Mental Health

MILITARY MEDICINE, 180, 7:e839, 2015

Excessive Video Game Use, Sleep Deprivation, and Poor Work Performance Among U.S. Marines Treated in a Military

Mental Health Clinic: A Case Series

LT Erin Eickhoff, NC USN*†; LCDR Kathryn Yung, MC USNR*†; Diane L. Davis, MSN, RN, FNP-BC, PMHNP*†‡; CAPT Frank Bishop, MC USN‡; CAPT Warren P. Klam, MC USN, (Ret.)*†; CDR Andrew P. Doan, MC USN*†‡

ABSTRACT Excessive use of video games may be associated with sleep deprivation, resulting in poor job performance and atypical mood disorders. Three active duty service members in the U.S. Marine Corps were offered mental health evaluation for sleep disturbance and symptoms of blunted affect, low mood, poor concentration, inability to focus, irri- tability, and drowsiness. All three patients reported insomnia as their primary complaint. When asked about online video games and sleep hygiene practices, all three patients reported playing video games from 30 hours to more than 60 hours per week in addition to maintaining a 40-hour or more workweek. Our patients endorsed sacrificing sleep to maintain their video gaming schedules without insight into the subsequent sleep deprivation. During the initial interviews, they exhibited blunted affects and depressed moods, but appeared to be activated with enthusiasm and joy when discussing their video gaming with the clinical provider. Our article illustrates the importance of asking about online video gaming in patients presenting with sleep disturbances, poor work performance, and depressive symptoms. Because excessive video gaming is becoming more prevalent worldwide, military mental health providers should ask about video gaming when patients report problems with sleep.

BACKGROUND Excessive play of video games is a growing problem and can manifest as severe emotional, social, and mental dysfunction in multiple areas of daily living.1,2 Similar to substance abuse, individuals who play video games excessively can manifest an Internet gaming disorder (IGD) associated with severe physiological problems and emotional dependence.3 Individ- uals with IGD share behavioral similarities with patients struggling with substance abuse, exhibiting psychological triggers, cravings, and addiction-seeking behaviors. It is not uncommon for addictive behaviors to be co-occurring,4 and patients with IGD can possess comorbid, underlying neuro- psychiatric disorders.5,6 Similarly, substance addictions can co-occur with mental disorders.7 Currently, IGD is not rec- ognized as a “DSM-5” diagnosis; however, the editor of the “American Journal of Psychiatry” has acknowledged that IGD warranted inclusion in the DSM-5 and it is a disorder requiring further study.8 In addition, excessive video gaming has been noted to be associated with sleep deprivation, and sleep deprivation alone can be associated with significant personal, social, and professional consequences.9 The American Psychiatric Association’s nine proposed criteria for IGD were based on preliminary research that compared

videogame use with gambling addiction.6,10 These criteria include the following:

(1) Preoccupation with videogames (2) Tolerance manifested by increasing amounts of time

invested in videogame use (3) Escape of adverse moods through videogame use (4) Loss of relationships/opportunities as a result of video-

game use (5) Reduced participation in other activities as a result of

videogame use (6) Deceit to continue videogame use (7) Continued videogame use despite adverse consequences (8) Difficulty reducing videogame use (9) Withdrawal (manifested as restlessness and irritability)

upon discontinuation of videogame use

It is important for providers who treat patients with pri- mary insomnia, insomnia because of stress, and primary hypersomnia to consider IGD as cause for sleep deprivation associated with anger, irritability, and poor work perfor- mance because of excessive video gaming.

In the military, active duty personnel are carefully moni- tored for job performance, social problems, and personal fit- ness by leadership at all levels throughout their career. The Marine Corps Force Preservation Council (FPC) can monitor these aspects of service members’ lives and career monthly. When a military member does not meet readiness standards, administrative correction is implemented, and when appropri- ate, the service member is encouraged to utilize appropriate counseling and medical resources. In the military mental health system, providers often evaluate, assess, counsel, and

*Substance Abuse Rehabilitation Program (SARP), Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.

†Department of Mental Health, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.

