Digital Morphine
“I was on fire . . . I couldn’t speak or see to unbuckle my seatbelt or open the door. I believe that my guardian angel just took me out of the truck.”
First Lieutenant Sam Brown is lying in the burn unit of Brooke Army Medical Center (BAMC) in San Antonio, Texas, describing the horrible events that took place earlier that year, 2008, in Kandahar, Afghanistan, when his Humvee was hit by an IED and exploded. His body was engulfed in flames, and he suffered third-degree burns over 30 percent of his body; his injuries were so severe that he was kept in a medically induced coma for the first few weeks to help him survive.
While his eyes looked the same as in the pictures of the handsome cadet who had recently graduated from West Point, his face now bore the scars of badly burned flesh. As he would later tell NBC’s Natalie Morales in a 2012 interview: “I literally thought that I was going to die and my instinctual reaction was to throw my arms up in the air and cry out to God. And I remember thinking ‘how long will it take for me to burn to death?’”
But the IED explosion and the initial burn was only the beginning of what would be a very long and painful process. According to Dr. Christopher Maani, the anesthesiologist in BAMC’s burn unit: “With burn injury, that rehabilitative process can go on for weeks to months, sometimes even years if the burn is significant enough as it was in Sam’s case.”
Sam had to endure more than two dozen painful surgeries, but the most excruciating pain came from the daily wound care and the physical therapy that followed. In fact, the procedures were so painful and unbearable that there were times when Sam’s superior officers would have to order him to undergo treatment. As with many burn victims, narcotic painkillers are the only medication that can provide some relief from the daily ritual pain. While narcotic opiates have an analgesic effect that stimulates pain-dampening endorphin release, they are also highly addictive. As Sam grew increasingly concerned about his growing dependence on narcotics, Dr. Maani suggested a new experimental treatment to help Sam lessen his pain: a video game called SnowWorld.
SnowWorld is a cartoon-looking virtual reality game set in the arctic ice where a series of penguins march back and forth as Paul Simon’s cheery song “You Can Call Me Al” plays in the background. During the game the player, who is wearing a wraparound plastic virtual headset, uses a joystick to throw snowballs at the cute penguins.
When I interviewed Sam, he said: “I went into this totally a skeptic, but was willing to give it a try.” The game had been developed several years earlier at the University of Washington by Dr. David Patterson and Dr. Hunter Hoffman, two psychologists who had been working on non-opioid pain-management methods specifically for burn victims at Harbor View Burn Center in Seattle. Patterson and Hoffman discovered that while patients were immersed in virtual reality games, their sensation of pain greatly decreased.
Indeed, in 2011, the military conducted a small study using SnowWorld and got even more dramatic results: for soldiers in the most severe pain, SnowWorld worked even better than morphine.1 The researchers were not exactly clear on what the exact mechanism of this video analgesic effect was as some ascribed it to “cognitive distraction.”
But we know from a study by M. J. Koepp (1998)2 that video games raised dopamine levels 100 percent—and those were old-school, 2-D 1998 video games, not immersive 3-D virtual reality games. Is it possible that, rather than just “cognitive distraction,” Sam’s neurotransmitters were being stimulated to release pain-killing dopamine and, perhaps, endorphins as well?
In my interview with the navy’s Dr. Doan, he expressed the view that there is indeed an endorphin-increasing mechanism that is not entirely understood; as previously mentioned, he embraces the notion of screens acting as “digital pharmakeia.”
When I asked Sam about this, he said: “I was for sure feeling less pain than I was with the morphine. I think it definitely could have been an increase in my dopamine or endorphins.”
Even Dr. Hoffman is surprised when it comes to the success of video game pain-management therapy: “The fact that you’re getting such huge reductions in pain using something that’s not a drug is a paradigm shift,” he said.
Brain imaging would eventually confirm that the burn patients treated with SnowWorld virtual reality were indeed experiencing less pain in the parts of their brains associated with processing pain. All of these stunning findings have led the military to further pursue the use of virtual reality and video games as a quasi-digital drug in order to help treat pain.
* * *
Most people are shocked to hear that a video game can actually be more potent than morphine. While this is a phenomenal advance in pain-management medicine and treatment of burn victims, it begs the question: just what effect is this digital drug—which is more powerful than morphine—having on the brains and nervous systems of seven-year-olds—or fourteen year-olds—who are ingesting very similar digital drugs via their glowing screens? And, further, if stimulating screens are indeed more powerful than morphine, can they be just as addicting?
Trapped Down the Rabbit Hole of Digital Addiction
As I stood in the heavy downpour and knocked on the door of the cedar shingle ranch house I felt a sense of apprehension. Although a bit dated and frayed around the edges, by all outward appearances it looked like a normal suburban house where a happy family with 2.2 kids might live, complete with a tan minivan in the driveway parked next to a free-standing basketball hoop and backboard. It all looked very Ozzie and Harriet.
Yet I knew that inside that innocuous suburban house lived “Peter,” a sometimes violent 18-year-old video game-playing recluse; a digital Howard Hughes who had become homebound for the past four years as he had become trapped by his own psychiatric demons that were fed by his gaming addiction. I was apprehensive because, although I’m comfortable around mental illness and addiction, I’m a bit more tense during the rare occasions that I have to do a home assessment because you can never be quite sure what you’ll find once you get past the front door. And, perhaps most unsettling, if there is a problem, they have the home field advantage.
