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I own gizmos, lots of them, and have been deeply involved with technology since my childhood. I’ve sold, programmed, gamed on and constructed computers. I have also studied them: prior to becoming a psychiatrist, I was an engineer. Even before I knew Id from Ego, it was blatantly obvious that technology affected people in deep ways – ways that we had little understanding of. It has been about 30 years since the personal computer was widely introduced into people’s lives – 30 years of a grand social experiment, now in almost every society across the globe. And yet, we still have but a crude understanding of how technology impacts people. What does it do to their relationships, to their sense of self? Since I became a physician more than a decade ago, I’ve been interested in that question.

In the United States, an average of nine computer games are sold every second, every day, 365 days a year. In a nation of 300m people, around 200m play computer and console games. The typical gamer is older than many imagine: 35 years old, according to the industry trade group the Entertainment Software Association. But the future is in the children. “When kids get to the six- to eight-year-old age range is when we see them turn into more serious gamers,” says Anita Frazier, a market research analyst for the NPD Group. “This appears to be a critical age at which to capture the future gamers of the world.”

Capture indeed. In the US, around 2 per cent of the gamers – that is, 4m people – are heavy users. They average around 40 hours a week, some playing less, some much more. One out of three gamers – 66m people – play around 20 hours each week. It is people like these who helped generate a record $18bn (£9.1bn) in US sales last year.

If a physician in Europe or the United States learned that you game on computers for 40-plus hours a week, they would probably be baffled. Dealing with such matters is not part of our training. In Asia, however, you would probably get a psychiatric diagnosis. Because of public health efforts and widespread media reporting, doctors in Asia recognise excessive computer use as a serious issue. There have been three high-profile game-related murders in China, Vietnam and South Korea, where people have killed over virtual objects or access to computers. More importantly there have been 10 natural deaths in young men who were gaming for 60 hours and more in public nternet cafés. It appears that, as with long aeroplane travel, sitting for hours in front of a computer may cause blood to coagulate. The resulting blood clot, if it travels to the lungs, can kill. Of greatest concern, though, is an epidemic in NEETs – people not in education, employment or training. Adolescents and young men (the vast majority of excessive use occurs in males) are simply dropping out of society and living virtually. One Asian country in particular, South Korea, is measuring such data. Using a sensitive and culturally specific test, something badly needed in the West, researchers in South Korea found that around 2.1 per cent of their children and adolescents (210,000) have “internet addiction”. Another 12 per cent (1.2m) are considered at high risk. And, in those afflicted, it is highly impairing and difficult to treat. In one sample, 20 per cent required hospitalisation.

And then there is China. The Chinese government is worried enough to have forced game manufacturers to build disincentives into their games – features to discourage three or more hours of play. Although their data probably overestimates the problem, Chinese researchers have estimated that an astounding 13.9 per cent of their adolescents - some 10m people - have internet addiction. At an international conference in 2007, Tao Ran, the Director of Addiction Treatment at Beijing’s main military hospital, stated that computer games are “making our children stay up all night, sleep all day, and lazy”. Parenthetically, he added: “They are becoming like Americans.”

While enjoying his ability to needle the international audience, he was clearly angered over one game, World of Warcraft. This particular game is a worldwide phenomenon with more than 10m monthly subscribers – more than the population of Ireland and Scotland combined. The researcher, a high official, stated his belief that introducing the game to China represented “the second imperialist invasion of China by the United States”. Never mind that the game is made by a French company.

Internet addiction, or the more accurate and general term Pathological Computer Use (PCU), is not an established diagnosis but one that might be included in the next version of the mental-health diagnostic guidebook, the DSM-V. The manual is due out in 2012 and will define the landscape of mental-health diagnoses for the next several decades. If PCU is real, it is important that it be included in the book. The disorders that get listed get taught and researched.The proposed diagnosis of PCU has four criteria. The first is that the computer use must be excessive. “Excessive” is a purposefully vague term, meant to be determined by the patient’s particulars. Gaming for 60 hours a week might be normal if one is holed up in Antarctica during the winter. Gaming for 10 hours might be excessive if one is in the middle of final exams. In studies by Nick Yee, a researcher based in the US, users often classify themselves as addicted when they are playing around 30 hours or more a week. Note, however, that PCU does not always manifest through gaming. Inappropriate use of pornography and endless social networking are but two other areas of excessive use.

The second criterion is the concept of tolerance – the need to spend more time or money on the computer in order to feel satisfied. While the average gamer buys about two games every three months, heavy gamers need more. They buy around 13 games and upgrade their systems to use newer technology. The third criterion is that one’s mood be notably altered when using the computer. Often, the user may feel more alive or relaxed when using. When access is limited, however, they may become enraged or depressed. The final criterion is perhaps the most important: the computer use must produce significant problems. Someone – the patient, his wife, a boss, etc – has to be complaining loudly.

