Video games have come a long way since Pac Man and Tetris. Games today simulate reality in massive user-generated worlds. Players chat by voice or text with people around the globe. Virtual characters work for gold, get married, become sick, and even host religious gatherings. Psychologically, games allow players to avoid real life while engaging and even succeeding in a semi-real fantasy world.

Video games are pervasive among youth culture. There’s not a child psychiatrist out there who doesn’t see patients who play games at least sometimes. Learning which type of game your patients are playing is a great way to build rapport. Recently I saw a boy who had huge fights with his parents about turning off his game after school. After learning more, I convinced him to play an older style game (which you can turn off easily) after school, and a more interactive game later, which led to less conflict and better grades.

The online, collaborative aspect of modern games is what makes them so interesting, insidious, and addictive. In the past, kids could spend hours playing a game, press pause to eat dinner, and then return to the game without missing a beat. Because many of today’s games are often interactive, if you step away, you might miss something.

Part of the appeal of these games can be explained by the classic New Yorker cartoon: “On the Internet, nobody knows you’re a dog.” Online, kids are able to recreate themselves—or not. The Asian teenager whose parents don’t speak English is able to be a talkative warrior. The socially phobic girl might find that she can make friends more easily online than in school, even if she keeps the same personality—or she might prefer to wander the virtual world by herself.

Video Games and Violence

We can’t talk about games without discussing violence. The link between video games and violence is unclear. There is a sense that violent video games could desensitize kids to violence, but there is no conclusive evidence that links video games with major violence, partly because major acts of violence are so rare (Ferguson CJ et al, J Youth Adolescence 2013;42(1):109–122). However you look at it, video games can be just one of many factors in real world violence.

For medicolegal reasons, if your patient is spending hours playing games, it is worth asking whether they are violent shooting games. If so, then follow up about guns in the house and violent plans, just to make sure that the game isn’t a trial run for something sinister.

Gaming Addiction

In terms of understanding and treating video game addiction, the United States is behind Asia. In countries such as South Korea and China, video game addiction is considered to be an urgent public health issue.

Asian awareness of video game addiction stems from two main factors. First, there were a series of high profile deaths connected to gaming, including a couple that took care of a virtual infant while their real infant starved to death, and a man who refused medical attention for shortness of breath because he did not want to stop playing. Second, in Asia, these games are typically played in Internet cafes—in comparison to the United States, where home computer usage is the norm—so video game addicts are more visible in public.

In the US, we tend to treat the comorbid disorders, which are present in about 86% of patients who are addicted to video games (Block JJ, Am J Psychiatry 2008;165:206–307). In Asia, therapists tend to screen for Internet addiction as part of the initial assessment, making that a specific treatment focus.

Not aggressively screening for and treating video game addiction is a mistake on our part. Our patients were born with technology integrated into their lives. For many of them, it may not be strange to develop a simulated character at the expense of their own character. Asking whether they play video games with their school friends or only online friends is a good way to find out whether the games are a continuation of offline life or something separate.

Ongoing studies around the world show that heavy users tend to play up to 20 and 30 hours, and sometimes more than 40 hours per week (Haagsma MC et al, Cyberpsychol Behav Soc Netw 2012;15(3):162–168). Most video gamers are male, and they often play well into their 20s. Female gamers often play for fewer hours, but have higher depression and social phobia ratings than male players (Wei HT et al, BMC Psychiatry 2012;12(1):92).

Treating Video Game Addiction

Treatment is multifactorial. Most important, we need to recognize that it’s worth discussing. Patients have to feel comfortable talking about their excessive gaming habit, which can be difficult when it has to do with things like monsters and magic. In fact, talking about gaming can feel dangerous for patients, because they feel powerful and successful when playing, but that feeling can disappear rapidly when discussing it in an office.

In terms of medication, there is only a small study of 11 patients who took bupropion (Wellbutrin) and played 25% fewer hours of video games (Han DH et al, Exp Clin Psychopharmacol 2010;18(4):297–304). Anecdotally, one of my patients had a similar result with Wellbutrin XL 300 mg.

The general approach is to have the patient spend more time in the real world and less time in the virtual world. Finding ways to engage the patient in the offline world is one way to approach this—preferably suggesting things that encourage psychological and social development. This can be as simple as joining a sports team or engaging in physical exercise, or as exotic as sending a patient on an outdoor adventure program (Outward Bound, NOLS, Overland) where computer time is very limited. South Korea has camps dedicated for video game addiction.

A family-wide approach to treatment can be useful, because patients addicted to video games may not have the motivation to change on their own. Use games as rewards for engaging in other activities, have parents keep the power cord, and limit screen time to weekends or evenings only. I tell parents to use a kitchen timer, which keeps the game to under an hour, and puts the blame on an object (the timer) rather than on the parents. Finally, consider making the family vacation “electronic-free,” although some families discover the child is not the only member of the family jonesing for a fix.