‡Department of Ophthalmology, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.

doi: 10.7205/MILMED-D-14-00597

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treat military members who have failed to meet standards set by their chain of command. These military members are offered evaluation by mental health providers for underlying mental disorders when they exhibit or endorse symptoms of depression, anxiety, anger, fatigue, as well as other symp- toms. In this case series, we describe three cases where the service members were evaluated by mental health providers because of poor job performance, insomnia, and depressed mood. We discovered that the symptoms were associated with sleep deprivation because of 30 to 60 hours of online video gaming per week. The sleep deprivation because of excessive video gaming appears associated with daytime drowsiness, fatigue, poor concentration, irritability, poor work perfor- mance, and blunted affect. The patients also exhibited crav- ing, anger, and irritability when not able to play video games.

CASE DESCRIPTIONS

Patient 1 A 24-year-old male enlisted service member in the U.S. Marine Corps (USMC) was referred for a voluntary mental health evaluation by his medical officer after complaints of depressed mood, poor concentration, inability to focus, irri- tability, and insomnia, which were intensifying over the pre- vious 3 months. Upon examination, the patient exhibited a slumped posture, poor eye contact, and restricted and dys- thymic affect. He expressed concerns that his command was “out to get him” because he could not concentrate at work and was “constantly messing things up.” His command noted that the patient was not able to complete tasks that he was previously able to complete competently. The patient was noted to scan the room slowly and often stared at his feet. Initially, he did not engage with the provider, never smiled, or showed expression throughout the interview. The patient was guarded. He displayed no unusual thought con- tent, and he denied experiencing symptoms consistent with major depressive disorder, mania/hypomania, psychosis, post- traumatic stress disorder (PTSD), obsessions, or compulsions. The patient denied experiencing any active suicidal or homi- cidal ideation. He was diagnosed with attention deficit hyper- activity disorder (ADHD) during elementary school but was treated without medications. He endorsed being forgetful, difficulty sitting still, fidgeting, losing his keys and other important objects, difficulty organizing tasks, poor attention to detail, and being reluctant to engage in educational opportuni- ties. On the basis of his prior medical history of ADHD and current symptoms, he was diagnosed with ADHD as an adult. The patient was started on atomoxetine 25 mg orally daily and titrated up the dose to 40 mg daily, which he tolerated well. His ADHD symptoms improved on this medication.

The provider asked about “gaming.” While discussing video games, the patient’s entire demeanor changed almost instantly from a blunted affect to a demeanor of animated elation. He regularly played Internet-based role-playing games, such as “World of Warcraft.” He became engaged in

the interview and enthusiastically shared about his video games. He also became more focused, and surprisingly expressed happiness and joy. The patient was working 40 to 50 hours on average weekly and endorsed playing multiplayer online games for more than 30 hours a week. He routinely slept only 3 to 4 hours nightly. The patient was given educa- tion on sleep hygiene to include shutting off the computer 30 minutes to an hour before sleep. He was not able to comply with the latter and continued to play video games late into the night, even though he was informed that excessive gaming was jeopardizing his work performance and health. He experi- enced craving and irritability when cutting back playing video games. The patient was referred to psychology services for therapy, coping skills, and symptom management.

Patient 2 A 25-year-old male active duty USMC mechanic was being treated for alcohol dependence in a residential treatment facility, Substance Abuse Rehabilitation Program (SARP). The patient expressed homicidal ideation and was hospital- ized on the psychiatry service for 1 week. After discharge, he was seen in residential treatment by mental health services. During the interview, the patient denied experiencing symp- toms associated with mania/hypomania, psychosis, PTSD, obsessions, or compulsions. He also denied experiencing any active suicidal ideation. He endorsed persistent depressed mood, poor concentration, lack of focus, irritability, anger, and insomnia for 3 months, suggestive of a mood disorder. He also exhibited slumped posture, poor eye contact, and seemed disengaged. The patient also scanned the room slowly and often stared at his feet. He did not smile and showed little facial expression throughout the interview. Before the initial interview, he expressed homicidal ideation to the staff. He had described dreaming about decapitating other people in detail and reported being able to imagine carrying out the beheading. When asked about video gaming, the patient became animated, enthusiastic, and smiled often. He reported that playing violent first-person-shooter video games online made him dream and visualize how to decapitate heads, just like he was doing in the games. The patient reported playing 50 to 60 hours weekly while working more than 40 hours weekly. He endorsed sleeping and eating very little, as well as receiving less than 4 hours of broken sleep nightly for the past year. Because all electronic devices are removed and residential patients have supervised and restricted Internet computer time, he reported withdrawal from gaming as being much more uncomfortable than any symptoms associ- ated with stopping his alcohol use. He endorsed cravings for the video games and irritability associated with abstaining from playing video games. He shared that video gaming helped him to escape negative moods and depressive symp- toms. The patient did not exhibit withdrawal symptoms associated with alcohol use.

