Mr. A was an 18-year-old Caucasian adolescent, a recent high school graduate from the Pacific Northwest, who was referred to the Baylor Psychiatry Clinic for a focal evaluation. This outpatient multidisciplinary assessment was conducted over 3 days and involved psychiatric interviews by three psychiatrists, psychological testing, and social work evaluation of his family. Mr. A’s parents sought psychiatric evaluation for their son because of concerns regarding his "obsession" with online gaming, which seemed to have overshadowed all other priorities in his life. Mr. A’s parents were particularly hoping that the evaluation team would view his game-playing as a manifestation of treatable obsessive-compulsive disorder (OCD), but they worried that it might be a form of addiction. Mr. A reported that his life had been taken over by the game-playing: "I play 12–16 hours a day, I do not sleep, and I’ve never had a girlfriend." He said he wanted to "figure out what the problem is, take care of it, and be successful in college." He dreaded that he’d repeat his high school pattern of "making only 2 days of class per week" when he got to college and end up "stuck at home."
Mr. A had a lifelong history of school refusal and anxiety about new social situations, in part related to the fact that his family had relocated 14 times in his 18 years of life; the last move was in 2000 just before his eighth-grade year. His anxiety led to home schooling off and on throughout his school years. Ultimately, Mr. A elected to enroll in a small private school at the beginning of his sophomore year. He received straight A’s his first year, leading the school to place Mr. A in accelerated classes. However, the advanced coursework became more than he could manage, and Mr. A began to play Diablo II, an online role-playing game, with increasing frequency until, by the spring of his junior year, it was nearly his only activity. His parents objected to this behavior and took his computer away, leaving Mr. A to spend most days in bed. His depression progressively worsened until, when he began expressing suicidal ideation, his parents sought an emergency psychiatric evaluation. Mr. A was admitted to an inpatient adolescent psychiatric unit and was diagnosed with OCD, generalized anxiety disorder, and major depressive disorder. After 1 week, Mr. A was discharged taking sertraline and olanzapine.
Mr. A barely passed his junior year, returning to school only to take his final examinations. Despite promises to "buckle down and study" during his senior year, Mr. A’s motivation rapidly dissipated. He would often skip classes and instead go to friends’ houses to play computer games or sleep in his car (after staying up all night playing computer games). Mr. A’s mother reported that he stole both money and credit cards from his parents to buy more gaming supplies. Mr. A admitted to having stolen from his parents to buy gaming supplies but denied any history of compulsive stealing from stores (which he found too intimidating). Mr. A was no longer playing Diablo II but had been focusing on a "massive multiplayer online game" called World of Warcraft that he played approximately 12–16 hours per day. In this game, he operated as the character Rava, whom he described as "like a shaman" who was able to "blast fire and ice," walk on water, hurl thunderbolts, heal himself and others, and resurrect the dead.
After graduation, Mr. A’s parents insisted that he get a job and restrict his gaming—neither of which he did. Mr. A stated that he felt "things ha[d] gotten worse" because he had no friends and had not applied for any jobs. Although he endorsed goals such as attending college and finding a girlfriend, Mr. A admitted, "I just cannot picture myself being successful." He acknowledged intense feelings of guilt regarding past behaviors, which at times became so severe that he experienced thoughts that he would be better off dead or even killing himself, although he denied any past or current plan or intent. Mr. A continued to experience diminished energy and poor concentration.
Upon a psychiatric review of symptoms, Mr. A denied any episodes of elated or expansive mood coupled with a decreased need for sleep, an increased activity level, a flight of ideas, or pressured speech. Although he endorsed some risk-taking behavior, this was confined to measures he took to pursue his interest in online gaming. Mr. A admitted that he tended to worry excessively, often leaving him feeling "on edge," with resulting fatigue, muscle tension, and poor concentration. Mr. A also endorsed recurrent, unexpected panic attacks, sometimes on a daily basis, and admitted that he worried about when or where the next panic attack would occur. Mr. A avoided situations in which there would be a large group of people because he became anxious that he would say or do something that appeared foolish. He reported that he was afraid of the dark and to walk outside alone, fearing that someone would "jump out at him." Mr. A denied any history of trauma or physical or sexual abuse.
