Nidal Nabhan Abou, MD

Since the arrival of increasingly violent video games and the media coverage attracted by recent mass killings, an emotional debate has developed concerning the impact of video games on aggressive, violent, and criminal behavior. Findings from meta-analyses are contradictory: some studies show an increase in aggressiveness, while others suggest a decrease in criminality.

Game platforms are becoming increasingly diverse and easily accessible (computers, consoles, tablets, mobile phones). This dramatic growth is a source of concern. Considered in the past to be an eccentric pastime doomed to rapid disappearance, video games are now solidly anchored in the popular culture.

The conclusions drawn by the first literature review on this topic in 1998 suggested that there is a link between violent video games and aggressiveness.

 Data showed an increase in aggressive moods or thoughts and hostility after playing violent video games and suggested impairment of prosocial behavior.

 studied the mechanisms underlying the aggressiveness caused by video games. She hypothesized that under certain environmental conditions, aggressive behavior was likely a consequence of the desensitization and disinhibition caused by violent video games. The repetitive nature of the games was thought to promote aggressive types of cognitive schema. Once this schema is established, it is reinforced by the learning process and the repetitive enactment of violence seen in video games.

 identified 3 studies that showed a rise in aggressiveness that resulted from the use of video games by children aged 4 to 8 years. The data concerning adolescents were insufficient to draw any conclusions; however, an experimental study revealed an increase in aggressiveness in high school students.

 revealed a positive correlation between exposure to violent video games and increased levels of aggressiveness in children and young adults of both sexes. This correlation appears to be proportional to the time spent playing games. The researchers concluded that video games increased behavioral, emotional, and cognitive aggressiveness, and decreased prosocial conduct.

The most recent meta-analysis by Greitemeyer and colleagues6 revealed a significant correlation between exposure to violent video games and a rise in aggressiveness, together with a decline in prosocial behavior. The results were similar to those of Carnagey and colleagues,

 who observed a lower level of neurovegetative stimulation during the viewing of genuine violent scenes in participants who had played a violent video game beforehand. Moreover, playing a violent video game even for 20 minutes led individuals to become less sensitive to real violence. The authors emphasized the fact that desensitization to violence could increase the risk of aggression.

Exposure to violence in video games did not always have a negative effect. Although human or fantasy violence was associated with a stronger effect than violence in sport games, overall the influence on aggressiveness was weak and less significant than that of violence on television.

 rejection of the hypothesis that violent video games can induce aggression. Following this statement, an increasing number of scholars expressed skepticism regarding the link between violent digital games and real-life violence, and numerous studies have cast doubt on this link.

 suggested that the effects of violent video games were overestimated as a consequence of the biases introduced by publications challenging the correlation of aggressiveness with video games. Once the publication biases were corrected, the extent of the effect (eg, the strength of the association between violent video games and aggressiveness) dropped to 0.04 [−0.03, 0.11].

 Also, by taking other variables into account, such as intra-family violence, the correlation between video games and aggressiveness could no longer be established.

The player’s personality also plays a moderating role in the relationship between video games and aggressive thoughts or behavior.

 showed that measurements of aggressiveness made in the laboratory were not correlated with violent acts encountered in real life. The effects of game violence were not observed in the normal environment of players, thus complicating the extrapolation of laboratory data.

 looked at the effects of cardiovascular and affective response to video games to gauge whether there were changes across social context or with game content (violent or nonviolent video games). No significant differences were found between players of nonviolent video games and players of violent video games. Similarly, Tear and Nielsen

 failed to find evidence that playing violent video games led to diminished prosocial behavior after exposure to antisocial, violent, nonviolent, or prosocial games. These results confirmed those of Unsworth and colleagues,

 who found that the majority of participants in their study were unaffected by exposure to video game violence and several even experienced a decrease in anger.

 observed that the preference for aggressive games was associated with lower aggression scores among Japanese adolescents. Findings indicate that any correlation between violent video game exposure and delinquency is nonsignificant.

 concluded that “focusing on such easy but minor targets as violent video games causes parents, social activists, and public-policy makers to ignore the much more powerful and significant causes of youth violence that have been well established.”

Results from a long-term study show no relationship between game playing and aggression or delinquency after 1 year of exposure.

 Nor were any effects seen on delinquency, aggressiveness, violence, or bullying at 1- and 2-year follow-up.