This is what I knew about Peter based on his case file and from phone conversations with his mother: He had always been anxious as a boy, but he became depressed after his father had died several years earlier. The tipping point came in the ninth grade when he was suspended for the entire school year for a prank that had gone terribly wrong. Alone at home with his anxiety and depression, he found escape in his Xbox; what had once been a weekend recreation had turned into a 16-hour-a-day addiction. He had now become so addicted that he couldn’t stop playing and had become agoraphobic and unable to leave the house or go to school.
During the extremely rare occasions that he had to leave the house—for a doctor’s appointment, for example—his mother and brother would have to sedate him and physically drag him out as he fought, kicked and screamed. When his mother tried to pull the plug on the game, he became violent and would punch holes in the walls or throw things at her. The poor woman had to get a restraining order while he still lived in her house. Overwhelmed and worn out, she eventually gave in and settled into a pattern of compliant enabling; she would just let him play all day and night and bring him his meals when he demanded them.
Psychiatrists confirmed his anxiety and agoraphobia diagnosis and the school district was forced to send tutors to his house for two hours a day to provide him some semblance of an education. The district had also tried contacting various agencies to help, but the problem was that, at 18, he was a legal adult and could refuse treatments and interventions. That’s when the school asked if I’d be willing to go to his house to assess him to see if I could get a better sense of the severity of the problem and perhaps coax him into some kind of treatment.
After a minute or two in the rain, his mother finally opened the door and invited me in. I couldn’t help feeling a sense of being stuck in a time warp as her low beehive hairdo matched the wood paneling and the 1970s furniture with framed photos of a happy family that no longer existed. Thrilled to have someone come to the house to try and help, she greeted me warmly and sat with me in the dining room as she spilled her heart out about her son’s situation. I genuinely felt for her; she was a very decent woman who had tried her best to keep things together after her hard-working husband had died. When she was done, I asked if I could speak with Peter.
“He just woke up; he’s in the living room eating his breakfast that I just brought him.”
It was 1:00 p.m.
She walked me into the living room where Peter was sitting on a chair that Archie Bunker would have been proud of. I hadn’t seen him in four years, since the last time he’d been in school. Since then, he had grown quite a bit—both vertically and horizontally; he had to be at least 40 or 50 pounds heavier. He was staring with a dazed look on his face at a large bulky old-style television that had the show Cops blaring on it. While his gaze was fixed toward the TV, his expression was blank—almost catatonic; I’m not even sure if he was watching the TV or just staring and zoning out in that direction. He had on a soiled white t-shirt and dirty red sweat pants; on the coffee table in front of him was a plate of eggs, bacon and toast that their huge Labrador was eating off his plate.
I slowly sat in an ottoman next to him as he just continued to stare straight ahead.
“Hi Peter. Do you remember me, Dr. Kardaras? We had met at school a few years back?”
He briefly looked at me out of the corner of his eye and almost imperceptibly nodded as he kept looking at the TV.
“I just wanted to come and see how you’re doing and maybe ask you some questions. Are you OK with that?”
Again, the barely there nod.
I asked him a series of questions about his childhood, his schooling, his family, his anxiety. Mostly I got one or two-word low-mumbled responses. But then everything changed when I asked him about his gaming; that’s when he sat up and actually looked at me.
“I . . . I like to play Modern Warfare 2 . . . and Modern Warfare 3.”
He still mumbled, but there was better articulation because he was now more engaged.
“What is it that you like about playing video games?”
He had a difficult time finding the words. He tried several times but couldn’t say much.
I tried again. “Peter, try and finish this sentence: ‘The thing I like the most about playing video games is . . .’”
He nodded and tried to answer, “The thing I like the most about gaming is . . . is . . . I love trickshot . . . I love the sensation I get when I get one.”
He was half-smiling now as you could see he was fantasizing about this thing called “trickshot.” He then sat up even higher and said, with more enthusiasm:
“I love the sensation. I’ve never had that doing anything else in my life.”
“What’s trickshot?” I asked.
He tried to mumble a description, but got frustrated because he wasn’t able to verbally describe this panglorious thing called a trickshot. His face then lit up as he had a flash of inspiration: “Can . . . can I show you?” he asked.
“Sure. I’d love to see.”
He slowly got up and ambled—you could tell that he wasn’t used to walking—over to an adjacent doorway that led into a dimly lit room. My stomach tightened as I followed him into his own Heart of Darkness: a dimly lit dark-paneled room that was the gateway into the digital war games that his whole life revolved around.
In that room, there were three huge computer screens attached to two gaming devices set up at angles on a large table—it almost looked like pictures of a flight simulator that I had once seen. As he powered up, the screens came alive with flashing lights and the sound of machinegun fire. He began to explain that he was part of a Clan of about another 20 gamers.
He began to show me clips of prior trickshots; from what I gathered, a trickshot is a complex sniper maneuver where the player/sniper uses an array of spinning moves and employs a variety of combinations on the controller to create a unique “no scope” kill shot. This complex move often required weeks of coordinated play and effort in order to accomplish. Then, the Holy Grail of trickshots was to record them as a YouTube video with the hope that your clan can become popular enough to get on a YouTube gaming channel like SoaR.
As I watched him immerse himself in the virtual battlefield, he became an entirely different person than the quasi-catatonic young man that had been sitting in the living room just minutes earlier. Now he was an able commando fighter engaged on a mission that required agility, dexterity and coordination. He went from a catatonic kid without a passion or a purpose to a member of a Clan that all fought together to attain the oh-so-climactic trickshot. His mother would tell me that the first time he got a trickshot, her normally nonverbal son shouted and hollered so loudly that she thought he was being attacked.
