The Perfect Storm for a Killer: Video Game Addiction and Violent Video Games My heart grieves for

the lives lost at Sandy Hook Elementary. As the smoke clears from this tragedy, the question of violent video games and video game addiction must be addressed. Based on reports in the media, the shooter may have shot the mother in fear of being committed for mental illness1, the computer was destroyed2, and the shooter played hours of the game Call of Duty3. In my years struggling with video game addiction during medical school and ophthalmology residency, I raged when I couldnt play my games. When an addict does not have access to their drug of choice, in the case of video games the digital drug of choice, rage and anger are common. I envision two most likely scenarios: 1) mother smashed the computer and the shooter raged; or 2) shooter smashed the computer and then raged, both being a manifestation of the acute depression followed by refractory psychosis associated with withdrawal symptoms. Ive been there, and it is real. Clearly, without additional facts associated with the Sandy Hook Elementary tragedy, this may only seem theoretical; however, there is hard evidence our society is ignoring. The perfect storm for the formation of a killer is mental illness combined with violent video games. A child addicted to anything is mentally ill, whether it is an addiction to drugs, alcohol, or video games. When the drug or activity of choice results in dysfunction, this is defined as addiction. Unfortunately, the medical community ignores violent video game addiction because there is no diagnostic ICD9 code or DSM criteria, the written guide for psychiatric illnesses. As a society, we agree that pornography leads to sex crimes and deviant sexual behaviors. We generally do not give children access to pornography because of the consequences of this potentially addictive behavior. However, when a game like Grand Theft Auto allows a child to have sex with a prostitute, kill her, and steal her money, we allow teenagers to play because it is only a game. It is only a game is a ridiculous response because we do not allow our children to watch pornography, as it is only a video. Adam Lanza's Motive: Did Fear Of Being Committed Lead To Sandy Hook Elementary Shooting? (UPDATE). Huffington Post. http://www.huffingtonpost.com/2012/12/19/adam-lanza-motive_n_2329508.html Accessed 12/21/12. 2 Adam Lanza Tried To Destroy His Hard Drive. Heres How We Can Still Follow His Electronic Trail. Slate. http://www.slate.com/blogs/future_tense/2012/12/21/adam_lanza_s_hard_drive_ might_be_destroyed_but_we_can_still_follow_his_electronic.html. Accessed 12/21/12. 3 Connecticut school massacre: Adam Lanza 'spent hours playing Call Of Duty. The Telegraph. http://www.telegraph.co.uk/news/worldnews/northamerica/usa/9752141/Conne cticut-school-massacre-Adam-Lanza-spent-hours-playing-Call-Of-Duty.html Accessed 12/21/12.
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The evidence for violence and addiction associated with video games extend beyond my personal opinion and experiences. In one national study of over 1,100 8 to 18year-olds in the United States, Gentile found that 8.5 percent would classify as pathological gamers4. Although this could be considered a somewhat small percentage, the true nature of the problem becomes clear when one considers this percentage in population terms. There are about forty million children between eight and eighteen in the United States. Approximately 90 percent of them play video games. If 8.5 percent of them are pathological, thats over 3 million children seriously damaging multiple areas of their lives because of their gaming habits! Thats over 3 million children who probably should get some help, but most wont because there is no medical diagnosis for the pathological use of technology. Once there is, it will be similar to the approach focusing on dysfunction. The medical diagnostic definition matters because, until there is one, insurance companies will not pay for treatment. A new study from Ohio State University that will be published in the Journal of Experimental Social Psychology shows that violent video games promote aggression5. The researchers found that people who played a violent video game for three consecutive days showed increases in aggressive behavior and hostile expectations each day they played. Meanwhile, those who played nonviolent games showed no meaningful changes in aggression or hostile expectations over that period. What happens to our minds when we devote significant hours to a task or an activity? What happens to our brains when we focus hours and hours on a video game? Stickgold and his research team at Harvard University published an experiment in the research journal Science illustrating that people who played the video game Tetris for seven hours over a period of three days experienced hallucinatory replay of the activities as they fell asleep.6 This phenomenon is referred to as The Tetris Effect. The game Tetris is a puzzle game where falling blocks of various shapes must be aligned to form a continuous line.7 When such a line is created, it disappears, and any block above the deleted line will fall. When a certain number of lines are cleared, the game enters a new level. As the game progresses, each level causes the blocks to fall faster. The game ends when the stack of blocks reaches the top of the playing field, and no new blocks are able to fall. Gentile, Douglas. Pathological Video-Game Use Among Youth Ages 8 to 18. Psychol Sci. 2009 Jun; 20(6):785. 5 Violent Video Games: More Playing Time Equals More Aggression. http://researchnews.osu.edu/archive/violgametime.htm Accessed 12/21/12 6 Stickgold et al., Replaying the game: hypnagogic images in normals and amnesics. Science. 2000 Oct 13;290(5490): 350-3. 7 Tetris. Wikipedia. http://en.wikipedia.org/wiki/Tetris. Accessed September 19, 2011.
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Participants playing Tetris have reported intrusive visual images of the game at sleep onset.8 When a child has mental illness or addiction to video games, allowing the childs mind to fill with intrusive, violent images is the perfect storm for a non-empathetic killer. Cris Rowan, expert in child psychology and author of the Virtual Child The terrifying truth about what technology is doing to children, proposes the following formula for the making of a pathological killer: (technology addiction from youth, with Tetris Effect) + (violent media exposure) +/(psychotropic medication) + (deprivation of movement, touch, human connection and nature) = pathological killer Rowan proposes that introduction of technology to children too early results in medical problems, psychological dysfunction, and failure in life (see figure 1). Rowan emphasizes that our technological society has strayed away from traditional teaching and mentoring of children that lead to desirable outcomes (see Figure 2). Whether or not there is an ICD-9 code or DSM criteria for video game and Internet addiction, I know personally it is real from my own struggles with playing 50 to 100 hours a week for more than ten years. I am not alone. I know of an ophthalmologist in his 60s who plays World of Warcraft between patients all day and wears moisture goggles for dry eye, likely from staring at this computer screen. If this surgeon was drinking between patients, then we would not tolerate this behavior. However, because it is only a game, excessive and problematic video game playing is widely tolerated throughout our society. It is time that as physicians, we stand up and make a difference in our childrens lives and futures by recognizing and providing treatment options to this pervasive addiction. Andrew Doan, MD, PhD Author of Hooked on Games, which is available in print and on the Kindle on Amazon.com. More information can be found at www.hooked-on-games.com

Leutwyler, Kristin. Tetris Dreams. Scientific American. October 16, 2000. http://www.scientificamerican.com/article.cfm?id=tetris-dreams. Accessed September 7, 2011.
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