Mr. A endorsed a minimal history of compulsive behaviors, such as repeatedly checking door locks or his watch, both of which relieved anxiety to some degree. He denied any past or current disordered eating, alcohol abuse, or illicit/prescription drug abuse. Mr. A described difficulty maintaining attention when it came to his schoolwork. He denied feeling driven, talking excessively, or interrupting others.
Mr. A denied any history of suicide attempts or self-mutilation. He had several trials of outpatient psychotherapy and had tried a number of different medications, including sertraline, fluoxetine, mirtazapine, olanzapine, aripiprazole, gabapentin, alprazolam and—most recently—lamotrigine. He did not feel that any of these medications had been helpful, and he had discontinued the use of all of them.
Mr. A had an extensive family psychiatric history involving both maternal and paternal relatives, including alcohol/substance abuse, depression, bipolar disorder, OCD, and one completed suicide (his great-grandfather). His mother acknowledged a personal history of substance abuse (now in full remission), as well as ongoing struggles with anxiety, depression, OCD, and posttraumatic stress disorder. Most recently, Mr. A’s 16-year-old sister admitted to alcohol and illicit drug abuse and self-mutilation and was subsequently diagnosed with OCD and major depressive disorder.
Mr. A was the only son of married parents; his father was employed as a pathologist, and his mother worked as a homemaker. The family practiced orthodox Catholicism. Mr. A reported that for most of his life, he had been a perfectionist. He recalled working to do his best on schoolwork because of "not liking to let teachers down." He stated that when he decided to do something, he "put[s] everything into it." Mr. A admitted to having "too high of standards" and would sometimes not do something at all rather than perform beneath his expectations. This perfectionism extended into his religious practices, and he frequently felt as though he had failed to live by the church’s standards.
He had some friendships that were almost entirely based on Internet role-playing games, but he felt that these were highly meaningful to him. In regard to his sexual practices, "Mr. A described with great shame sexual behavior with animals that required violent treatment of the animals, but he tearfully denied any sense of pleasure from this aspect of the acts." Mr. A described an overwhelming urge to engage in this sexual behavior and reported multiple failed attempts at stopping before successfully discontinuing this activity. He described it as though a different part of him was involved in this behavior: "It was like watching another person [perform these acts], as though someone else was inside me and had taken over." He said that his current behavior was now limited to masturbation, which, according to his religious beliefs, was a "mortal sin." He often worried about going to Hell and did not see the possibility of going to Heaven while he continued to engage in this activity.
His mental status examination showed that Mr. A was a quiet, slightly overweight man who was moderately groomed and casually attired. He exhibited significant difficulty making or maintaining eye contact. Mr. A exhibited mild restlessness, but no other motor abnormalities were noted. His speech was of normal rate, tone, and volume. He indicated that his mood was "OK," although his affect was clearly dysphoric and paralleled the emotional content of his speech. Mr. A denied any auditory or visual hallucinations. He endorsed periodic passive suicidal ideation but denied any plan or intent. Mr. A denied any homicidal ideation and exhibited no behavior or speech suggestive of delusional beliefs. Of note, Mr. A disclosed his history of sexual contact with the family cat in the first 15 minutes of our 2-hour interview, a behavior reminiscent of the Catholic sacrament of "confession." His thought processes were noted to be logical, goal-directed, and rather concrete. Despite the fact that his parents did not allow him to play online games during the 3-day evaluation, he was not inordinately anxious.
Lisa von Wahlde, L.M.S.W.
Mr. A was the eldest of four children (16-, 7-, and 2-year-old sisters) and was born while his father was still in medical school. Although he initially was able to spend a lot of time with Mr. A, his father found his free time significantly limited after beginning residency and following the birth of the couple’s second child. As a baby, Mr. A was described by his parents as being "different" from other infants. His father explained that Mr. A, even at an early age, had always been a sensitive person who needed to be around adults, specifically his parents, at all times.
Triangulation existed between Mr. A, his mother, and his father. The dynamic between Mr. A and his father showed a diffuse boundary in which the father highly identified with his son in the areas of "people pleasing" and exploration of self, sexuality, and spirituality. A rigid boundary was represented in the dynamic between Mr. A and his mother in the aforementioned areas of mistrust. Of course, the tension between the parents also contributed to the enmeshment in the family system. This was exemplified by the father’s alliance with his son and the mother’s confrontational personality. The parental tension further shook the family foundation, leaving the children without stable boundary models.
