Mental Health Clinic: A Case Series
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
MILITARY MEDICINE, Vol. 180, July 2015 e839
Downloaded from https://academic.oup.com/milmed/article-abstract/180/7/e839/4160631 by guest on 04 June 2018
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…
