The Cyber Effect (9 page)

Here's the bad news. If you answered yes to four or more of these, according to Zehr, you may have a problem. And you might want to get some professional advice about it.

Compulsive gaming is by far the most studied cyberbehavior. It is most prevalent among young men, and studies report that compulsive gaming is often found together with mood or affective disorders, including depression, anxiety, and ADHD.

The other thing: It can be fatal.

Twenty-year-old Chris Staniforth of Sheffield, England, knew what his passion in life was: online gaming. In 2011, the bespectacled super-gamer with brown hair and a kind face had just been admitted to Leicester University to study computer game design. While he owned a range of different consoles, and collected them, he had recently gotten a new Xbox and was playing a lot of
Halo
, a bestselling online military sci-fi shooter game—since the series was first launched in 2001, more than 60 million copies have been sold—in which players battle invaders from outer space.

“
Chris lived for his Xbox,” said his father, David Staniforth. “When
he got into a game, he could play it for hours and hours on end, sometimes twelve hours in a stretch.”

After a day of marathon gaming, Chris woke up in the middle of the night with a strange feeling in his chest but was able to go back to sleep. The next day, during a visit to a job placement center, he reached down to pick up a pack of gum that he'd dropped and felt a jolt, then a spasm, and fell to the ground. A friend who was with him called an ambulance, but it was too late. A local coroner confirmed that Chris had died of pulmonary embolism. A blood clot that had formed in the veins of his lower body—deep vein thrombosis, or DVT—had traveled to his lungs, blocked his arteries, and killed him.

DVT is caused by inactivity, by sitting still for long periods of time. In the past, those at risk were passengers of overseas flights and bedridden hospital patients. Americans might remember the NBC White House correspondent David Bloom, who died in 2003 in Iraq after spending hours immobile in a tank while embedded with the U.S. infantry. An estimated three hundred thousand to six hundred thousand people develop DVT each year in the United States, and between 10 and 30 percent of all patients die within thirty days. So-called extreme gamers—the 4 percent of the total U.S. gaming population who average 48.5 hours a week in front of a screen—are at risk for DVT, which has led the U.S. media to call this life-threatening condition “
gamer's thrombosis.”

In Asia, where marathon gaming is more prevalent, competitive gamers or extreme gamers gravitate to popular public arcades or gaming halls called Internet cafés that are open twenty-four hours a day in some countries. In the West, we probably think of an Internet café as a quiet coffeehouse that offers Wi-Fi or an Internet hookup, with maybe a few spare computers to borrow. In the East, the term increasingly describes a phenomenon that has taken over India, China, South Korea, Taiwan, and the Philippines, where the old computer game and pinball arcades have been replaced by thousands of gaming centers—sometimes called “PC bangs” or “LAN centers”—where rows and rows of chairs and consoles provide gamers with a PC with a LAN high-speed connection for as little as a dollar an hour. There, surrounded by dozens of fellow gamers, a gaming enthusiast can binge-game, usually going online
to meet dozens of other gamers on a MMORPG (massive multiplayer online role-playing game) like
League of Legends, World of Warcraft, Counter-Strike
, or
StarCraft
. Evenings, after dinner, the cafés are traditionally filled with competitive gamers, usually over eighteen years old, who are welcome to pay and play all night.

In this exciting setting, you can imagine the additional incentives to keep playing—surrounded by other gaming enthusiasts in the room, and cheered on by your gaming cohorts online. The question is, where is the gamer? Are they sitting in the real-world environment of the café, or are they immersed or even lost in cyberspace?
A number of fatalities point to a break with reality.

In 2012, an eighteen-year-old boy in Taiwan, a gamer who went by the name “Chuang,” booked a private room in an Internet café and holed up there without eating or sleeping for forty hours to play in a marathon session of
Diablo III
, then died of what is suspected to be a fatal blood clot. The same year, also in Taiwan, Chen Rong-yu, twenty-three, played
League of Legends
for a day straight and was found dead in a PC bang with his hands stretched out for the keyboard and mouse. Gamers continued to enter and leave the room, oblivious to the dead young man in their midst.

There are more than twelve thousand Internet cafés (and counting) now in South Korea, where
professional gaming is now a multimillion-dollar industry. But the cafés have come under scrutiny, and appear to be the epicenter of dark tales and addiction.
A spike of concern was provoked when an unemployed married couple became so hooked on a role-playing game called
Prius Online
, a virtual world where they were caring for a virtual baby named Anima, that they neglected to feed or care for their actual baby, who'd been born prematurely and was unhealthy. When the real baby died of malnutrition at three months old, the couple was reportedly gaming at an Internet café. (This became the subject of an HBO documentary,
Love Child
, in 2014.)

Other disturbing tales have surfaced in the media—almost too awful to believe. In 2010, a twenty-two-year-old Korean man was charged with killing his mother when she nagged him to stop gaming. He left her corpse in order to return to the café and keep playing. Another
man, gaming at a café in the city of Taegu, played
StarCraft
continuously for fifty hours and died of a heart attack.

When reading stories like these, of such passionate engagement, you almost have to remind yourself,
This is a made-up game in a virtual world
. What causes this kind of dedication, persistence, and devotion?

