.

Question:   I have heard that three out of every ten people in the US are clinically depressed or anxious, enough so that they are unable to effectively cope with home, work, and/or life demands. What is Body-Mind-Behavior Therapy (BMBT) and what can it do for me?

Answer:  Our holistic, midnfulness-based cognitive-behavioral approach will help you overcome your problems and live a happier, more fulfilling life utilizing our  proprietary approach, BMBT.  Rather than teach you tricks or give you pills to avoid or cope with anxiety, depression, and other painful emotions, we teach you how to live with them through non-judgmental acceptanc, living in accordance with the things that are important to you, your values.

Visit the "Our Practice" page for more details!

Question:  What is an addiction and is video game addiction a diagnosable condition?

Answer:  Addiction – Inability to control and impulse or continued involvement in an activity despite negative consequences associated with pursuing it. 

The American Society of Addiction Medicine defines addiction as:

“A primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviors. The addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships. Like other chronic diseases, addiction can involve cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

DSM-V plans on possibly including video game/internet addiction in one of the following four categories in the 2012 release:

Impulse Control Disorder

Obsessive-Compulsive Spectrum Disorders
Impulsive-Compulsive Spectrum Disorders
Substance and Behavioral Dependencies

Question:  What is the difference between addication, abuse, and dependence?

Answer:  The three can be separated like this:

Addiction – Inability to control and impulse despite negative consequences associated with pursuing it. 

Abuse – A maladaptive pattern of behavior that is not considered dependent

Dependence – When an individual persists in a behavior despite problems related to that behavior, dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the behavior and withdrawal symptoms are possible when behavior is reduced or stopped. 

Question:  What are some of the behavioral and physical symptoms of game addiction?



• Most non-work hours are spent on the computer or playing video games 
• Falling asleep at work
• Falling behind with responsibilities
• Loss of productivity at work and at home
• Dropping out of social groups and liked hobbies
• Being irritable when not playing a video game or being on the computer 
• Lying about how much time you spend playing computer or video games 
• Playing computer or video games results in intense feelings of pleasure or guilt that seem uncontrollable
• Spending more and more time playing video or computer games to get the same enjoyment
• Withdrawing from friends, family, or your spouse to the point of disrupting family, social, or work life
• Experiencing feelings of anger, depression, moodiness, anxiety, or restlessness when you’re not gaming
• Spending significant sums of money for online services, computer upgrades, or gaming systems
• Thinking obsessively about being on the computer or playing video games even when doing other things
• Sneaking off to play video games, lying about amount of game time, or playing while others are sleeping to avoid discovery
• Work performance suffers because the gamer has stayed up all night playing games and is too tired to complete tasks
• Boss may find person asleep on the job or failing to complete assignments on time, which could result in disciplinary action or even termination
• Playing games during work hours, using company computers and equipment


• Carpal tunnel syndrome
• Sleep disturbances 
• Backaches or neck aches 
• Headaches 
• Dry eyes 
• Forgetting to eat, shower, shave, or take care of basic hygiene

Question:  What are the demographics of people affected by video game addiction?


• The “average” gaming addict is 35 years old and male
• Approximately 88% of Americans youth play video games at least once per month
• 53% of adults are gamers
• 10% of regular gamers will become addicted (more than 21 hours per week)
• The majority of gamers are between ages 24 and 35
• 60% of gamers are men; 40% of gamers are women
• Female gamers reported greater depression and lower health status than non-players.
• Male gamers reported higher body mass index and more Internet usage than non-players.
• Both male and female gamers demonstrated greater reliance on the Internet for social support.
• Adult addicted gamers were more likely to be socially withdrawn, sacrificing real-life social activities to play video games, and were more likely to lead 
  a sedentary lifestyle and be overweight.
• More than half (53 percent) of American adults play video games
• About one in five adults (21%) play every day or almost every day
• Adolescents and young adults tend to dominate the gaming scene, but adults tend to be more avid players, playing more frequently and thus 
  sometimes falling prey to video game addiction
• 75 percent of video game players are over the age of 18, and the average game player is 35 years old
• Roughly one-third of adult gamers find time to spend 10 hours or more playing video games every week compared to 11 percent of teens
• Adults are less likely than teens to play online games or on video game consoles, preferring instead to play on the computer
• Adults are less attracted to massive multiplayer online games (MMOGs) like World of Warcraft than teens
• Female gamers outnumber male gamers in the 25-34 age category
• Boys diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) or hostility are more likely to become addicted to the Internet.
• Girls diagnosed with depression or social phobia are more likely to develop an addiction to the Internet
• For children and teens with ADHD, the constant stimulation offered by the Internet (including social networking sites that are constantly updated and
  fast-paced video games) offers the perfect outlet
• For those with depression, social phobia or hostility, the Internet has a therapeutic effect, permitting them to create their own online identity without 
  having to function “normally” in the real world.
• Children and teens with ADHD are easily bored and have an aversion to delayed reward.
• Internet behavior is characterized by rapid response, immediate reward and multiple windows with different activities, reducing feelings of boredom 
  or delayed aversion.
• While playing online games, striatal dopamine is released, possibly compensating for the dopamine deficit in teens with ADHD.