Most patients are forced into therapy by their circumstances and have a limited desire to address their computer use. While they may agree it causes problems, rarely do they want to stop. Indeed, the topic of limiting computer time will usually trigger anger. Rather, patients want the therapist to address “real-life” problems. I’ve seen people who have dropped out of school, lost marriages or become recluses because of their computer use. They want the real-life problem fixed but do not want to address the cause.

Compulsive computer users usually request afternoon appointments and come to sessions looking tired. Many wake up to come to therapy after a gaming binge of 10 to 14 hours. In some ways, this is to be expected and is a by-product of how games are designed. In order to reach the challenging levels of most online games players must join clubs, sometimes known as guilds. Since guilds generally meet at night, that is when pathological users start their day. If guild members live in different time zones, the patient might keep pace with the other members’ clocks – a 3am bedtime for one guildmate might be a 6am bedtime for another. As a result, heavy-use gamers often go to bed in the early morning and then wake at midday. If they have morning obligations, they just sleep less and develop chronic sleep deficit.Often, by the time they seek help, those with pathological computer use are isolated, failing at life and depressed. Coexisting anxiety disorders, obsessive--compulsive disorder and substance abuse are not uncommon. In one study from Asia, a typical patient had more than two other diagnoses in addition to compulsive computer use. Most patients want medication, such as a stimulant, to wake them up during the day. They do not want to change the way they use computers; they just want to sleep less and to work more efficiently.

When conflict and problems occur in real life, compulsive users tend to immerse themselves ever deeper in the virtual world, where they are powerful, respected and in control. In those moments when the patient surfaces and allows himself to feel anything in the real world, he often feels rage and despair. The computer is the one solution, perhaps the only solution, that makes him feel better.

As people become more immersed, their use of language also changes. The virtual and the real worlds begin to blend together. As a therapist, it becomes increasingly difficult to discern virtual and real experiences. A typical example might go like this: a patient describes being frightened by a past girlfriend. The two had briefly experimented with sex before breaking up. Now the patient was being stalked. “Did you call the police?” the therapist asks. No, the patient does not know what his ex-girlfriend looks like. It made no sense until one realises the sex (and maybe the stalking) all occurred in the virtual world. To the patient, there was no distinction. Increasingly, all of life is a digital construct of ones and zeros.

An Oxford University philosopher, Nick Bostrom, has written that there is perhaps a one-in-three chance that our concept of reality is a lie – that we are all actually just electrons (or the equivalent) in virtual simulations. Are we merely imitations of life, programmed to be unaware of our status? Many compulsive computer users seem to believe so. To them, the virtual and the real have become equally important and interchangeable. We are all avatars. Avatars playing with avatars in the game World of World of Warcraft. A cosmic joke. I find Bostrom’s theory profoundly disturbing and shockingly relevant. In his papers, he tries to argue that, even if we are avatars in some larger simulations, that does not mean “all the bets are off and you would go crazy”. I find this unconvincing.Bostrom’s theory bring us to the edge of madness. We exist on a foundation, based on our senses. We believe that we have form, that we breathe, that we eat, that we exist. Without that, what are we? Do our wishes and hopes still have meaning? These are philosophical questions, meant to be pondered. But what happens when you live them, eight or more hours each day, in a world that seems terribly important, but which exists only for as long as the electricity bill is paid?

I have treated schizophrenics in whom there is a similar loss of grounding. The disease attacks one’s sense of self, the frame where one’s physical and mental reality begin and end. The illness causes people to live in a dream-like world, where thought and sensation blend between people and objects. A patient may believe another person’s ear is actually his ear, stolen in the night. A table might be talking to him. As the parameters that define “self” and “other” dissolve, the risk of violence – suicide or homicide – seems to increase. If somebody were stealing parts of your mind and body, wouldn’t you want to stop it?

The disturbing thing is that Bostrom’s theory is being independently discovered, first-hand, on computers throughout the world. Given enough exposure to virtual reality, people cannot help but begin to question whether their real lives are merely simulations of life. The concept is subversive and potentially toxic to the human mind. More-over, it combines in a particularly noxious way with compulsive computer use. When technology is used compulsively, it soaks up at least 10 to 12 hours a day; it redefines relationships to include virtual entities and objects, like the computer itself; it encourages processing emotion through the computer.

When a person has few real-life relationships, sexual and aggressive impulses get expressed through avatars, games or other online activities. Now, limit access to the computer and make someone live in the real world: this person is alone, without friends, powerless, without physical accomplishments, and with many hours to consider his plight. In the midst of all that, he is questioning the very basics of whether he exists and where. In short, it is a recipe for disaster. Consider this from another perspective. The virtual world offers a sense of power, fairness, equality, logic and immortality. Reality, by comparison, is capricious, unfair and cruel. Is it any wonder that the virtual is so tantalising? But reality must be heard – bills have to be paid and people need to eat. Eventually, the power must go off. And, at that time, the omnipotence is pierced. The compulsive computer user must confront a monumental mismatch between one’s power and stature in virtual and real life. The interruption of the virtual is a narcissistic fall of huge dimensions. And it occurs in the backdrop of questions about which form of existence is truly real. What results is a dangerous mix of despair and rage. And, as society increases its exposure to the virtual, we should expect more of it.

