Many doctors feel ambivalent
about their patients' use of
computer games. Perhaps they
do not understand computer gaming or
just consider it to be an activity that offers
patients an escape from other pressures.
Moreover, they might just assume
that most persons who play computer
games are children. If the clinician only
treats adults, gaming may not seem
relevant. Nothing could be further from
the truth, as shown by the following
CASE VIGNETTE 1
SW, a 34-year-old construction worker with
a history of pathological gambling presents
for the treatment of depression after making
2 consecutive and serious suicide attempts.
SW initially describes 1 year of depressive
symptoms leading to the loss of his job.
After running out of money, he was evicted
from his housing. Homeless for a few days,
he then moved in with an ex-girlfriend.
There, he was witness to her having sexual
relations with other men. This triggered the
Or so it seemed. His recollection made
sense, except for one detail that caught my
ear. During his evaluation, SW made a passing
comment about avoiding his rent-seeking
landlord by "holing up" in his apartment
and "playing games on the computer." I
asked for more information.
With reluctance, SW began talking about
his computer gaming. He noted that he had
plenty of work and money before discovering
World of Warcraft, a popular multiplayer
game. He found it highly compelling and
became an expert at it. Within a few months,
he joined a gaming "guild" and was on the
computer much of the day. SW found himself
thinking about the game while at construction
jobs, often rushing home after work to
play. He dreamed about the game, craved its
use, delayed logging off of it, hid the fact that
he was playing it from others, and felt miserable
when he was unable to play.
Three months before his suicide attempts,
SW stopped going to work. He found
the game irresistible and stayed at home in
order to play. As a result, SW fell behind on
his rent and became "very depressed." He
said, "The only thing I could do safely was
play the game. There I was really powerful
and successful." SW would leave his apartment
only for food. After 2 months, SW was
At his ex-girlfriend's home he was unable
to hook up the computer and despaired
over what his life had become. SW noted,
"The sex thing was just the last straw."
Presently, SW is living with his father and
sneaks onto the computer for "about an
hour or two" each day. He uses it to play the
game and recently discovered that he has
logged over 3000 hours of use in the past
SW's treatment is focused on his depression,
which is mild at present, and on
reengaging him with real, as opposed to virtual,
objects.We have linked the compulsive
computer use to his prior problems with
pathological gambling. I recommended that
he work at his construction job as much as
possible and avoid the use of computers.
Barriers to treatment
As this case suggests, there are substantial
barriers to discussing computer
gaming with patients. First and foremost,
the clinician must recognize it
as an issue worth talking about.
Next, the clinician must help the patient
overcome his or her shame. Although
gaming and other computer use
is usually enjoyable, patients are often
embarrassed about it and hide the extent
of their use.
It is understandable that patients
rarely talk about their virtual worlds and
computer gaming. Some games deal
with fantastic phenomena, like magic or
monsters, and talking about such things
in the real world may make patients feel
foolish. Other times, games simulate
that which would otherwise be illegal or
unethical; the virtual is used to experiment
with the forbidden.
There are other barriers that the clinician
must circumvent. Discussing
computer gaming sometimes feels dangerous
to patients. Although many patients
describe feeling powerful and
successful when using their machine,
these feelings can dissipate when their
system is powered down. Indeed, patients
have often become morose and
self-hating when they start to consider
the many thousands of hours they have
spent playing on the computer.
Exactly how much time players
spend on the computer varies. The entertainment industry claims that the average
gamer plays for 6.8 hours per
week.1 I doubt the estimate, believing it
to be low. In an ongoing self-selected
study involving nearly 4000 participants,
gamers were found to play an average
of 22 hours each week; many exceeded
40 hours.2 In 2 studies, each with
several thousand participants, 10% to
50% of the cohort felt that they were
"addicted" to computer game play.2,3 In
unpublished data provided by about
1000 self-selected gaming enthusiasts,
about 30% described themselves as
compulsive gamers. Many played for
40 or more hours a week in addition to
their college or work schedules. Of
note, these data were collected in 1994,
before widespread use of the Internet
(JB, unpublished data, 1994). Thus, I do
not label the problem "Internet addiction"—
it occurs without the Internet.
Rather, I prefer the term "compulsive
Gaming by adults
Once clinicians start asking about computer
use, they often learn surprising details.
For example, despite popular perception, computer gaming is common
in adults. The average computer game
player is about 33 years of age, and
about a quarter of game players are older
than 50 years. About 62% of gamers
are men.1 In one series of studies looking
at several thousand self-selected
Internet gamers, 50% were employed
and 36% were married.4
It is important to note that even if the
computer use is extensive, not all gaming
1. Entertainment Software Association. 2006 Sales, Demographics
and Usage Data. Essential Facts about the
Computer and Video Game Industry. Available at:
2. Yee N. The Daedalus Project: mapping the phenomena.
October 2002. Available at: http://www.nickyee.com/hub/addiction/mapping.html.Accessed January 2, 2007.
3. Seay AF, Jerome WJ, Lee KS, Kraut RE. Project
massive: a study of online gaming communities. Conference
on Human Factors in Computing Systems.
CHI '04 extended abstracts on human factors in computing
systems, Vienna, Austria. New York: ACM Press;
4. Yee N. The Daedalus Gateway: The psychology
of MMORPGs. Player demographics. Available at:
http://www.nickyee.com/daedalus/gateway_demographics.html. Accessed January 2, 2007.
5. Harper E.World of Warcraft hits 7 million subscribers.
Joystiq [blog]. September 7, 2006. Available at:
http://www.joystiq.com/2006/09/07/world-of-warcrafthits-7-million-subscribers. Accessed January 2, 2007.