Do you ever think you might have a serious problem because you have to check your e-mail about a hundred times a day? Do you get angry or agitated when you can't check your e-mail or send text messages? Excessive e-mailing and text messaging is just one subtype of potential pathological addiction. And some people suffer from excessive gaming. But even if you check e-mail a hundred times a day and play online games 35 hours a week, don't worry: you're probably not pathological yet. "Carl" is an example of a guy who plays online games 35 hours a week. He's a 51 year old Transportation Planner from California with a friendly, down-to-earth demeanor. After work, he spends about five hours a night fighting monsters, completing quests, and talking to Orcs and Trolls in a game called 'World of Warcraft.' WoW, as it’s commonly known, is a 'massively multiplayer online role-playing game' (MMORPG) with over 10 million subscribers, set in the fantasy Warcraft universe. Carl’s record for sitting in front of the computer playing WoW is three and a half days with no sleep, few bathroom breaks, and a perfect 'level 70' avatar by the end of the campaign. That pales in comparison to his son's record of six days of WoW straight through. According to Dr. Louise Nadeau, a professor in the Department of Psychology at the University of Montreal, mental health professionals now have a new affliction to face: Internet addiction. Pathological aspects of compulsive gambling and alcoholism have been well documented, but when it comes to Internet addiction, "there is no reliable study or clinical data on the issue," says Dr. Nadeau. So her lab hopes to develop this idea to determine just how much internet use it takes before someone is considered to be addicted, as well as to determine how the disease evolves, and how mental health practitioners can intervene and treat it. "The problem isn't widespread," she says, "but we know of serious cases in which teenagers don't leave the house, don't have interpersonal relationships, and have been isolated in front of their computer screen for the past two or three years, and only speak in the language of the characters they play with in network video games." Does Carl think it's addictive? "Oh, definitely," he says, "It can affect your family a little bit. They'll say things like, 'Why don't you do anything with me?' or 'why don't you pay attention to me?' With me personally, I know I should be doing other stuff, but I really want to play this!" According to Dr. Jerald J. Block, a board-certified adult psychiatrist in Portland, Carl’s gaming, while excessive, probably wouldn't qualify him for a pathological diagnosis. But Dr. Block is trying to help other mental health practitioners make it easier to diagnose the condition by adding excessive internet use as a pathological disorder in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM, a handbook that mental health professionals like Dr. Block use to diagnose different categories of mental disorders, lists the criteria for substance dependence, a related disorder, as three or more of the following: 1) continued use even though you recognize that it is having negative effects on your life 2) tolerance (you need more of it to get the same feeling) 3) withdrawal (you have certain symptoms like anger or depression when you don't have the substance) 4) large amounts over a long period 5) unsuccessful efforts to stop, and/or 6) time spent obtaining the substance replaces social, occupational, or recreational activities. Carl realizes that sometimes his gaming does take the place of social or recreational activities. "Sometimes," he says, "my friends and I won't do any of the quests in the game, we'll just go and sit up on top of a mountainside overlooking these waterfalls—which you can hear through the speakers—and we'll just enjoy the trees and the animals and just sit there and talk." Dr. Block explains addictive internet use in similar terms: 1) excessive use, often associated with a loss of sense of time or a neglect of basic drives 2) withdrawal, including feelings of anger, tension, and/or depression when the computer is inaccessible 3) tolerance, including the need for better computer equipment, more software, or more hours of use, and 4) negative repercussions, including arguments, lying, poor achievement, social isolation, and fatigue. "In a few years," says Dr Nadeau, "we'll have couples in therapy because the Internet will have become their main occupation." In the United States, the prevalence of the disorder isn’t accurately known, but in China, Li Jianguo, vice-chairman of the Standing Committee of China's National People's Congress (NPC), just called for closer supervision of children using the Internet to prevent addiction. Li estimates that about 10 percent of Chinese children who use the internet are addicted, while the South Korean government estimates that approximately 2.1 percent of South Korean children are addicted and require treatment. Furthermore, 20 to 24 percent of those children may require hospitalization. Dr. Block explains that it is hard to accurately measure the phenomenon in the US because patients are reluctant to talk about it. It can be many different things: shame, denial, minimization. "Computer gaming is generally very enjoyable, and patients can get a lot from it," says Dr. Block. "So, they are reluctant to talk to a psychologist about it as a problem that's generating other issues in their life because they don't want to put it at risk; they don’t want to lose that part of their life." "There's also the issue of shame. As an adult, we're taught that we're not supposed to play games. So if we play games at the expense of our work or our relationships, people don't particularly like that about themselves." On the other side of the coin, therapists might be a part of the problem. "We choose this vocation because we're probably one of the most people-oriented physicians," says Dr. Block. "But maybe we're not using technology that much because we're in our office talking all day. So we may be the least comfortable people in the room when it comes to understanding how patients are using technology and how to discuss it with them." On top of that, you have to understand the games to have a meaningful conversation with gamers about the game. So there's kind of a cross-cultural phenomenon even with people who are computer literate—like a language barrier if you don’t quite understand the game. "I watched an interview of an adolescent who lived behind a computer screen," says Dr. Nadeau, "and the discourse was astounding. He was speaking a language that I literally couldn’t understand--a mix between all the avatars, and reality.” So why do so many people spend so much time online that it could hurt other relationships in their lives? Do they get the same high as a gambler? "We don’t know yet, says Dr. Nadeau. "The people who really live behind a screen are much more introverted than gamblers. Gamblers try to control the game, whereas the people in front of the screen tend to lack social skills. And so certainly one of the angles is to find out how to build coping skills, interpersonal skills, and communication skills with these patients." "For me," says Carl, "it relaxes me and it's an escape route from reality. Sometimes if I'm frustrated after work and just want to destroy something, I'll take my level 70 character in to a level 40 area and go clean them out." And who doesn't have those kinds of days at work? In the long term, there may be certain common elements between different addictions, like the craving and withdrawal symptoms, which may be related to how the neuro-circuitry is affected when addictive substances are used for prolonged periods. An area of future research would be to examine whether or not there are neuro-chemical changes that occur in the brains of online addicts. But excessive computer use isn’t always bad; not all gaming is pathological. "Sometimes," says Dr. Block, "the computer use can be a support mechanism—a useful thing. In fact, there are some patients to whom I’ve even recommended computer use." In a case study in Psychiatric Times, Dr. Block presents different scenarios not only of when computer use turns pathological, but also when patients actually benefit from the distraction of gaming. "The problem," says Dr. Nadeau, "is how to get out of it once it is no longer adaptive. When does that behavior make you start to use maladaptive coping skills, and make you incapable of functioning?" So: if you play over 45 hours a week, there may be a problem. But if you find yourself wanting to check e-mail every two minutes, it probably isn’t something to worry about. We're getting closer to understanding the prevalance of excessive internet use, and your excessive e-mail fix probably isn't excessive. The most important thing to ask, according to Dr. Block, is whether it is producing problems in your life, not necessarily how many times you check your e-mail each day or how many hours you play a game. Even if you are addicted, Dr. Nadeau says "we’ve seen with these patients so far that they have been fairly able to be re-integrated into the world. So if there are neurological changes, they don’t seem to be permanent.” And for Carl, he wouldn’t even be considered an extreme gamer at only 5 hours a night. For that it would take more than 7. Most online games, by the way, are sold to the extreme gamer.