1. W. Scott Huddleston, PGY4 ETSU Department of Psychiatry Grand Rounds 9/9/11 Faculty Mentor: Jill McCarley, MD

2. No financial bias Personal bias I’m a geek I play video games, including those discussed in this presentation

3. Rapidly growing userbase World of Warcraft is the largest  Last released data suggested 11.4 million subscriptions Impact on Mental Health Depression Anxiety Addiction – news reports

4. MMOs – massively multiplayer online [games] Social: Second Life Adventure:  World of Warcraft  Everquest

5. Players create characters Gender Appearance Role Assigned tasks lead to rewards More and better items Skills Customization More “heroic” tasks

6. Similarity to Skinner boxes Varying reward structure  Less random with newer games  Variable timing persists

7. Thousands sharing the same environment Social aspects significant Interaction can be chat or animation based Temporary groups Permanent groups  Size and explicit function varies  Can persist across multiple games

8. “End-game” at maximum level Various situations requiring varied numbers of people Two main categories Player versus player Player versus environment

9. Two teams directly competing against each other Most situations have tactical objectives Points/rewards for performance Competitive sports are a decent comparison

10. Different games have different specifics 10+ people Varied situations Each player has a role to fulfill Teams work together to achieve objectives without direct competition with each other Wall-climbing or ropes courses as analogue

12. Literature – survey reliant Medical literature drawn from PubMed and Psychinfo searches More MMO specific data drawn from Daedalus Project Most research into MMOs focused on Adventure rather than Social type

13. 2011 Norwegian survey of 2500 (816 respondents) 56.3% played video games regularly MMO players tended toward higher frequency of play

14. 85% or so are male Average age Males 28.3 (SD is 8.4) Females 32.5 (SD 10.0) Marital Status Males 32.6% Females 57.0%

15. Playing video games can lead to increased dopaminergic receptor occupancy in the caudate Part of the reward response pathway Males have higher activity in mesocorticalimbic system than females

16. Primary focus of medical literature No definitive diagnostic criteria Behavioral model similar to gambling Most proposed criteria agree: Excessive use Withdrawal symptoms Interference with daily functioning

17. Disputed Ranges from 0.6% through 11.9% Discrepancies among criteria Males tend to be much more likely to develop issues

18. College survey of males (2009) Little correlation between frequency of play and  GPA  BMI Positive correlation:  Bored  Lonely  Stressed

19. Park et al, 2010: PET imaging comparing 11 “overusers” vs 9 control Increased glucose metabolism  Right middle orbitofrontal gyrus  Left caudate nucleus  Right insula Decreased metabolism  Bilateral postcentral gyrus  Left precentral gyrus  Bilateral occipital regions

20. Two recent studies by Han et al using fMRI Increased cue-induced activity in frontal-lobes Similar to findings in both traditional substance abuse and pathological gambling Genetic study (also Han) 75 control vs 79 “excessive internet game players”  DRD2 Taq1A1 allele linked to excessive use and