That video gaming room was like a power source for Peter. Inside that room, he was alive and animated; but as soon as we left and walked back into the living room, he plopped back onto his Archie Bunker chair with all the energy and enthusiasm of a not-so-spry 98-year-old and was quickly back to catatonic Peter. The shift was so profound, it reminded me of Awakenings, the brilliant book by Oliver Sacks in which severely catatonic patients briefly come to life with the new “miracle” drug L-dopa—as portrayed by Robert DeNiro in the 1990 film by the same name—only to eventually go back to their catatonic state.
The only difference was that Peter didn’t start out catatonic. Anxious and depressed, yes, but he had once been relatively normal and functional. Instead, his animating L-dopa—his video games—rather than being his miracle cure, seemed to have caused his non-gaming catatonia and malaise. Sure, the video game seems to animate him, but now he spends his entire waking life immersed in a digital fantasy war zone fighting with his clan and seeking to attain the orgasm-like trickshot—and when he’s not playing, he’s unable to leave his house and is a catatonic agoraphobic mess.
By any clinical definition he’s an addict, except his addiction is to a screen—or, more specifically, to the dopamine-activating interactive world that the screen acts as a portal to. I got it. I understood. I gathered up my notes, thanked him and his mother and left; I didn’t want to stay too long.
Being immersed in an interactive and exciting battleground where you’re in full control has its addictive appeal—I just didn’t want to pull a Colonel Kurtz and get pulled in too deeply myself.
Interestingly, Peter’s case is also a perfect nature-versus-nurture experiment as he has an identical twin brother who didn’t fall down as deeply into the rabbit hole of video game addiction and is subsequently much better adjusted psychologically.
I made several recommendations to both Peter and his mother about mental health programs where he might be able to slowly emerge from his game, leave the house, and slowly reconnect with the real world. At the time of this writing, Peter has refused all suggestions of help and still lives primarily on the battlefield of Modern Warfare 3.
And like any scared and trapped enabling family member of an addict, his mother keeps the electricity going and makes sure that the trays of food are still dutifully delivered to his gaming den whenever he yells out.
The Addiction Riddle
How does someone like Peter get trapped down the rabbit hole of addiction? Yes, he had some emotional and psychological issues, but how did he become so obsessively and compulsively consumed by his gaming world that he became a Howard Hughes-like shut in?
But before we can fully understand tech addiction, we must first understand what addiction itself is.
If we were to watch daytime TV, we’d be convinced that the world is full of “love addicts” or people “addicted” to Game of Thrones or hot yoga. But I think that most of us understand true addiction as ingesting a substance or engaging in a behavior in a way that is pathological—that is, a person continues with the addictive behavior in a compulsive way despite adverse consequences. Think Amy Winehouse or John Belushi.
But adverse consequences can have a pretty wide range—dying isn’t necessarily part of the definition of addiction—just ask Peter. Typically, in the addiction treatment field, we think of something as being an addiction if a person continues to ingest the problematic substance or engage in the problematic behavior despite consequences such as losing their jobs, jeopardizing their relationships, or negatively affecting their physical health or their schooling.
But beyond symptomatic criteria that help us to diagnose addiction, what is it really? I mean, at its essence—what is it?
For many, clinicians and researchers alike, the understanding of addiction is sort of like a riddle wrapped in a mystery inside an enigma. Many have a hard time categorizing it—is it a bad habit, a lack of willpower, a disease, a mental disorder, a moral failing, a genetic condition, a psychological condition? Etiological theories abound.
For most people, clinical definitions aside, it’s sort of like the old line from Supreme Court justice Potter Stewart in 1964, when he tried to define the highly subjective notion of obscenity: “I know it when I see it.” I think that’s true for addiction; most of us know it when we see it.
But perhaps even more importantly, if we are really trying to understand addiction, we should ask the further question: why and how does someone become an addict? This is an important question, because if we’re to understand how an iPad can be electronic cocaine, we need to understand how good old powdered cocaine can be so compulsively addicting.
I think most of us can understand why someone might try getting high—why someone might smoke a joint or do a line of coke; odds are that most people reading this have probably dabbled in a little mind expansion themselves. Hell, our last two presidents have even admitted skiing down a white line or two in their youth. Yet how come they didn’t become full-blown addicts while others who dabbled did?
Is it our genetics? Or the result of trauma or a rough childhood? Perhaps people with addiction have a neurochemical imbalance? Or are addicts simply people with poor impulse control and minimal will power?
People who don’t understand addiction often ask: just how can a person become so compulsive about ingesting a substance—be it alcohol, cocaine, heroin or a pill—or engaging in an addictive behavior like gambling, sex or Internet use, sometimes even to the point of total self-annihilation? To the nonaddicted, it just doesn’t make sense.
Of course it doesn’t—addiction isn’t rational.
Certainly Peter’s behavior wasn’t rational by any definition of the word. Let me provide another example of addictive irrationality from my clinical work: When I was just beginning my career in mental health, I had the opportunity to work at a hospital rehab facility on the East End of Long Island where I was assigned to do the intake on a new patient who had just recently had a heart transplant.
Heart transplants, although somewhat more common these days, are still very risky, complex and involved medical procedures that require quite a bit of medical follow-up and medication management. After all, another person’s heart is now beating inside the patient’s chest—no small feat. So our new admit, “Michael,” arrived with a bulging satchel of medications that he needed to take daily, from immunosuppressants to antibiotics.
I met Michael, who was 42, while the nurses were sorting through his prodigious number of medication bottles, and I found him to be very pleasant; he was smart and funny and laughed easily. In fact, if I hadn’t known about his heart or addiction history, I never would have guessed that he had any issues at all.
