Addressing the epidemic of video game overuse
■ A message to all physicians from AMA President Ronald M. Davis, MD.
On April 29, the video game "Grand Theft Auto 4" went on sale. According to Reuters News Service, the launch was expected to be "the biggest entertainment event of the year, with first-week sales forecast to be up to $400 million, beating those of last year's 'Halo 3' from Microsoft." The game, as Reuters explains, "casts players as an Eastern European immigrant who runs drugs, shoots cops and beats up prostitutes after falling in with a crime syndicate."
A 2004 Kaiser Family Foundation survey of American kids ages 8 to 18 found that 35% play computer games and 52% play console or handheld video games on any given day. Popular video game consoles include Sony's PlayStation, Microsoft's Xbox and Nintendo's Wii.
The most popular video game played on PCs is "World of Warcraft." Its manufacturer, Blizzard Entertainment, claims that more than 10 million people subscribe to WoW, including more than 2 million in Europe, more than 2.5 million in North America and about 5.5 million in Asia.
In June 2007 the Nielsen Co. reported that WoW players in the United States use the game 2.5 hours per day on average (equivalent to 38 days of continuous playing per year), outranking the next most-played game by four times. Illustrating the game's impact on global economy, the New York Times Magazine reported in a June 17, 2007, cover story that 100,000 persons in China work as "gold farmers" -- playing WoW in sweatshop conditions to earn WoW currency (gold coins) sold to Western gamers for real money.
What does all of this have to do with health? A lot.
The AMA Council on Science and Public Health issued a report in June 2007 on "Emotional and Behavioral Effects of Video Game and Internet Overuse." The report, which is available online, reviewed potential benefits of video game use, including the use of games in training, as learning aids, in patient education, for stroke rehabilitation, and as therapy in moderating certain phobias (link).
An article in the July 23/30, 2007, American Medical News offered many examples of how video games are used in medicine and public health. For instance, "Dance Dance Revolution," a competitive console game in which players move their feet on a floor pad to mirror on-screen dance steps, is being used in public schools throughout West Virginia to combat youth obesity.
However, the council's report focused on the adverse health effects of video game "overuse." Those effects can be divided into three categories: physical, behavioral and psychosocial.
Regarding physical effects, the council reviewed evidence that video game use is associated with epileptic seizures, upper-extremity musculoskeletal disorders and increased metabolic rate. A letter in the June 7, 2007, New England Journal of Medicine, for example, reported a case of acute, intense shoulder pain in a medical resident after playing the Wii tennis game; the final diagnosis was "Wiiitis," a form of "Nintendinitis."
Physical effects probably include an impact on weight. In a study of 872 children (grades one to three) living in Switzerland, published in the June 2004 issue of Obesity Research (now named Obesity), researchers reported that the use of electronic games and television viewing were independently associated with obesity, with a nearly twofold increased risk for obesity per hour per day spent playing electronic games.
With respect to behavioral effects, several small studies suggest an association between playing violent video games and having aggressive thoughts and behaviors. Research on the effects of violence in other media (e.g., television) may be relevant to video game playing; according to the AMA's council, the preponderance of research shows that exposure to violent media increases aggressive cognition, affect and behavior, and decreases prosocial behavior in the short term.
The psychosocial effects of video game overuse are particularly disturbing. Web sites such as On-Line Gamers Anonymous and World of Warcraft Widows provide innumerable anecdotal examples of how video game overuse can harm or destroy friendships, marriages and other family relations, and can impair performance in school and at work.
The risk of psychosocial effects is greatest for massively multiplayer online role-playing games. MMORPGs, as defined by the online user-written Wikipedia, are "a genre of computer role-playing games in which a large number of players interact with one another in a virtual world." Popular MMORPGs include World of Warcraft, RuneScape and Guild Wars.
A player assumes the role of a fictional character (avatar) and is often part of guilds or clans that carry out prescheduled missions or raids. Players have specialized roles, creating an interdependence among guild members. (WoW guilds typically include about 50 players). During missions, communication occurs on several levels, including talking via headsets and in-game e-mail/messaging. Relationship-building among guild members continues on each guild's Web site through public postings and private exchanges.
In a book about MMORPGs, based on hundreds of interviews of gamers, R.V. Kelly 2 explains that these games are so absorbing because the virtual worlds are "set up in such a way as to appeal to the most essential wants and needs of the human psyche" -- the urges to get ahead in the world, to accomplish something, to be part of a larger endeavor, to escape from harsh reality, to help others, to solve problems, to live a heroic life, to interact with people without getting physically or emotionally hurt, and to live in a world that makes sense. When Kelly asked players why they played the game or why they couldn't leave their virtual world, one of the answers was always, "because of the friendships I've made here."
Should a diagnostic category be created for video game overuse, analogous to pathological gambling, in the American Psychiatric Assn.'s Diagnostic and Statistical Manual of Mental Disorders? Several of the criteria used to define that disorder in DSM-IV would seem to apply to video game overuse, including: escape -- the subject gambles to improve mood or escape problems; lying -- the subject tries to hide the extent of his or her gambling by lying to family, friends or therapists; and risked significant relationship -- the person gambles despite risking or losing a relationship, job or other significant opportunity.
An editorial in the March American Journal of Psychiatry argued for inclusion of Internet addiction (including excessive gaming) in DSM-V.
The AMA committee that heard testimony on the council's report in June 2007 concluded that formal recognition of problem gaming as an addictive illness would be premature. So the AMA House of Delegates did not take a stance on that issue but voted to forward the council's report to the APA for "review and consideration" when it revises DSM-IV. The house also recommended more vigilance by parents in monitoring and restricting their children's use of video games and the Internet, more research to assess the effects of video game use on youth and to determine appropriate limits for their total screen time, physician education on assessing media usage by their pediatric patients, and evaluation and improvement of the current rating system for video games.
My wife and I have three sons, each of whom has been an avid gamer. So this issue is personal to us. But it is also personal to millions of other parents in the United States and abroad.
Is it personal to you? If you have a story about how video game overuse has affected you or someone you care about, I'd love to hear it.
The health implications of the growing epidemic of video game overuse are enormous, but few resources have been devoted to confronting this problem in the areas of research, education, treatment and policy. It's time for physicians, medical associations and their alliances, medical schools and other stakeholders to get into this game.