Question:  Why do people get “hooked" on video games?


• The High Score
Whether you've tried out the latest edition of Grand Theft Auto or haven't played a video game since PacMan, the high score is one of the most easily recognizable hooks. Trying to beat the high score (even if the player is trying to beat his own score) can keep a player playing for hours. 

• Beating the Game

This "hook" isn't used in online role-playing games, but is found in nearly every gaming system. The desire to beat the game is fed as a player "levels up," or finds the next hidden clue. 

• Role-Playing

Role-playing games allow players to do more than just play - they get to actually create the characters in the game and embark on an adventure that's somewhat unique to that character. Consequently, there's an emotional attachment to the character, and the story makes it much harder to stop playing.

• Discovery

The exploration or discovery tactic is most often used in role-playing games. One of the most popular online games currently is World of Warcraft, and a good portion of the game is spent exploring imaginary worlds. This thrill of discovery (even of places that don't really exist) can be extremely compelling. 

• Relationships

Again, this is primarily an online "hook." Online role-playing games allow people to build relationships with other players. For some kids, this online community becomes the place where they're most accepted, which draws them back again and again.

• Massive Multiplayer Online Role-Playing Games (MMORPGs) 

MMORPGs can be especially addictive because there's no ending. Unlike standard games like Super Mario Brothers, where you win when you save the princess, you can't rescue the princess in an MMORPG. 

Question:  What is the best treatment for gaming addiction?

Answer:  Others may disagree, but research and empirically supported data has concluded that Cognitive-behavioral therapy (CBT) is most effective. The most important consideration is to find a therapist who you can get along with, trust, and is LICENSED to practice in your state and certified by a major certifying body for their profession:

Licensed Therapist Categories (may vary by state)

Licensed Professional Counselor (LPC)
Licensed Clinical Social Worker (LCSW)
Licensed Psychologist

Question:  What treatment options are available for someone with a gaming addiction?


Self-Help Books and Groups

Online Gamers Anonymous (12-Step Program similar to AA)


Individual Out-Patient Therapy (CBT)

Body-Mind-Behavior Therapy (BMBT)

Priority #1 – Eliminate possibility for suicide and reduce therapy interfering behaviors 

Body – Complete physical, history, and assess diet, exercise and sleep habits

Mind – Begin CBT/ACT, focusing on mindfulness, then progressing through appropriate techniques

Behavior – Focus on behavioral activation, getting client to set goals based on values, make a commitment to prioritize/implement goals on a schedule

Relapse Prevention – Teach the client the skills necessary to prevent relapse, set up booster appointments, and leave the door open for future contact

CBT                                                                              ACT

Cognitive Restructuring                                            Creative Hopefulness
Problem Solving/Decision Making Training           Mindfulness and Acceptance
Social/Coping Skills Training                                    Control as the Problem
Cue exposure and response prevention                  Self as Context
Imaginal rehearsal                                                     Cognitive Defusion
Role Playing                                                                 Values Clarification
                                                                                       Committed Action 

Individual/Couples Group Therapy

Couples Out-Patient Therapy

Individual Residential Treatment

Additional Information on Gaming Addiction

The following facts were retrieved from: on July 3rd, 2011.  I would like to thank the folks at TechAddiction for providing the information and references:

Personality traits like trait anxiety, sensation seeking, neuroticism, and aggression appear to be related to the development of gaming addiction. 

Mehroof, M et al. (2010). Online gaming addiction: The role of sensation seeking, self-control, neuroticism, aggression, state anxiety, and trait 

anxiety. Cyberpsychology, Behavior, and Social Networking, 13, 313-316.

Regions of the brain associated with cravings in substance abuse also appear to be activated in gaming addicts when they view images of video games.

Ko, C. et al. (2009). Brain activities associated with gaming urge of online gaming addiction. Journal or Psychiatric Research, 43, 739-747.

There is a difference between "excessive gaming" and "addictive gaming". Two gamers may play for an identical number of hours each day, but their psychological motivation and the meaning that gaming has within their lives can be very different. Gaming addiction should be defined by how much the game negatively impacts others areas of life, not by how much time is spent playing.

Griffiths, M et al. (2010). The role of context in online gaming excess and addiction: Some case study evidence. International Journal of Mental 

Health and Addiction, 8, 119-125.