As I did his intake, I got to know more about his story: charming Michael had once been a chef in the highly stressful restaurant scene of a major city who had coped with that stress for many years by drinking nightly; at some point, alcohol turned to cocaine and cocaine turned to crack. It was this sporadic crack addiction that not only derailed his career, but also did a number on his heart—thus the transplant. He emphasized that his cardiologist had told him to be careful walking up and down stairs so as to not strain his new heart, and that if he smoked crack again, he would die.
When I came to work the next morning, Michael was already up and about. He was at the nurse’s station signing himself out AMA—against medical advice. He looked different from the calm, rational man I had spoken to just a day earlier; this Michael was agitated and wild-eyed.
“Michael, what are you doing?” I asked.
He avoided eye contact as he mumbled something under his breath. I tried again:
“Where are you going? What about what we talked about yesterday—getting clean and sober to save your life?”
His face was flushed, and he was sweating. He just looked at me and said: “I gotta go smoke crack . . .” He then tossed his big black duffel bag over his shoulder and ambled toward the elevators. I never saw him again.
His decision seemed so impulsive, so irrational. Yet the day before, I had been speaking to a sane, thoughtful human being. What had happened?
There are no simple answers.
In what I call the “perfect storm” model of addiction, we understand that various factors such as genetics, environment, psychology and neurobiology come together to create the explosive phenomenon of addiction. But it’s also important to keep in mind that no one person’s perfect storm of addiction is exactly the same as anyone else’s; the intensity and combination of factors contributing to the addiction are a unique amalgam within each person.
We also know that certain people are more prone than others to addictive behavior; for argument’s sake, we might say that these people are more predisposed toward having addictive personalities. Further, we know that having addiction in one’s family can predispose a person toward that condition and that the children of addicts are eight times more likely to develop an addiction problem.3
What is less clear is why. It’s been debated whether that increased risk is a consequence of genetics, the modeling of addictive behaviors or simply dysfunctional family dynamics that can create the emotional and psychological conditions for addictive vulnerability. Or perhaps all of the above.
We know, too, that trauma and abuse correlate highly with addiction, by some estimates quadrupling the odds that a person will become an addict. Then there is Attachment Theory, according to which an addict is a person who may not have been consistently and appropriately nurtured in childhood and who then grows up prone to codependence, forming a pathological attachment to an external entity, be it a person, alcohol, cocaine or an iPad—all to help fill the void of nurturing.4
For all of these reasons, it’s commonly accepted in the addiction psychology field that the problem is less about the particular substance or behavior than about the underlying perfect storm of genetic, psychological, environmental and neurobiological factors that make a person ripe for addiction—any kind of addiction.
Harvard’s Dr. Howard Shaffer, one of the world’s foremost addiction experts and a friend and colleague of mine, has developed a “syndrome model” of addiction. He analogizes addiction to a virus that compromises the immune system and compares the multiple expressions of addiction (i.e., alcoholism, gambling, opiate addiction, video games) to opportunistic infections that an addictively predisposed person needs to come into contact with in order to “catch.” For example, the addictively predisposed person with the weakened addiction immune system who comes into contact with alcohol is more likely to become an alcoholic; if that same addictively predisposed person, however, is exposed to pain pills, then pill addiction it is. And so on.5
Having said that addiction is more about a person’s vulnerability to addictive substances and/or behaviors, we do know that certain substances or behaviors have a stronger magnetic pull for the vulnerable person; crystal meth tends to be more addicting than alcohol, for example.
Why is that?
As Dr. Steve Hyman, the former director of the National Institute of Mental Health, asks:
“Why does the brain prefer opium to broccoli?”6 Why do our brains gravitate toward certain substances—or behaviors—more than others? And how might highly stimulating technology act in the same way as a highly addicting drug?
Understanding the addiction riddle—how a person can pursue something so compulsively and often so self-destructively, be it crack or technology—will require an exploration of some interesting concepts along the way: the dopamine tickle. Myelin. And Rat Park.
The Dopamine Tickle
In order to fully understand addiction, we need to understand the brain’s reward system and the impact of dopaminergic substances or behaviors on that reward pathway.
How dopaminergic (dopamine activating) a substance or behavior is correlates very highly with the addictive potential of that substance or behavior. Dopamine is the feel-good neurotransmitter that’s the most critical element in the addiction process. When a person performs an action that satisfies a need or fulfills a desire, dopamine is released into the nucleus accumbens, a cluster of nerve cells beneath the cerebral hemispheres that are associated with pleasure and reward, also known as the brain’s pleasure center.
In simple terms, engaging in a dopaminergic behavior increases dopamine levels so that the dopamine-reward pathway is activated, thus telling the individual to repeat what he or she just did in order to get that feel-good dopamine reward (or what I like to call the dopamine tickle) again.
As an evolutionary adaptation, the dopamine tickle is a survival mechanism; it rewards and, thus, incentivizes essential biological functions such as eating and procreation. Eating and sex feel good because they increase dopamine; we then remember that and seek out those activities again in order to recapture the feel-good dopamine high.
Natural dopaminergic activities—eating, sex—usually come only after effort and delay and, as mentioned, serve a survival function. But addictive drugs and addictive behaviors, like gambling and video gaming, provide a shortcut to this reward process, which floods the nucleus accumbens with dopamine without serving a biological function.
Unfortunately, evolution hasn’t provided an easy way to withstand that dopamine onslaught, so that when people become addicted, they experience a dopamine reduction or shutdown in order to give some relief to their overwhelmed receptor cells. With this reduced capacity to produce dopamine naturally, the addicted person then needs to ingest the addictive substance or engage in the addictive behavior just to maintain his or her dopamine levels.