Both of Mr. A’s parents described his relationship with his 16-year-old sister as being "close." His mother, however, believed that at times, the siblings were "too close." Both parents felt that Mr. A had little difficulty making or keeping friends, although they described his group of six close friends as being "misfits" and "outcasts" with whom other children would probably not choose to be friends. His parents worried that Mr. A’s poor personal hygiene and unwillingness to bathe regularly might lead to social isolation. His father reported that Mr. A had discussed being interested in girls but had difficulty feeling comfortable interacting with the opposite sex.
His mother expressed great distress regarding Mr. A’s history of sexual behavior with animals. Mr. A’s father stated that he did not believe that Mr. A was a "sexual pervert" like his mother believed but rather a boy who was in conflict between following his hormonal urges and obeying the doctrine of his orthodox Catholic faith. Mr. A’s mother had stated that she was most likely unable to welcome Mr. A back into the home because she was nervous regarding his unpredictable and impulsive behavior and felt unable to trust him.
Psychological testing on Mr. A included the following: the WAIS-III (coding and symbol search), portions of the Wechsler Memory Scale—Revised (1), the California Verbal Learning Test, Second Edition—Adult Version (2), the Trail Making Test (3), the Stroop Color and Word Test (4), the Continuous Performance Test (5), the Wisconsin Card Sorting Test (6), the Rorschach Test (7), the Thematic Apperception Test, the Incomplete Sentences Test (8), the Brown Attention-Deficit Disorder Scales (9), the Millon Clinical Multiaxial Inventory—III (10), and the Minnesota Multiphasic Personality Inventory—2(MMPI). Mr. A demonstrated excellent memory function with no deficits in executive cognitive functioning. Projectives suggested a proclivity for science fiction images but no disturbances in perception or associative thought processes. Themes that emerged in the Thematic Apperception Test included fear that others would think he was crazy, the inevitability of death and illness, desires to escape, regret and sadness, and a wish to be a hero who compassionately saved others and doled out retribution for evildoers. He described a high number of attentional problems involving difficulties with activation, sustaining effort, and reducing intrusion of emotions into cognitive functions. On the MMPI, he showed a marked overendorsement of pathological items that appeared to be a "cry for help." Avoidant and schizoid interpersonal tendencies were present, as were marked anxiety, depression, and alienation and antagonism toward authority.
Although Mr. A occasionally experienced periods of heightened productivity and some impulsivity regarding his "need" to acquire gaming supplies, he did not meet the criteria for either a manic or hypomanic episode. Nor did he meet the criteria necessary for a diagnosis of OCD. Although from a lay perspective he might have appeared to be "obsessed" with gaming, his gaming was not connected in an unrealistic way to some dreaded event or situation that might be prevented or neutralized by engaging in the behavior. In addition, the behavior (gaming) was not experienced by Mr. A as unreasonable or distressing. In fact, the exact opposite was true: Mr. A relied upon this activity as a means of escape, allowing him to avoid the unpleasant anxieties of his internal world. Although his "checking behaviors" (door locks, schedules) may be seen in patients with OCD, Mr. A’s symptoms were a manifestation of generalized anxiety, comparable to his fear of the dark or being attacked by a stranger while walking alone.
In regard to attention deficit disorder, the diagnosis could not be definitively ruled out at this point. During psychological testing, Mr. A endorsed a high number of attentional problems. Although both his depressive and anxiety-related symptoms could create this constellation of complaints, the disorder could not be excluded until Mr. A could be reevaluated during a period when his symptoms were under more adequate control.
Mr. A’s current clinical presentation might be attributed to three major factors: a set of anxiety disorders (with an undercurrent of depression), a developmental crisis of late adolescence/early adulthood, and problematic family functioning. Mr. A’s self-reported history supported the diagnosis of major depressive disorder, which currently appeared to be in partial remission. In addition, Mr. A suffered from generalized anxiety disorder, social phobia, and panic disorder. The coexistence of these disorders left Mr. A markedly impaired in interpersonal settings and led him to pursue interaction in the virtual realm of online gaming. This realm also provided an opportunity for self-development, as Dr. Gabbard will discuss.
