According to the Centers for Disease Control and Prevention (CDC), there are approximately 50,000 violent deaths each year in the United States. Until recently, there were no comprehensive data available to the public regarding these deaths. It was with this in mind that the National Violent Death Reporting System (NVDRS) was created, not only to provide statistics of reported violent deaths, but also to educate and possibly prevent more violent deaths from occurring.
Many doctors feel ambivalentabout their patients' use ofcomputer games. Perhaps theydo not understand computer gaming orjust consider it to be an activity that offerspatients an escape from other pressures.Moreover, they might just assumethat most persons who play computergames are children. If the clinician onlytreats adults, gaming may not seemrelevant. Nothing could be further fromthe truth, as shown by the followingcase vignettes.
CASE VIGNETTE 1
SW, a 34-year-old construction worker witha history of pathological gambling presentsfor the treatment of depression after making2 consecutive and serious suicide attempts.SW initially describes 1 year of depressivesymptoms leading to the loss of his job.After running out of money, he was evictedfrom his housing. Homeless for a few days,he then moved in with an ex-girlfriend.There, he was witness to her having sexualrelations with other men. This triggered thesuicide attempts.
Or so it seemed. His recollection madesense, except for one detail that caught myear. During his evaluation, SW made a passingcomment about avoiding his rent-seekinglandlord by "holing up" in his apartmentand "playing games on the computer." Iasked for more information.
With reluctance, SW began talking abouthis computer gaming. He noted that he hadplenty of work and money before discoveringWorld of Warcraft, a popular multiplayergame. He found it highly compelling andbecame an expert at it. Within a few months,he joined a gaming "guild" and was on thecomputer much of the day. SW found himselfthinking about the game while at constructionjobs, often rushing home after work toplay. He dreamed about the game, craved itsuse, delayed logging off of it, hid the fact thathe was playing it from others, and felt miserablewhen he was unable to play.
Three months before his suicide attempts,SW stopped going to work. He foundthe game irresistible and stayed at home inorder to play. As a result, SW fell behind onhis rent and became "very depressed." Hesaid, "The only thing I could do safely wasplay the game. There I was really powerfuland successful." SW would leave his apartmentonly for food. After 2 months, SW wasevicted.
At his ex-girlfriend's home he was unableto hook up the computer and despairedover what his life had become. SW noted,"The sex thing was just the last straw."Presently, SW is living with his father andsneaks onto the computer for "about anhour or two" each day. He uses it to play thegame and recently discovered that he haslogged over 3000 hours of use in the pastyear.
SW's treatment is focused on his depression,which is mild at present, and onreengaging him with real, as opposed to virtual,objects.We have linked the compulsivecomputer use to his prior problems withpathological gambling. I recommended thathe work at his construction job as much aspossible and avoid the use of computers.
Barriers to treatment
As this case suggests, there are substantialbarriers to discussing computergaming with patients. First and foremost,the clinician must recognize itas an issue worth talking about.
Next, the clinician must help the patientovercome his or her shame. Althoughgaming and other computer useis usually enjoyable, patients are oftenembarrassed about it and hide the extentof their use.
It is understandable that patientsrarely talk about their virtual worlds andcomputer gaming. Some games dealwith fantastic phenomena, like magic ormonsters, and talking about such thingsin the real world may make patients feelfoolish. Other times, games simulatethat which would otherwise be illegal orunethical; the virtual is used to experimentwith the forbidden.
There are other barriers that the clinicianmust circumvent. Discussingcomputer gaming sometimes feels dangerousto patients. Although many patientsdescribe feeling powerful andsuccessful when using their machine,these feelings can dissipate when theirsystem is powered down. Indeed, patientshave often become morose andself-hating when they start to considerthe many thousands of hours they havespent playing on the computer.
Exactly how much time playersspend on the computer varies. The entertainment industry claims that the averagegamer plays for 6.8 hours perweek.1 I doubt the estimate, believing itto be low. In an ongoing self-selectedstudy involving nearly 4000 participants,gamers were found to play an averageof 22 hours each week; many exceeded40 hours.2 In 2 studies, each withseveral thousand participants, 10% to50% of the cohort felt that they were"addicted" to computer game play.2,3 Inunpublished data provided by about1000 self-selected gaming enthusiasts,about 30% described themselves ascompulsive gamers. Many played for40 or more hours a week in addition totheir college or work schedules. Ofnote, these data were collected in 1994,before widespread use of the Internet(JB, unpublished data, 1994). Thus, I donot label the problem "Internet addiction"-it occurs without the Internet.Rather, I prefer the term "compulsivecomputer use."
Gaming by adults
Once clinicians start asking about computeruse, they often learn surprising details.For example, despite popular perception, computer gaming is commonin adults. The average computer gameplayer is about 33 years of age, andabout a quarter of game players are olderthan 50 years. About 62% of gamersare men.1 In one series of studies lookingat several thousand self-selectedInternet gamers, 50% were employedand 36% were married.4
It is important to note that even if thecomputer use is extensive, not all gamingis pathological.
CASE VIGNETTE 2
RT is a 38-year-old man with a 16-year historyof schizophrenia and multiple hospitalizations.He presents for maintenance treatment.He is in good health, is stable andnondelusional, is in an extended remission,and is compliant with his medication.