Then, as a double whammy, chronic exposure to addictive substances or behaviors then negatively affects the frontal cortex—the brain’s decision-making center, which is associated with impulse-control, otherwise known as a person’s “braking mechanism”—which in turn compromises a person’s ability to refrain from the addictive substance or behavior, making it harder to “just say no.”
Research has also shown that people who are predisposed toward addiction have lower baseline levels of dopamine and other feel-good neurotransmitters such as endorphins and norepinephrine; thus they’re more likely to get hooked on any substance or behavior that increases dopamine—anything that gives them that dopamine tickle—simply because their brains crave it more than those of people who have normal baseline neurotransmitter levels.7
We also know that certain substances or behaviors tickle dopamine more than others. For example, brain imaging research shows us that eating—especially eating craving foods like chocolate—can raise dopamine levels by 50 percent; while sex can raise dopamine by 100 percent; snorting cocaine increases dopamine by 350 percent; and ingesting crystal meth creates a whopping 1,200 percent increase in dopamine.8 That’s why we’d say that crystal meth has the highest dopaminergic effect—and thus the highest addictive potential—amongst the substances just mentioned.
So how dopaminergic are virtual experiences? According to one groundbreaking study by Koepp in 1998, video games increase dopamine as much as sex does, about 100 percent. And keep in mind that those are positively quaint 1998 video games, not the 72-inch LCD, ultrarealistic, hyperstimulating and highly arousing games of today.
Think about it this way: we’d be horrified if our young children were exposed to something as inappropriate and stimulating as sex, yet we’re letting them get virtual brain orgasms every time they play video games. Knowing that, is it really any wonder that kids are so hooked on their electronics?
As the navy’s Dr. Andrew Doan puts it: “The problem is that video game playing (VGP) is estimated to increase brain dopamine levels equivalent to sex; thus, VGP is risky in young minds that cannot say ‘no’ as VGP literally hijacks their thoughts.”
There’s one other very important factor that we need to keep in mind in trying to fully understand the addictive potential of video games: the reward schedule, also known as the schedule of reinforcement, a term used by psychologists to describe the pattern or frequency of dopamine-tickling rewards.
As mentioned earlier, natural dopaminergic activities require time and effort: if I get a dopamine tickle when I eat a piece of chocolate cake, we can say that that event has a buildup (I get the cake and cut it), an actual engagement period (I eat the cake) and a coming-down period (I digest the cake). The same can be said for sex—arousal, fooling around and then climax; for the young and vigorous, maybe a rinse-and-repeat. But I’m not repeatedly rewarding myself (getting the dopamine tickle) continuously over a period of hours.
Drugs and virtual stimulation, however, can be quickly repeated, over and over again. I can keep playing Minecraft or shooting the target in a shooter game as my dopamine squirts in rat-tat-tat fashion, and it’s that rapid reward schedule of a continuous brain orgasm that creates such a powerful addiction dynamic.
While an adult may have the willpower to refrain from engaging with tech as powerful and addicting as sex, from a developmental standpoint, since the brain’s frontal cortex—the brain’s “braking mechanism,” which control impulsivity—isn’t fully developed until well into a person’s twenties, a child simply doesn’t have the neurobiological apparatus to handle that level of stimulation.
Thus once little Johnny and Suzie experience that feel-good, electronic orgasm-like dopamine tickle, they want to push the repeat button again . . . and again . . . and again . . . and again . . .
How compulsive are video games? Here’s a telling factoid: according to the manufacturer, gamers have played the Call of Duty series—one of the more popular first-person-shooter games—for 25 billion total hours. (In a first-person-shooter game, the player sees through the eyes of the shooter and controls the gun.) That adds up to 2.85 million years—longer than the course of human existence!9 And that’s just one game franchise.
A rather prophetic episode of Star Trek: The Next Generation called “The Game,” which aired 25 years ago, back in 1991, vividly depicts this addictive brain orgasm effect; the crew of the Enterprise is given a virtual headset game that produces an intensely euphoric sensation. They become so addicted to the devices that they walk around in a perpetually trancelike state—not unlike that of Google Glass wearers—and are almost taken over by another species while in their euphoric stupor.
But addiction is about more than just dopamine; we also need to understand myelination, another critically important neurological factor in the addiction process, which can, in turn, better help us to understand tech addiction.
Myelin—the Brain’s High-speed Bandwidth
In 2001 the pioneering UCLA neurologist Dr. George Bartzokis, in his groundbreaking “myelin model” of brain disease, was able to prove the existence of another very important brain dynamic associated with addiction: the role of myelination, otherwise also known as the brain’s “white matter.”10
When talking about the brain, most people tend to think of “gray matter,” the network of roughly 100 billion neurons* that form the brain and give it its pinkish-gray color. But in addition to gray matter, we also have white matter, also known as myelin, a pale lipid composed of cholesterol that, like cable insulation, envelopes the trillions of stemlike parts of neurons called axons that connect neuron-to-neuron to form a single, functioning neural network.
Without myelination, our brains would be as frustratingly slow as a dial-up connection. According to Bartzokis, “Think of the Internet. Myelination makes axons more efficient; it increases bandwidth. Axons are able to do more so that our brains are able to do more.”11
Okay, a faster-working brain; but why else is myelin so important?
Myelination occurs as part of a healthy developmental process. As we grow and learn, our myelination increases in areas of the brain that need it. According to Dr. Robert F. McGivern, a San Diego State University research psychologist, “If you take a very young brain, say a three- or a four-year-old, the brain organizes itself around experience. You can train that child to learn to read very early and the brain will be well-myelinated in those parts of the brain needed for reading.” Reading thus becomes hardwired via myelination.
