CASE VIGNETTE 2
RT is a 38-year-old man with a 16-year history of schizophrenia and multiple hospitalizations. He presents for maintenance treatment. He is in good health, is stable and nondelusional, is in an extended remission, and is compliant with his medication.
RT reports that over the past 2 years, he has spent about 6 hours per day playing computer games (over 4000 hours). He is an officer in his gaming guild and has several highly advanced characters in an online game. RT supervises other players in his guild. Aside from gaming, RT works occasional computer-related jobs. He also socializes in the real world at a temple and with friends.
In his therapy, we are exploring ways that RT can use his computer and gaming skills to generate income. RT currently "farms," wherein his online game characters kill monsters for the loot they drop. RT collects the virtual treasures and then sells them online for real cash. Occasionally, he also sells off one of his high-level characters for several hundred dollars.
Virtual versus real-world
One of the difficulties therapists encounter when discussing gaming with patients is understanding gaming terminology and concepts. For example, SW and RT are in guilds, which are groups of players who create a social club and work together in a multiplayer game to conquer difficult challenges. Some tasks within games may require as many as 40 cooperating people—online at the same time—to have a fair chance at success. Thus, people form guilds to collect the necessary players with the right skills so that all can advance in the game.
Some tasks may present many tough opponents. For that reason, the game may be programmed to allow a group enough time to complete its specific goals. In the most difficult area of a game, the players are often given up to a week to finish the task. If, however, the group takes too long, a quest can reset and all the defeated opponents within it are "reanimated." In addition, when a player drops out because of real-life interruptions—like dinner or a phone call—it can cause the entire group to fail. Thus, such disruptions are strongly discouraged and many guilds will ban undependable players. If a high-level player is banned, advancement in the game becomes nearly impossible until the others in his group join up with a new group.
Such demands for consistency tend to shift gaming late into the night and make it a private activity—more guild members are available at night and reallife interruptions are few. As a consequence, gamers like SW may advance their sleep cycles and become sleep deprived. They might also neglect real-life relationships to preserve their virtual ones.
Questions to ask
If a patient is willing to talk about his computer gaming, I first determine whether the game is being used in the single-person or multiplayer mode. This can be confusing. Some games are played cooperatively with the computer against "fate" (eg, simulated bricks fall randomly and the game's tools must be used to control them). These games are single-person. However, most games are played with other entities that are allies or are trying to prevent the player from obtaining some goal. These participants are either simulated personas (robots or "bots") or are screen representations of real people who are simultaneously playing the game elsewhere in the world. I clarify with patients whether real people are managing these virtual characters. Gamers can readily tell you the sort of gaming environment in which they are playing.
If the patient is playing with real people, I then ask how the players communicate. How engaging is it? Does it lead to meetings in other virtual, or even real, settings?
It is useful to understand that with fewer ties to reality, the gaming experience changes and can become more intense and private, much as the sensory isolation of the couch in psychoanalysis can dramatically alter a patient's experience of therapy. As a result, it may be important to note whether a patient plays games alone or avoids using wellestablished Internet technology that, like a telephone, allows him to talk with or hear other players that he may team up with.
Finally, comorbidity between compulsive computer use and other psychiatric diagnoses seems to be the rule rather than the exception. When there are other issues, do not underestimate how stabilizing computer gaming can be for some patients.
CASE VIGNETTE 3
JM is a 24-year-old college student. From age 17 until 20, he lived on the street and was dependent on intravenous heroin. After overdosing and nearly dying twice, JM entered a treatment program. He was successfully treated and began a long-term remission.
At the same time, JM began playing an online role-playing game. He recently noted that he has logged over 2500 hours of play in the past year (about 7 hours per day). He credits his recovery, to some degree, to the distraction and engagement offered by the game. He also believes he is addicted to it and, as a result, has no time or interest for activities like dating or off-line socializing.
JM's history is notable for heavy computer gaming before the age of 17. When familial issues and a move disrupted his gaming, he began using drugs. The drug use escalated rapidly, and he stopped using his computer.
In therapy, we have noted the gaming compulsion but have made no active effort to stop it. In my clinical judgment, to stop the gaming would put the patient at high risk for a more serious problem—a relapse into opiate use. Although we discuss it, I am unsure of the safest way to reduce computer use and reengage JM in real-life relationships and responsibilities. Presently, he has no desire to do so, and I am tempering my own agenda and clinical ambition.
As in this case, I strongly urge caution when one is tempted to recommend "shutting off" the computer; I am greatly concerned about unintended consequences, especially an increase in overt aggression after discontinuing computer gaming. I know of several cases in which suicide and/or homicide attempts have followed abrupt, physician-recommended stops in gaming.
In 2006, more than $7 billion was spent on video gaming software in the United States.1 World of Warcraft has over 7 million subscribed players.5 Our patients are using computer games in ever greater numbers, for hours on end. It is time that we take a much closer look at what makes the games so compelling and what characterizes normalcy and pathology in this new realm of human experience.