The patient was educated on sleep hygiene and did not have access to video gaming at SARP. Within 2 weeks of

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being absent from playing video games, he reported sleeping 7 to 8 hours nightly without medication. With abstinence from gaming and being able to achieve regular sleep, the patient’s homicidal ideations resolved, and his mood improved during his residential treatment. The patient’s insight was good and he reported understanding the association between his behav- ioral choices and his ability to function at work and socially. However, he was unwilling to quit playing and verbalized that he would reduce his hours online instead of eliminating gaming completely. Remarkably, after 35 days of sobriety and abstinence from gaming, his depressive symptoms resolved, suggestible of a substance (defined in a broader sense as alcohol and/or video games)-induced mood disorder.

Patient 3 A 22-year-old active duty USMC service member was referred to mental health for evaluation after perceived sui- cidal ideation. The patient was seen voluntarily and endorsed texting people about a “permanent solution” to his problems. This patient was taking bupropion sustained release 150 mg twice daily and zolpidem 10 mg nightly for the previous 8 months without improvement of symptoms. He was being treated for depression, precipitated by two deaths in his family, with medications and psychotherapy. However, the patient stopped scheduling his psychotherapy appointments. When he began to be symptomatic again, he saw a new therapist who on initial examination reported problems with sleep and “insomnia,” stating the sleep medication “does nothing.” He also reported problems with anxiety, anger, irritability, poor concentration, and inability to focus that persisted for 3 months. He denied experiencing symptoms consistent with mania/hypomania, psychosis, PTSD, obsessions, or compul- sions. The patient also denied experiencing any active suicidal or homicidal ideation. He appeared stoic with a blunted affect during the interview. When asked about playing video games during the interview, he became excited, animated, and happy to discuss his gaming. He reported playing online first-person- shooter video games 4 to 7 hours daily during the week and 12 to 14 hours daily during the weekend. He played video games more than 60 hours per week while he worked a full- time active duty job. In addition, the patient reported drink- ing 4 to 5 beers daily and much more on the weekends. He complained of drug-resistant insomnia with a history of failed medication trials of trazodone and temazepam pre- scribed by a previous provider. The patient was diagnosed with alcohol use disorder and scheduled for SARP intensive outpatient treatment and psychology services. The patient was provided education on sleep hygiene, alcohol abuse, and IGD. At the time of the appointment, the patient agreed to “cut down” his screen time and described experiencing craving and irritability when his gaming was removed.

CONCLUSIONS Because IGD is becoming more prevalent worldwide, military mental health providers should ask about video gaming

when patients report problems with sleep. When job perfor- mance suffers, active duty service members are evaluated by the Marine Corps FPC. Sometimes these FPC reviews result in voluntary referrals for mental health evaluations. In these three cases, the service members were voluntarily referred to mental health after endorsing symptoms of blunted affect, poor concentration, inability to focus, irritability, and insomnia. All the patients shared sleep deprivation associated with 30 to 60 hours of video gaming online per week. The sleep deprivation because of excessive video gaming appears asso- ciated with daytime drowsiness, fatigue, poor concentration, irritability, poor work performance, expressed anger, and blunted affect. Our case series emphasizes the need for vali- dated screening tools to identify excessive video gaming and IGD. Because IGD is not yet a DSM-5 diagnosis, military mental health providers do not routinely screen for IGD; thus, we do not know if these individuals fit diagnostic criteria for IGD based on DSM-5 guidelines.10–12 On the other hand, our patients endorsed several IGD symptoms based on DSM-5 criteria: withdrawal symptoms when Internet gaming was reduced, continued excessive use of Internet games despite knowledge of psychological problems, use of Internet games to escape or relieve negative mood, work performance jeopardized by Internet gaming, and unsuccess- ful attempts to cut back on Internet gaming. Furthermore, all three of these patients reported insomnia as their primary complaint. When asked about playing video games, all of these patients reported 30 hours to more than 60 hours of video gaming per week in addition to maintaining a 40-hour or more workweek. Our patients discussed sacrificing sleep to maintain their video gaming activities. We believe that additional research is indicated to determine if excessive video gaming and IGD are associated with sleep deprivation and insomnia. It is interesting to note that one patient reported that withdrawal from his devices and gaming as being much more uncomfortable than any symptoms associ- ated with abstinence from alcohol.