But how does this happen?
A newborn infant is born with billions of brain cells; each brain cell—or neuron—has branching appendages called dendrites, which reach out to make connections with other neurons. When electrical signals pass from neuron to neuron, synapses are stimulated; as those synapses are stimulated over and over again, those neural connection patterns become hardwired via myelination, which forms in those heavily used areas.
Neurologists call this the “sled on a snowy hill” phenomenon: the first exposure to something or the first time we learn to do something is like the sled first making tracks on fresh snow. On subsequent tries, your sled will tend to follow those grooves; as we repeat those sled rides over and over again, we learn as our brains myelinate in the areas devoted to those activities.
Recent brain imaging research has confirmed the existence of this hardwiring myelination process and has allowed us to see that there are physical differences between a child’s brain that has been appropriately stimulated and one that hasn’t been appropriately stimulated; connections that aren’t appropriately stimulated by repeated exposure and/or experience atrophy, creating a use-it-or-lose-it situation.
That’s what happens with language. When an infant is exposed to the complexities of language, the neural pathways devoted to language myelinate—the sled forms tracks in the snow—and become hardwired, making language acquisition permanent and relatively effortless and organic. But if there’s no language stimulation during those critical early years, there are no “snow tracks,” and so the language-development window closes and language connections atrophy as the brain loses its ability to hardwire and myelinate for language.
Interestingly, that same brain imaging is now also showing us that it’s not just understimulated neural pathways (as in feral children) that can lead to neurological differences and developmental problems—but that the overstimulation of the glowing, flashing screens of iPads and video games can damage myelin in neural pathways as well.
That’s because myelin is extremely vulnerable to disruption; oligodendrocytes, the brain cells that produce cholesterol for proper myelination, are easily damaged by things such as head trauma, environmental stressors, toxins, stress hormones, certain drugs—and overstimulation. What problems can develop as a result of this myelin-destroying overstimulation? Our ability to pay attention and focus, our ability to feel empathy and our ability to discern reality can all be adversely affected by overstimulation during key developmental windows.
That’s why Bartzokis’s myelin model research in the early part of the new millennium was so important, as he was able to show the critically important role of myelination in healthy human brain development.
Just as importantly, he was also able to prove the correlation between impaired myelination and various brain disorders. Bartzokis believed that those myelination abnormalities drive various neuropsychiatric disorders across our entire life cycle—everything from ADHD and autism in infants and children to schizophrenia and drug addiction in teens and young adults to Alzheimer’s in seniors.
And Bartzokis was able to prove it. His brain research was the first of its kind that empirically showed that drug addiction can damage myelin. In his 2002 study published in the Journal of Biological Psychiatry, he compared the brains of 37 male cocaine-dependent subjects with those of a control group of 52 non–drug dependent subjects, all between the ages of 19 and 47, and clearly showed the adverse impact of cocaine on brain myelination.12 “If you look at the data,” Bartzokis says, “you will see that the average 40- or 45-year-old cocaine addict has the same amount of white matter as the average 19-year-old.”
In his earlier research, Bartzokis had discovered that healthy brains continue to grow and myelinate until we’re roughly 50 years old; now, his addiction research clearly showed that drug use stunted myelin growth and development. Bartzokis concluded, “The [healthy] age-related expansion in white matter volume occurring in normal control subjects was absent in the cocaine dependent subjects.” These decreased-myelination results were repeated in other studies using other drugs, including alcohol, opiates and marijuana.
And now, a little over ten years after Bartzokis’s original work, we have research from several recent brain-imaging studies that show us that tech exposure can also alter brain structure and myelination in exactly the same way that drugs can.
Yes, that’s right: that iPad that your child’s school thought would be so wonderful as a first-grade learning tool is making your child’s brain resemble that of a drug addict.
The recent research: In 2012 a research team led by Dr. Hao Lei of the Chinese Academy of Sciences discovered that the brains of people who had been diagnosed with Internet Addiction Disorder had myelin (white matter) integrity abnormalities in brain regions involving executive attention, decision making and emotional generation. Their study compared the brains of 17 IAD subjects and used as a control 16 healthy subjects. In their findings, published in the Public Library of Science, Dr. Lei states: “The results . . . suggest that IAD may share psychological and neural mechanisms with other types of substance addiction and impulse control disorders.”13
In other words, screen addiction looks like drug addiction in the brain.
In 2013 a brain-imaging study entitled “Decreased Functional Brain Connectivity in Adolescents with Internet Addiction” in PLOS One, conducted on 12 adolescents diagnosed with IAD and 11 healthy control subjects, concluded that “Internet addiction is associated with a widespread and significant decrease of functional connectivity.”14 As I’ve mentioned, functional connectivity relates to the brain’s white matter/myelination. This study shows that gaming is associated with a decrease in all-important myelination.
A September 2014 brain-imaging study in PLOS One entitled “Disrupted Brain Functional Network in Internet Addiction Disorder: A Resting-State fMRI Study,” by Wee et al., also found similar myelination and connectivity problems with gamers.15 The researchers indicated that “there is significant disruption in the functional connections of IAD patients, particularly between regions located in the frontal, occipital, and parietal lobes. Our findings . . . suggest that IAD causes disruptions of functional connectivity and, importantly, that such disruptions might link to behavioral impairments.”
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There was also an amazing American study done at the Indiana University School of Medicine in 2011. In this study, by taking brain scans at both the beginning of the study and then again after subjects had spent one week playing violent video games, the researchers showed cause-and-effect brain changes after just one week of video game playing.16
Yes, measurable brain changes after just one week.