In one significant study of excessive gamers, brain imaging was done while subjects described their urge to play games online and recalled various gaming experiences that were provoked by pictures.
The results showed that their cravings had a similar neurobiological pattern as the cravings for drugs in drug addicts and the cravings for alcohol in alcoholics.

The brain doesn't lie. This study and others show a biochemical component in compulsive online activity, which means the behavior could qualify as a “true addiction” and “disorder,” using the clinical definition. In 2007, when the American Psychiatric Association (APA) began preparations to update DSM, one of the subjects discussed at length was compulsive Internet gaming.

When the APA identifies a new clinical disorder, it's a big deal in my world—and a game-changing event for mental health practitioners, patients, and their families. It is a decision meant to stand the test of time, an acknowledgment that a behavior has been consistently proved by studies to be serious and is understood well enough for criteria for diagnosis to be established and proper medical intervention and treatment options suggested. Once “legit” in the eyes of the APA, a disorder receives more widespread attention in the media and journals of medicine and can qualify for health insurance coverage.

The impact on private and public mental health practitioners, who aren't on the front lines of research, is tremendous. They turn to—and trust—DSM to give them strong and clear guidelines about how to diagnose a disorder and care for real patients in their offices and clinics.

A work group of twelve members of the APA and twenty outside advisors with expertise in related specialties of substance use and addiction
was assembled and met over a period of five years to discuss compulsive Internet gaming, as well as the more general term,
Internet addictive behavior
. They looked at studies and literature on potential nonsubstance-addictive-related behaviors—including gambling, Internet gaming, Internet use, shopping, exercise, and work. (Excessive eating and excessive sexual behavior were discussed with the eating disorders and sexual disorders work groups.) The result?

In the case of
Internet gaming disorder, the evidence in 250 studies done in countries around the world shows a persistent and escalating problem of youth, adolescents, and young adults, mostly male, who demonstrate symptoms of addiction-like behavior while playing online games. When DSM-5 was released in 2013, it was noted that Internet Gaming Disorder is most common in male adolescents 12 to 20 years of age. According to studies it is thought that Internet Gaming Disorder is more prevalent in Asian countries than in North America and Europe.

The APA suggested that these four components were essential for behavior to be described as Internet addiction and recommended further study:

In China, one of the first countries in the world to define overuse of the Internet as a clinical condition, and perhaps where the problem of compulsive gaming is perceived as more serious and prevalent, more action has been taken. The government developed treatment centers to cure teens of “Internet addiction.”
In South Korea, the government found an escalating number of “addicted” teens who were compromising on sleep, schoolwork, and real-world friends in order to play online
games. In 2011, a “Shutdown Law” was enacted, prohibiting those sixteen years old and younger from logging online between midnight and 6:00 a.m. The following year, an amendment prevented under-eighteens from playing online between midnight and 6:00 a.m. unless specifically allowed by their parents or guardians. As of 2015, there were five hundred “Internet addiction” inpatient units in hospitals and treatment centers in Korea, as well as prevention programs in place in every single school system. The most interesting recent development is in
Taiwan, where legislation was passed in 2015 that allows for parents to be fined up to 50,000 Taiwanese dollars ($1,595 U.S.) if their child's use of electronic devices “exceeds a reasonable time.” It is unclear how “reasonable” is defined or how the government plans to monitor it.

The climate seems to be 180 degrees different in the United States, where a discussion about making “e-Sports,” or gaming, an official college athletic sport has begun. Kimberly Young argues that this seems irresponsible in the face of study results that have found gaming associated with many problems. Take, for example, the 2004 story of thirteen-year-old Zhang Xiaoyi in China, who played
World of Warcraft
for thirty-six hours straight—what's called a gaming marathon—and afterward jumped out the window of a tall building, having left behind a note saying that he wanted to join the heroes of the game. If you play a game for thirty-six hours straight, any game, you are likely to be mentally and physically exhausted to the point of being delusional.

But the problem of gaming isn't simply a matter of excessive playing. Young writes on her blog that at her addiction center, “
we see addicted gamers who are more than twice as likely to have ADD/ADHD, get into more physical fights, and have health problems caused by long hours of game play (e.g., hand and wrist pain, poor hygiene, irregular eating habits). Many need treatment to improve their academic performance and return to normal functioning.”

She continues: “[T]here should be great concern about American colleges deeming video games as sport. It is important that we first understand the impact of these games on our youth. While video games can be fun and entertaining, I continue to hear from families who are struggling because of a child's gaming habits. What may seem like a competitive sport could be masking a deeper problem.”

In the late 1960s and early 1970s, a series of studies on impulsivity and delayed gratification were conducted by psychologist Walter Mischel at Stanford University that are now referred to as the
Stanford Marshmallow Experiments. A child was offered a choice between one small reward provided immediately or two small rewards if they waited for a short period, approximately fifteen minutes, during which they were left alone in the room. The reward was sometimes a marshmallow. Other times it was a pretzel or a cookie.

Some children had no difficulty waiting out the fifteen minutes in order to get the double reward. Some children were incapable of that. In follow-up studies that went on for decades, the researchers found that children who were able to wait longer for the enhanced reward tended to have better life outcomes, as measured by higher SAT scores, higher educational attainment, even better body mass index (showing, I suppose, restraint with food consumption), and other life measures.