A 2004 review of the literature did not show a clear relationship between an individual’s exposure to violent representations and criminal acts.

 In fact, the preponderance of evidence shows a negative correlation between violent video games and crime. A study by Ward

 revealed a negative correlation between an increase in the sale of video games and criminality. Cunningham and colleagues

 found that for a 1% increase in the sale of violent video games, the incidence of crime decreased by 0.03%. Findings from Markey and colleagues

 also suggest that violent video gaming is associated with a decline in criminality.

These various studies suggest that despite an increase in aggressiveness, violence in video games could be the cause of a reduction in criminality. Moreover, it appears that the relationship between media and crime is more complex than that revealed by experimental studies.

Although it has been suggested that several mass murderers were influenced by violent video games, scientific data do not support any causal link between exposure to video game violence and school shootings.

 Furthermore, no evidence was found of the use of violent video games by the perpetrators of mass homicide.

The concerns about the effects of violent video games on aggressive thought patterns, emotions, and behavior are justified. Until now, no study has been able to show that exposure to violent digital games is associated with an increase in criminality, aggressiveness, or violent behavior. Nevertheless, these paradoxical results are not incompatible. There is indeed a tremendous difference between aggressiveness and hetero-aggressive outburst. It is likely that the answer lies in the complexity of the concept of committing an act. Exposure to violent video games could be one factor, among many others, in a constellation of parameters leading an individual to commit an aggressive act.

The research is inconsistent, and thus psychiatrists may wish to be more careful in their public statements linking violent digital games to harm. There is indeed a lack of scientific data dealing with the relationship between violent video games and this interaction between the individual’s mental state and aggressive outcome. More research is needed before we can fully understand the influence of violent video games on real life.

Dr Fournis is in the dÃ©partement de psychiatrie et d’addictologie, Angers, France, and Dr Abou is in the service de psychiatrie adulte lavallois, Laval, France. They report no conflicts of interest concerning the subject matter of this article.

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Articles

What effect does exposure to violence in video games have on behavior? These authors examine the evidence.

Violence, Crime, and Violent Video Games: Is There a Correlation?

On December 18, 2012, French psychiatrist Daniele Canarelli, age 58, received a 1-year suspended prison sentence by the Criminal Court of Marseille. Dr Canarelli had been found guilty of multiple practitioner failures and misconducts after one of her patients-Joel Gaillard-killed 80-year-old Germain Trabuc on March 9, 2004. The court also sentenced Dr Canarelli to pay 7500 euros and 1000 euros, respectively, to each of Mr Trabuc’s sons.

French psychiatrists rarely face lawsuits.

 In cases involving harm by a patient to a third party, a hospital or insurance company usually assumes liability and pays for damages. Legal cases that result in prison sentences for psychiatrists remain exceedingly rare. That is precisely why this case has caused such a stir in Europe.

Some background on this case: Joel Gaillard had been Dr Canarelli’s patient for nearly 4 years, between 2000 and 2004. During that time, Gaillard was repeatedly and mandatorily hospitalized at the request of his family or the regional government’s social services.

On the day that Gaillard murdered Trabuc, he was on probation and being treated as an outpatient. As such, Gaillard was the legal responsibility of the psychiatric hospital. Twenty days before the murder, Dr Canarelli had ordered the re-hospitalization of her patient, but the patient escaped during a consultation.

The jury found numerous and repeated lapses in judgment and actions on Dr Canarelli’s part. At the start of the trial, the court pointed out that the “law does not require from the physician an obligation of result” and that “predictability and zero risk do not exist.” The court also reassured psychiatric professionals by declaring that the case did not pertain to the entire profession. It was said at the trial that “the court is not judging psychiatry here, but rather a very specific case with a specific misbehavior of the treating doctor.”

Several acts of negligence were brought against Dr Canarelli. Charges outlined in the judgment text stated that under her supervision, the 4 years of therapy were marked “beyond any doubt” with “a succession of failures” and her attitude “resembled blindness.” These charges were based on the following:

Despite “an escalation of acts of aggression, of increasing severity” perpetrated by the patient while he was in treatment, “Dr Canarelli remained stubbornly attached to her treatment approach and ignored such obvious alarm signals. She did not question her methodology or change her approach, thus creating or helping to create the situation that led to the realization of the crime.”

