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
socializing
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.