Sleep deprivation in humans can cause psychosis-like symptoms in healthy individuals13 and cognitive symptoms that mimic ADHD.14 Therefore, excessive video gaming and sleep deprivation in our patients were associated with a blunted affect, poor concentration, inability to focus, and irritability. Although sleep deprivation can also be associated with excessive alcohol use, that two of our patients endorsed, we do not think that the sleep deprivation in these patients was solely attributable to alcohol use because they reported exces- sive gaming in lieu of sleeping. One of the patients had a prior history of ADHD as a child, which was not evident when he first joined the USMC because he was previously able to focus and successfully complete assigned tasks, including completing high school with a 3.4 grade point aver- age. It is possible that sleep deprivation associated with exces- sive video gaming contributed to the patient manifesting ADHD-like symptoms as an adult. Similarly, severe psychotic- like symptoms are associated with significant sleep deprivation,

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and perhaps our patient with symptoms of homicidal thoughts of decapitation was a consequence of both sleep deprivation and the influence of the violent games he was playing.15–17

This is in contrast to studies that have suggested minimal or no correlation between violent video games and violent behav- iors.18,19 Perhaps, in the setting of sleep deprivation and under- lying emotional dysregulation, violent media and games may have a more significant impact on behaviors and thoughts.

The pleasure and excitement associated with video game playing involve physiological arousal and stimulation of the hypothalamus–pituitary–adrenal (HPA) axis.20,21 Children and adolescents playing video games exhibit increase in heart rate, blood pressure, sympathetic tone, plasma norepi- nephrine, and food intake. The three elements that make video games highly attractive and pleasurable are immersive environments, in-game achievements, and social play.22 Fur- thermore, widespread Internet availability facilitates human- to-human interactions within video games and increases the attractiveness of gaming. Brain imaging studies show that fMRI reward responses are greater when gamers defeat human opponents in contrast to computer challengers.23 The excitement of video games may be associated with the games being digital simulators of life and dreams: war, battles, adventures, innovation, relationships, and fantasy. Games that build on the principles of social interactivity, increased immersion, and seemingly endless achievements are postu- lated to be neurologically and physiologically arousing as these games are digital simulators preparing the body to fight or flight. Built-in music added to the immersive environment of the video games stimulates the HPA stress response and release of cortisol.24 Playing the game “Tetris” competitively results in higher levels of testosterone when cortisol levels are low in men, supporting an interaction between the HPA axis and hypothalamus–pituitary–gonadal axis.25 Therefore, the arousal associated with HPA stimulation may provide the physiological and psychological stimulus disrupting sleep when individuals play video games excessively.

During the clinical assessment, all of our patients exhibited symptoms suggestive of depression. Nevertheless, the patients appeared to be activated when discussing their video gaming with the clinical provider. Individuals with IGD exhibited craving and fMRI activity in brain reward pathways when viewing images of games.26 Similarly, perhaps the discus- sion of the video games promoted craving and activation of brain reward pathways in our patients. This case series sug- gests that additional research is needed to determine the degree and triggers that activate individuals when discussing video game use. Furthermore, future studies are needed to investigate if video games affect men and women similarly, or if there are differences observed between them.

It is important to note that when active duty patients pres- ent with drug-resistant insomnia or sleep disturbances, it is necessary to ascertain how many hours are devoted to video game play and a detailed sleep inventory. Even without IGD, excessive play of video games may be associated

with sleep deprivation and behavioral ramifications affecting health. Additional research is warranted in this area. Our arti- cle illustrates the importance of asking about online video gaming in patients presenting with insomnia, poor work per- formance, and depressed mood. As video gaming increases in popularity and more patients potentially affected by IGD, standardized assessment tools and programs to reduce IGD are necessary. Perhaps force readiness could be increased by reducing sleep problems and IGD associated with excessive video gaming.

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