The doctor also failed to “establish the correct diagnosis.” This assertion may be debatable, but her reports concerning the patient revealed that she sometimes ruled out psychosis, which was noted by all the other doctors who examined the patient as well as by the expert who was appointed to the court after the murder.

The court found a clear discrepancy between the mental disorder meticulously described by the doctors who recommended “hospitalization without consent,” and the therapeutic approach adopted by Dr Canarelli. The patient had repeatedly objected to his hospitalization, as unanimously stated by experts who examined him on those occasions.

Dr Canarelli continued with the same therapeutic approach and prescribed successively longer “exit test” periods outside of the hospital, especially from October 2003 onward-despite several “alarming incidents and alerts” of which she had been aware.

Dr Canarelli was also accused of failing to take into consideration the experts’ recommendation in 2001 to transfer her patient to a specialized facility (at that time there were 4 such facilities in France where extreme cases were admitted). Nor did she consider the experts’ request to transfer the patient for treatment by another therapeutic team.

In January and February of 2004, Dr Canarelli had received alerts from the mental health center and the patient’s family. But “she did not make any concrete conclusion out of the information she received, and didn’t put it to proper use during her counseling appointment of February 19, 2004, with the patient.”

French Penal Code Article 121-3: When a Psychiatrist’s Patient Harms Someone…

There is [. . . ] transgression of the law, in cases of recklessness, negligence or breach of duty in terms of providing adequate care or safety, as stated by law or regulation, if it is established that the perpetrator has not completed the normal due diligence given, with regard to the nature of their duties, functions, skills and means put at their disposal.

individuals who did not directly cause any damage,

 but who created or helped to create the situation that led to the occurrence of the damage or 

who have not taken appropriate measures to prevent it,

 are criminally liable if it is determined that they have either manifestly violated, in a deliberate manner, their duty of providing care or safety as stated by law or regulation, or 

exposed others to serious risk that they could not ignore, through their own misconduct 

Dr Canarelli justified the non-use of coercive measures during therapy by “the need to establish and maintain a trusting relationship with the patient.” The court did not share this reasoning and argued that while therapeutic alliance is of “major importance,” the relationship of trust “is not an end in itself but only a means for patient adherence for the best outcome.”

Dr Canarelli’s conviction was mainly based on the principles of Article 121-3 of the Penal Code 

). According to the court, a series of faults or acts of negligence occurred that justified her 1-year suspended prison sentence.

This case has spread a feeling of anxiety among French psychiatrists, who are now bound to manage the “dangerousness” of their patients-as if they are able to predict and neutralize any possible dangerous acts that their patients might commit. The case also led to the creation of law 2011-803, on July 5, 2011. The objective of that law is to ensure that “dangerous” psychiatric patients are monitored and attended to.

In particular, this law replaced the “exit test” with “ambulatory care without consent.” In principle, the law enables greater intervention by psychiatric teams. However, it also increases the responsibility of doctors by requiring more transparency (methodology, location where the treatment is administered, frequency of visits or consultations, etc) and obligates them to notify authorities if the patient does not adequately follow the therapeutic program. In this new, legally binding context, French psychiatrists now justifiably believe that lawsuits against them will become more frequent.

 Jonas C, Senon JL. Responsibility in adult psychiatry. 

 BBC News Europe. France psychiatrist guilty over murder by patient. December 18, 2012. http://www.bbc.co.uk/news/world-europe-20774516. Accessed February 25, 2013.

Article 3211-2-1 The Code of Public Health.

Jonas C. The detailed certificate of the Act of July 5, 2011: Why? How? [in French]. 

 2012;170:699-702. ISSN: 0003-4487. doi:10.1016/j.amp.2012.09.011.

 Senon JL, Jonas C, Voyer M. Care given under constraint for mentally ill patients since the act of the 5th of July “relative to the rights and protection of people subject to psychiatric care and the modalities of their treatment.” 

 2012;170:211-215. ISSN: 0003-4487. doi:10.1016/j.amp.2012.02.019.

On December 18, 2012, French psychiatrist Daniele Canarelli, age 58, received a 1-year suspended prison sentence by the Criminal Court of Marseille after one of her patients killed someone.

Author | Nidal Nabhan Abou, MD

Articles

Violence, Crime, and Violent Video Games: Is There a Correlation?

Psychiatric Liability: A French Psychiatrist Sentenced After a Murder Committed by Her Patient