The Development of the Self in the Era of the Internet and Role-Playing Fantasy Games

Sara E. Allison, M.D.

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.

Tamra Shockley, M.S.

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.

Sara E. Allison, M.D.

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.

Glen O. Gabbard, M.D.