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 vignettes.
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 suicide attempts.
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 evicted.
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 year.
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 computer use."
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 is pathological.