For the study, 28 healthy young adult males, ages 18 to 29, all with low past exposure to violent video games, were randomly assigned to two groups of 14. Members of the first group were instructed to play a shooting video game for 10 hours at home for one week and refrain from playing the following week. The second group did not play a video game at all during the two-week period. Each of the 28 men underwent functional magnetic resonance imaging (fMRI) analysis at the beginning of the study, with follow-up exams at one and two weeks.
The results showed that after one week of violent game play, the video game group members showed less activation in the left inferior frontal lobe and less activation in the anterior cingulate cortex than in their baseline results and the results of the control group.
“For the first time, we have found that a sample of randomly assigned young adults showed less activation in certain frontal brain regions following a week of playing violent video games at home,” claimed Dr. Yang Wang, the lead researcher of the study. “The affected brain regions are important for controlling emotion and aggressive behavior.”
The frontal brain regions that Dr. Wang mentioned are the same brain regions that are affected by drug addiction; and now, for the first time, researchers had shown a direct relationship between playing violent video games over an extended period of time and a subsequent change in those brain regions associated with executive functioning.
Interestingly, after the video game group refrained from game play for an additional week, the executive regions of their brains returned to a state closer to that of the control group. It would seem that the brain’s plasticity—its ability to bounce back and compensate—was clearly at work. But what if a person continued playing violent video games? “These findings indicate that violent video game play has a long-term effect on brain functioning,” Dr. Wang says. “These effects may translate into behavioral changes over longer periods of game play.”17
All of this recent research linking screen exposure to neurobiological changes has excited academics in the field of brain science. Indeed, Professor Gunter Schumann, chair of biological psychiatry at King’s College in London, told the BBC, “For the first time . . . studies show changes in the neuronal connections between brain areas as well as changes in brain function in people who are frequently using the Internet or video games.” Neurologist and Oxford professor Baroness Susan Greenfield believes that video game addiction can even cause a form of what she describes as “dementia” in children.18
When looking at this brain-imaging research, some ask the inevitable chicken-or-the-egg question: is screen exposure causing the brain changes, or are those with preexisting and underlying brain abnormalities gravitating toward addictive gaming and screen time? Since most of the brain imaging studies (with the notable exception of Dr. Wang’s) are looking at the brains of gamers without having a baseline reading of that brain before the problematic gaming, it is a valid question.
Certainly we know that in substance addiction there can be a vicious cycle: sometimes people with underlying brain abnormalities or chemical imbalances are more likely to self-medicate and become substance addicted, and then the addiction further impairs or damages the neuroanatomy or neurochemistry of the brain, which then only further exacerbates the addiction.
Author and adolescent psychiatrist Dr. Victoria Dunckley describes that chicken-or-the-egg dynamic this way: “In gaming and Internet addiction research in general, the chicken and egg question is a legitimate one, but research suggests there are bidirectional influences that create a vicious cycle. In other words, vulnerable brains are more vulnerable to screen addiction, and then the addiction contributes to psychiatric pathology, which worsens the addiction.”
Let’s also keep in mind that Dr. Wang’s study did indeed do pre- and post-brain imaging and did show a causal relationship between excessive screen exposure and abnormalities in the frontal regions of the brain. So while it can be true that those with preexisting brain disorders can be gravitating toward gaming, it does also seem to be the case that excessive gaming changes brain structure—even in so-called normal brains.
Now that we’ve explored the neurobiology of addiction via dopamine and myelination, let’s take a look at the role that environment plays in the perfect storm of addiction.
Rat Park: Addiction and the Cage
Nature vs. nurture. Most of us have heard that phrase since grade school as a framing of the two competing theories of human nature: biological determinism vs. learned behavior or behavior shaped by our environment. The consensus these days is to reject the proposition as an either/or statement in favor of the more inclusive and comprehensive “and,” as in: it’s nature and nurture creating a perfect storm that determines who we are and how we behave.
Just how important our environment is in shaping who we are and how we behave was proven in an exquisitely simple yet illuminating experiment conducted in the late 1970s by Canadian professor Dr. Bruce Alexander. Dr. Alexander had been skeptical of earlier addiction studies done on rats in the 1960s; in those earlier experiments, the poor little furry rodents were put in Skinner boxes (named after the behavior guru B. F. Skinner). These boxes were small, cramped solitary-confinement cages where often-starved rats could get tiny pellets of food, provided that they pushed a little lever on the side of the box over and over and over again.
In the addiction experiments of the 1960s, a rat would be tethered to the box’s ceiling, with tubing that included a surgically implanted needle going into its jugular vein. Yes, it was as horribly unpleasant as it sounds. When the rat pushed the lever, the sweet relief of morphine would instantly surge into its little bloodstream (in other experiments, cocaine water was used).
Not surprisingly, these poor trapped rats hit those morphine levers like a retiree at the quarter slots in Atlantic City, and the little creatures became hopelessly addicted. That drugs-lead-to-addiction research then became part of the War on Drugs media campaign, which hyped the evils of illicit drugs; for most people, the evidence was in: drugs = hopeless drug addiction.
But Dr. Alexander was troubled by these conclusions. If the power of addiction lay in the drug, why didn’t all people who ingested them become addicted? He understood that rats, in their natural state, are highly social creatures not designed by nature to be isolated in Skinner boxes; was it possible that the prior experiments were merely indicating that an isolated and trapped rat might be more likely than a “free” rat to choose an anesthetic escape from an intolerable existence?