Mr. A’s internal world had been colonized by what are termed "massively multiplayer online role-playing games," or MMORPGs for short (11). Sometimes termed "heroinware," these games are simultaneously competitive and highly social. Because they run continuously in real time, players must be completely devoted to the game, which often becomes a substitute for real-life social interaction. It is easy to see how the term "Internet addiction" has arisen. A support group known as On-line Gamers Anonymous (www.olganon.org) has even sprung up.
However, whether or not these behaviors represent true addictions is controversial. A modest body of literature has developed on this subject (12–17). Part of the controversy centers on how the authors define an addiction. Physiological signs, such as withdrawal-related symptoms and increasing tolerance, are problematic as defining features because Internet use, like other so-called behavioral addictions, are without these elements. Some argue that engagement in self-destructive behavior despite adverse consequences is the core issue (14), whereas others stress alterations in neural circuitry that perpetuate the behavior. Indeed, some research on Internet game players has shown that repetitive playing leads to dopamine release in the nucleus accumbens in much the same way that other addictions do (15). Some of the psychosocial consequences, such as losing jobs or failing school, clearly resemble addictions.
On the other hand, some investigators have emphasized the positive aspects of role-playing Internet games. One survey of MMORPG users (11) found that they do not fit the profile of addicts. The subjects of this study denied irritability if forced to abstain from gaming for a day and reported that they would find fun elsewhere if MMORPGs did not exist. The investigators concluded that these game-players simply have a different perspective on social life. They seek social experiences that may not otherwise be available to them for a variety of reasons.
It is probably an oversimplification to approach the addiction issue as an either-or choice. In the case of Mr. A, a both-and conceptual model was more useful. He made fine distinctions between the specific games in this regard. He acknowledged that Diablo II was in many ways like an addiction, something that he had to do despite the adverse consequences resulting from his behavior. If his parents destroyed it, he would find a way to get another copy of the game. In his own words, "When I want something, I have to have it." But with other games, he found that he got bored and stopped playing on his own.
Apart from the addiction paradigm, the games allowed Mr. A to express aspects of himself that served a compensatory function psychologically. In other words, he could put on a new identity like a new suit of clothes, becoming someone who walked on water, healed others, and cast lightning bolts, in stark contrast to his daily experience of himself as inadequate. Young (18) conducted research of Internet users in which he found that some specifically chose identities that were the opposite of who they were in real life, frequently an ideal version of the self.
Hence, the evaluation team recognized that there are both positive and negative aspects to role-playing games on the Internet, and this point of view was shared with the patient and his family. The authors made the point to the family that total abstention from games would rob Mr. A of his most meaningful form of peer group interaction as well as the opportunity to develop a more consolidated sense of who he is. At the same time, excessive gaming interfered with face-to-face interactions that teach social skills and time needed to study and work. The authors also had to emphasize that "obsession" with role-playing fantasy games did not mean that it stemmed from clinical OCD nor did it fit a simple addiction model. These games allow for a playful expansion of the self. As Turkle (19) put it, "You can have a sense of self without being one self"(p. 258). While looking into the computer screen, the authors can play with the idea of becoming someone other than who the authors are. Virtual space is similar to the psychoanalytic notion of transitional space in that it is not truly an internal realm but lies somewhere between external reality and the internal world. When Mr. A sat down at the computer to play Diablo II, he was both real and not real.
Online role-playing also allowed Mr. A the opportunity to explore real and threatening aspects of himself but in an environment where consequences were not real. He could integrate violent and altruistic aspects of who he was through trying on different identities. Although some may worry that greater violence may be promoted by these games, the first long-term study of online video game-playing from the University of Illinois (20) suggested otherwise. These researchers reported that no association was found between time spent playing highly violent online games and the frequency of real-world aggressive behavior. Players and comparison subjects showed no differences.
The impact of role-playing games is of particular significance when we consider late adolescence through young adulthood, a period during which the evolution of a coherent sense of self is a fundamental maturational task. As demonstrated in the case of Mr. A, the increased substitution of cyberspace-based personas and relationships at the expense of face-to-face interaction may create a developmental double-edged sword. The Internet may provide a socially anxious youth the opportunity for modified peer group interactions, yet it does little to foster the development of genuine intimacy.