RT reports that over the past 2 years, hehas spent about 6 hours per day playing computergames (over 4000 hours). He is anofficer in his gaming guild and has severalhighly advanced characters in an onlinegame. RT supervises other players in hisguild. Aside from gaming, RT works occasionalcomputer-related jobs. He also socializesin the real world at a temple andwith friends.
In his therapy, we are exploring waysthat RT can use his computer and gamingskills to generate income. RT currently"farms," wherein his online game characterskill monsters for the loot they drop. RTcollects the virtual treasures and then sellsthem online for real cash. Occasionally, healso sells off one of his high-level charactersfor several hundred dollars.
Virtual versus real-worldsocializing
One of the difficulties therapists encounterwhen discussing gaming withpatients is understanding gaming terminologyand concepts. For example, SWand RT are in guilds, which are groupsof players who create a social club andwork together in a multiplayer gameto conquer difficult challenges. Sometasks within games may require asmany as 40 cooperating people-onlineat the same time-to have a fair chanceat success. Thus, people form guilds tocollect the necessary players with theright skills so that all can advance in thegame.
Some tasks may present many toughopponents. For that reason, the gamemay be programmed to allow a groupenough time to complete its specificgoals. In the most difficult area of agame, the players are often given up toa week to finish the task. If, however,the group takes too long, a quest can resetand all the defeated opponents withinit are "reanimated." In addition, whena player drops out because of real-lifeinterruptions-like dinner or a phonecall-it can cause the entire group tofail. Thus, such disruptions are stronglydiscouraged and many guilds will banundependable players. If a high-levelplayer is banned, advancement in thegame becomes nearly impossible untilthe others in his group join up with anew group.
Such demands for consistency tendto shift gaming late into the night andmake it a private activity-more guildmembers are available at night and reallifeinterruptions are few. As a consequence,gamers like SW may advancetheir sleep cycles and become sleep deprived.They might also neglect real-life relationships to preserve their virtualones.
Questions to ask
If a patient is willing to talk about hiscomputer gaming, I first determinewhether the game is being used in thesingle-person or multiplayer mode. Thiscan be confusing. Some games areplayed cooperatively with the computeragainst "fate" (eg, simulated bricksfall randomly and the game's tools mustbe used to control them). These gamesare single-person. However, mostgames are played with other entities thatare allies or are trying to prevent theplayer from obtaining some goal. Theseparticipants are either simulated personas(robots or "bots") or are screenrepresentations of real people who aresimultaneously playing the game elsewherein the world. I clarify with patientswhether real people are managingthese virtual characters. Gamers canreadily tell you the sort of gaming environmentin which they are playing.
If the patient is playing with realpeople, I then ask how the players communicate.How engaging is it? Does itlead to meetings in other virtual, or evenreal, settings?
It is useful to understand that withfewer ties to reality, the gaming experiencechanges and can become more intenseand private, much as the sensoryisolation of the couch in psychoanalysiscan dramatically alter a patient's experienceof therapy. As a result, it may beimportant to note whether a patientplays games alone or avoids using wellestablishedInternet technology that,like a telephone, allows him to talk withor hear other players that he may teamup with.
Finally, comorbidity between compulsivecomputer use and other psychiatricdiagnoses seems to be the rulerather than the exception. When thereare other issues, do not underestimatehow stabilizing computer gaming canbe for some patients.
CASE VIGNETTE 3
JM is a 24-year-old college student. Fromage 17 until 20, he lived on the streetand was dependent on intravenous heroin.After overdosing and nearly dying twice,JM entered a treatment program. He wassuccessfully treated and began a long-termremission.
At the same time, JM began playing anonline role-playing game. He recently notedthat he has logged over 2500 hours of playin the past year (about 7 hours per day). Hecredits his recovery, to some degree, to thedistraction and engagement offered by the game. He also believes he is addicted to itand, as a result, has no time or interest foractivities like dating or off-line socializing.
JM's history is notable for heavy computergaming before the age of 17. When familialissues and a move disrupted his gaming,he began using drugs. The drug useescalated rapidly, and he stopped using hiscomputer.
In therapy, we have noted the gamingcompulsion but have made no active effortto stop it. In my clinical judgment, to stop thegaming would put the patient at high risk fora more serious problem-a relapse into opiateuse. Although we discuss it, I am unsureof the safest way to reduce computer useand reengage JM in real-life relationshipsand responsibilities. Presently, he has no desireto do so, and I am tempering my ownagenda and clinical ambition.
As in this case, I strongly urge cautionwhen one is tempted to recommend"shutting off" the computer; I am greatlyconcerned about unintended consequences,especially an increase in overtaggression after discontinuing computergaming. I know of several cases inwhich suicide and/or homicide attemptshave followed abrupt, physician-recommendedstops in gaming.
In 2006, more than $7 billion wasspent on video gaming software in theUnited States.1 World of Warcraft hasover 7 million subscribed players.5 Ourpatients are using computer games inever greater numbers, for hours on end.It is time that we take a much closerlook at what makes the games socompelling and what characterizesnormalcy and pathology in this newrealm of human experience.
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Seay AF, Jerome WJ, Lee KS, Kraut RE. Projectmassive: a study of online gaming communities. Conferenceon Human Factors in Computing Systems.CHI '04 extended abstracts on human factors in computingsystems, Vienna, Austria. New York: ACM Press;2004:1421-1424.
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