Rats share this strong social aspect with human beings, and as Dr. Alexander understood, solitary confinement often drives humans insane. It’s well known that if inmates in isolation have access to mind-numbing drugs, they invariably take them. Thus, Dr. Alexander reasoned, couldn’t it be the isolating Skinner box and not the morphine that was driving these similarly incarcerated rats to drug addiction?
With that in mind, Dr. Alexander and his colleagues set about designing a study with two separate groups of rats: one group was kept in the isolation of Skinner boxes while the other got to frolic in what came to be known as “Rat Park,” a large open area filled with things that rats love: platforms for climbing, tin cans to hide in and running wheels for exercise. Oh, and it was coed. Apparently rats, like humans, enjoy sex as well.
The results were shocking: the rats in cages became addicts. But the rats in the freedom of Rat Park, not so much; in fact, they barely touched the drug water that was made available to them. Alexander concluded that addiction was less about the magnetic, addictive pull of the drug and more about the condition of a rat’s life; without healthy socialization and connection, a rat seemed to be much more vulnerable to addiction.19
But what about people?
As Dr. Alexander speculated, “People do not have to be put into cages to become addicted—but is there a sense in which people who become addicted actually feel ‘caged?’”
Years later, he wanted to see if he could test these findings on humans. Ethical considerations precluded him from caging people and offering them drugs; most universities tend to frown on such practices. But he was able to study the historical records of just such a “natural” experiment: the colonization of Native people and their subjugation on reservations.
Alexander realized that the Native peoples of Canada and the United States had been effectively put in their own Skinner boxes, which robbed them of their traditional cultural ties and normal socialization. He also discovered that before this colonization period, there were scant records of addiction: “There was so little addiction that it is very difficult to prove from written and oral histories that it existed at all. But once the [N]ative people were colonized, alcoholism became close to universal; there were entire reserves where virtually every teenager and adult was either an alcohol or drug addict or ‘on the wagon.’”
Western researchers used to blame the higher incidence of alcoholism among Native peoples on “genetic vulnerability”; English settlers would cite a variation of the racially charged “Indians just can’t handle their liquor” and would impose strict alcohol prohibition on reservations. Yet, very tellingly, on reservations where alcohol was available but Native culture was preserved, Native people were able to incorporate alcohol into their traditions without too much difficulty; in those cases, there were instances of alcohol consumption and some abuse, but no widespread alcoholism.
Today, most addiction experts have rejected the genetic-vulnerability explanation. Indeed, Rat Park—and the colonization of Native peoples—has shown us that social beings put in physical, mental or cultural isolation—“cages,” if you will—are more susceptible to addiction, including behavioral addictions like excessive Internet use.
According to Alexander: “The view of addiction from Rat Park is that today’s flood of addiction is occurring because our hyperindividualistic, hypercompetitive, frantic, crisis-ridden society makes most people feel socially and culturally isolated. . . . They find temporary relief in addiction to drugs or any of a thousand other habits and pursuits because addiction allows them to escape from their feelings, to deaden their senses, and to experience an addictive lifestyle as a substitute for a full life.”
According to this perspective, today’s epidemic of glowing screens is less about the screens and more about the isolating “hyperindividualistic, hypercompetitive, frantic, crisis-ridden society” that our kids inhabit.
When I interviewed Lt. Sam Brown about his experiences using virtual reality therapy, he made an insightful observation about another important addiction dynamic when he described how many of his soldier friends were getting addicted to video games: “Look, people are looking for purpose in their lives. Some of these games give you that. Whether you’re on a shared mission in Halo or whatever, if you don’t have a sense of purpose, these games can fill that void.” He added: “Probably the only reason that I didn’t get hooked those first couple of years is because I couldn’t use my hands well enough to handle the control board.”
How many kids today feel adrift and purposeless? Add to that the “hypercompetitive” and “hyperindividualistic” dynamic that Dr. Alexander mentioned, mix in a little stress, social disconnect and the seductively addicting escapism of glowing screens, and voilà!
Tech addiction.
Sure enough, according to the latest research, tech addiction is affecting young people more than adults: The American Journal of Drug and Alcohol Abuse found that 8.2 percent of Americans suffer from Internet addiction, but according to Internet Addiction: A Handbook and Guide to Evaluation and Treatment, the disorder affects more than 18 percent of college-age Internet users.
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The idea that we can become addicted to virtual tech is not a new one to some clinicians. Back in 1999, Dr. Peter Greenfield published a small, well-written book called Virtual Addiction, years before any of the most recent brain-imaging research and well before the intensity and pervasiveness of this generation of iTech. Instead of brain imaging, Greenfield used good old clinical criteria to assess that many people were developing increasingly problematic—even addictive—relationships with their technology.
That’s an important point that shouldn’t be understated. Brain imaging can be wonderfully illuminating, but the way that psychiatrists, psychologists and psychotherapists diagnose a mental disorder is by diagnosing clinical symptoms, not by using brain imaging. To point: I’ve diagnosed or worked with hundreds of alcoholics and addicts (who were drug or alcohol “dependent,” according to the older DSM-IV), and not one was diagnosed via an MRI.
I think it’s fair to say that if a person is using a substance or engaging in a behavior in such a compulsive way that it negatively affects—or even destroys—his or her life, then we can say that addiction is at hand.
In the next chapter, in order to get firsthand insight into the addictive and hypnotic power of hyperarousing screens, we will meet an amazing addiction researcher, neuroscientist—and recovering video game addict.
Note
* Recent research by Brazilian neuroscientist Dr. Suzana Herculana Houzel indicates that the oft-repeated 100 billion number is overstated; in a unique and innovative process wherein she analyzed healthy postmortem brains in a “brain soup,” she discovered that the actual number of human neurons is actually closer to 84 billion.