The therapeutic challenges presented by compulsive computer use are tremendous. Recognition and treatment are both difficult. Patients downplay their computer use. It is either a topic of shame or a valued asset, a prize not to be put at risk. Thus, it is usually the practitioner that needs to raise the issue. But most mental-health providers became therapists because they like people, not technology. They tend to be low-tech, puzzled by computers. Nor is there any formal curriculum or educational teaching about PCU. So, at the outset, there are significant barriers to recognising and conceptualising the issue. In addition, coexisting psychiatric illnesses are the rule, not the exception. As a result, the therapist will readily find the concomitant diagnoses without realising there is the compounding issue of pathological computer use. The PCU will then complicate and delay the patient’s recovery.

But even for those therapists who actively look for it, the disorder is a difficult one to address. Each virtual world has its own norms and peculiarities, and trying to discuss a virtual world you are unfamiliar with is like doing therapy in an unfamiliar language.

A few years ago, I wrote a paper defining to other therapists what, exactly, was meant by the term “virtual sex”. Recently, to my surprise, I was told that my description was antiquated and only applied to “old-timers”. In my paper, I had described virtual sex as, typically, a form of interactive erotica where two people write sexually explicit messages back and forth. But now I was told of the modern version: people bring their avatars into virtual villas that they own. There, they may walk to a nicely decorated bedroom. In addition to sidetables, lamps and paintings, there is probably a TV, DVD and bed. The virtual TV and DVD are then activated to play a real-life porn film, while the two (or more) avatars climb on to the virtual bed. The bed takes control of them, making them graphically participate in a selection of some 50 sexual positions, along with appropriately evocative vocalisations. The real people presumably masturbate while watching and listening to their avatars have sex in front of the porn flick. The virtual clothing, real estate, home furnishings, TV, porn film, bed and customisable genitalia are all sold online. Fetishes, such as operating a dungeon where one chains up and tortures one’s virtual sexual partner, are also accommodated. But is any of this important to therapy, or does discussing it border on voyeurism? It is very relevant. To take but one example, in this virtual world, people sometimes prostitute out their avatars. They participate in sex for virtual money. What if someone only selected virtual prostitutes that were designed to look like children? Certainly this is an enactment of which a therapist should be aware. Would this suggest a risk of paedophilia in real life? Or does discharging the impulse in the virtual world in effect prevent it from emerging in the real world? We can theorise, but we do not actually know. This is not some thought experiment; it happens and we need answers.

Recognition is one issue, treatment is another. Very little is known about what cures PCU. Essentially, two different approaches have been tried. The first approach advocates setting firm limits. If a patient exceeds his time limits online, the computer is powered off. If covert use continues, the computer is unplugged.

Finally, if the patient continues to misbehave, he is sent off to a wilderness camp or a rehab-like setting. Usually this is the approach used with children.

This method is not without risk. After restrictions are lifted, many people seem to binge. In South Korea, one-week retreats without electronic access were tried. These camps were discontinued after the children became disruptive and binged when regaining access to technology. It seems a longer disconnection is needed – at least two weeks. More importantly and by all accounts, when the computer use is restricted, rage often erupts. If parents or administrators are the ones setting limits, they are often the target for that anger. It is not trivial and can, at times, be dangerous.The other approach is to work with the individual, trying to understand how he benefits from his computer use. By understanding what is being avoided and/or sought, the patient may make better decisions about his computer use. This method is, however, time consuming and may lead to no change at all. Until research informs us better, perhaps the best approach might be a combination of the two approaches.

Checking out from reality and living in the virtual world is a global problem. Computer programs are ever more engaging and entertaining. As a therapist, I try to encourage my patients to reduce their use of technology. But it is difficult work and even I am often conflicted about what I am asking of my patients. If they comply, I know they will initially feel miserable. Even with time, they may never regain the same degree of power or significance that the computer offers them. Many relapse. The uncomfortable truth is that our treatment strategies for this malady are inadequate and often fail. Until we learn more or have better clinical tools, our best approach may be to work on prevention.

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September 1st, 2008
2:09 PM
This is an excellent, interesting and informative article. It makes many interesting points, with there being one point that I want to comment further on. As far as becoming immersed in a virtual world by allowing our perception of the real world to start coming from what we see on the screen, that can potentially happen to some extent with any video game. Although games like MMORPGs (e.g., WoW) are much more immersive than regular video games, I have found that I can focus so intently on certain simple video games (e.g., 3-D Pinball and Minesweeper) that I can almost completely ignore the real world with this very limited "virtual world" that I see in front of me. I believe that is what largely made video games, rather than other things like alcohol and drugs, be addictive to me as a way to temporarily escape reality. Part of my recovery was to really, truly admit to myself that this did not solve any of my real world troubles since they usually just got worse. Instead, as difficult and unpleasant as it was at times, I had to spend time and energy in the real world to deal with these problems.

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