Although he demonstrated superior cognitive abilities, Mr. A experienced great difficulty navigating the developmental tasks that typify the transition from adolescence to adulthood and exhibited a maturational delay in regard to emotional and social development. Given his family history, this struggle may be attributed in part to a genetically based harm avoidance temperament as well as several comorbid anxiety disorders. An additional influence may be his sheltered upbringing, as overprotective, anxious parents often unwittingly communicate to the child that the world is a dangerous place. The child may then become a container of the projected anxiety of the parent, a common situation in cases of school phobia. Mr. A was riddled with anxiety when he ventured out of his house, despite powerful impulses to oppose the wishes of his parents and assert his individuality. The enmeshed nature of the nuclear family makes the achievement of an identity even more problematic. Although one family message is to "leave the nest" and become independent, another message conveyed is that differentiation from the family is a formidable, if not impossible, task. The family may have needed Mr. A’s presenting problems to preserve its intactness.
The evaluation team stressed to the family that pursuing relationships online was both adaptive and maladaptive. The games were adaptive in the sense that they provided an arena within Mr. A’s comfort zone to engage in the developmentally appropriate task of group formation outside of the nuclear family. Mr. A interacted with a community of friends without the discomfort of face-to-face contact. One study (16), for example, found a direct correlation between levels of social anxiety and the amount of time spent playing online games. Mr. A was haunted by the sense that he was "transparent" and others could see through his facade to what he felt was his despicable core. Even the most benign communication held the risk of discovery, as the patient’s self-defeating tendency to "confess" his sins while face-to-face was experienced as overwhelming and difficult to control. Hence, online relationships provided much-needed "opacity" as a context to try out relationships.
On the other hand, spending 12–16 hours a day on the Internet served as a way of avoiding intimacy with peers and the expansion of his identity in the outside world. He was allowed contact and a sense of community without the expectation of genuine intimacy within these relationships. The resignation to these "good enough" exchanges presented a major developmental roadblock; the patient was willing to accept these less rewarding interactions in the interest of avoiding the risk of disclosure. With no peer-based development of identity, Mr. A was left largely to his own devices to cultivate a sense of self. However, he could not bear to integrate the painful aspects of his sexual identity nor could his harshly punitive superego permit that he "forgive and forget" the sins of his past. Thus, the patient remained frozen and unable to form a coherent identity, leaving him with a deficient and fragmented sense of self.
In summary, then, role-playing games may offer beneficial outlets to adolescents and young adults but also present substantial risks. Although the addictive component in some cases is striking, they also provide an experience of a virtual community, ameliorate social anxiety and loneliness, allow the "trying on" of new identities, and assist in the developmental task of forging a sense of identity apart from one’s family.
When it came to recommending treatment, the evaluation team was faced with the fact that there was no evidence base from which guidelines could be developed. Outpatient treatment had clearly failed. To endorse matriculation at the university of Mr. A’s choice would be to set him up for failure. His impaired level of functioning and his ambivalence about change led the team to recommend inpatient treatment at a specialized unit for young people with dual diagnoses. In such an environment, the addictive aspects of gaming could be addressed while the developmental tasks of defining oneself could also be a focus of treatment. Mr. A would be required to interact with his peers in a face-to-face milieu. He would also have the opportunity to be started on a selective serotonin reuptake inhibitor for his anxiety. Cognitive behavior techniques geared to relapse prevention could be taught, and a dynamic therapy process addressing his anxieties could also be conducted. Finally, family therapy could be part of the treatment plan so that the nature of the enmeshment could be identified and elaborated.
Intensive inpatient treatment also provided Mr. A with a chance to develop a greater sense of self without resorting to MMORPGs to define himself. While Erik Erikson (21) emphasized sameness and continuity in the achievement of identity, analysts and dynamic psychiatrists today would stress the flexibility and multifaceted nature of the self. As Mitchell (22) once pointed out, a paradox of good analytic therapy is that as patients learn to tolerate more facets of themselves, they begin to feel a more durable and cohesive sense of self. Thus, adolescents and young adults may need encouragement and assistance in accepting the diverse aspects of the self that are often in conflict with one another.
Presented in part at Grand Rounds at the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Sept. 7, 2005. Received Oct. 4, 2005; revision received Jan. 11, 2006; accepted Jan. 11, 2006. From the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Address correspondence and reprint requests to Dr. Allison, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030; email@example.com.