In a volunteer sample, 41% of online gamers acknowledged that they use gaming as an escape. In the same sample, 7% were viewed as "dependent". These gamers possessed several behavioral attributes that are related to more well established forms of addiction (e.g., mood modification, tolerance, & relapse).

Hussain et al. (2009). Excessive use of massively multi-player online role-playing games: A pilot study. International Journal of Mental Health and 

Addiction, 7, 563-571.

Most online gamers are male. Among male gamers, more severe online gaming addiction is correlated with older age, lower self-esteem, and lower dissatisfaction with daily life. This relationship did not hold true for female gamers.

Ko et al. (2005). Gender differences and related factors affecting online gaming addiction among Taiwanese adolescents. Journal of Nervous and 

Mental Disease, 2005, 273 - 277.

Online gamers who viewed themselves as playing excessively (EverQuest in this particular study) appeared to show several core components of addiction such as mood modification, tolerance, withdrawal symptoms, cravings, and relapse. 

Chappell et al. (2006). EverQuest - It's just a computer game right? An interpretive phenomenological analysis of online gaming addiction. 

International Journal of Mental Health and Addiction, 4, 205 - 216.

Online gaming addiction can be predicted by five critical factors: Curiosity, role-playing, obligation, belonging, and reward.

Hsu et al. (2009). Exploring user experiences as predictors of MMORPG addiction. Computers and Education, 53, 990 - 999.

Individuals with a gaming addiction may use MMORPGs to alleviate negative feelings and moods.

Hussain et al. (2009). The attitudes, feelings, and experiences of online gamers: A qualitative analysis. Cyberpsychology & Behavior, 12, 747-753.

Excessive use of technology is relatively rare. Compared to females, males are more likely to develop a gaming addiction. Boys are more likely to play aggressive or violent games while girls are more likely to play platform and puzzle games.

Griffiths (2008). In Children's Learning in a Digital World. Malden: Blackwell Publishing, 85 - 103.

In Germany, 1.5 - 3.5% of teenage internet users show signs of gaming addiction. Gaming addiction is associated with higher rates of anxiety and depression, and poorer academic performance.

Peukert et al. (2010). Phenomenology, comorbidity, etiology, diagnostics and therapeutic implications for the addictives and their relatives. 

Psychiatrische Praxix, 37, 219 - 224.

Computer gaming addiction is positively correlated with achievement motivation, sensation-seeking, a positive evaluation of one's intelligence, and a negative evaluation of one's skills in interpersonal relationships.

Zheng et al. (2006). Correlated factors comparison: The trends of computer game addiction and internet relationship addiction. Chinese Journal of

Clinical Psychology, 14, 244 - 247.

In a sample of German teens, 6.3% of subjects fulfilled the authors' diagnostic criteria for gaming addiction. These adolescents were mostly male and had low educational backgrounds. They tended to use computer gaming as a method of managing their moods. 

Klaus et al. (2008). Computer game addiction: A psychopathological symptom complex in adolescence. Psychiatrische Praxis, 35, 226 - 232.

In a Chinese sample, negative parenting styles (e.g., authoritarian) are closely associated with computer gaming addiction among high school students.

Wang et al. (2006). Research on the relationship between the tendency toward computer game addiction and parental rearing styles in senior 

high school students. Chinese Journal of Clinical Psychology, 12, 460 - 462.

In a sample of over 7000 computer game players, 11.9% meet the researchers' diagnostic criteria for gaming addiction. Additionally, there is only weak evidence that excessive gaming is associated with aggressive behavior.

Grusser et al. (2007). Excessive computer game playing: Evidence for addiction and aggression? Cyberpsychology & Behavior, 10, 290 - 292.

Online games, especially multiplayer role playing games are more often associated with gaming addiction than any other video game genre.

Van Tooik et al. (2010). Video game addiction and social responsibility. Addiction Research & Theory, 18, 489 - 493.

In a large German study (more than 15,000 participants) 3% of male students and 0.3% of female student were viewed as having a computer gaming addiction.

Rehbein et al. (2009). Excessive video game playing and video game addiction in adolescence: Results of a German nationwide survey. Die 

Psychiatrie: Grundlagen & Perspektiven, 6, 140 - 146.

It is possible that excessive video game play is caused by poor time management skills and an avoidance of other problems, rather than inherent addictive qualities of the games.

Wood et al. (2008). Problems with the concept of video game 'addiction': Some case study examples. International Journal of Mental Health and 

Addiction, 6, 169 - 178.

Gaming addiction is negatively associated with academic achievement. 

Chiu et al. (2004). Video game addiction in children and teenagers in Taiwan. CyberPsychology & Behavior, 7, 571 - 581.

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