by Carol W. Berman, M.D.
Reality can often be elusive for many of our psychotic patients, but the retreat into a fantasy game world is now a sanctioned past time for millions. How many psychotic patients are playing Pokémon Go and losing all sense of our consensual reality?
Jake* was a 22-year-old man who had been experiencing visual and auditory hallucinations since he was 17. He loved to play Pokémon and as a teenager, he had secluded himself in his bedroom to while away many hours with the game. When at age 18, he refused to bathe or eat for several weeks, his parents called 911. He was taken to a local city hospital and placed in the psychiatric ward. At that time, they thought his diagnosis was schizophrenia with all the usual DSM criteria. He was prescribed anti-psychotic medication, discharged, and given appointments to see a psychiatrist on a weekly basis. Jake, however, refused to take his medications or see the doctor. He continued to play Pokémon in his room by himself. He was hospitalized three more times over the next two years before he finally agreed that the medications and psychiatric treatment were a good idea.
He had been fairly compliant with the regimen until recently when he stopped taking his olanzapine and refused to see his psychiatrist. Of course, he started to hallucinate again. This time his parents decided to get him treatment with a private doctor, namely me.
Jake was a heavy-set young man dressed in a skimpy t-shirt and worn blue jeans. He clutched his smartphone in one hand, avoided eye contact, and looked like he wanted to hide under the chair. His speech was limited, but correct when he did talk. His parents waited for him outside, in a waiting room that was far from where we sat in my office. I finally warmed him up by talking about games and computers, of which I have limited knowledge, but enough to engage Jake. He admitted that he did not like taking his olanzapine because it made him so sleepy that he could not stay up all night and play the latest game he adored, Pokémon Go. For those unfamiliar with the game, Pokémon Go employs an augmented reality app on a smartphone to let users track and capture virtual creatures at real-life locations.
I asked him if he went outside and tried to catch the characters. He said he did and the best time was after midnight in Central Park. He said he was not afraid to go there. On the contrary, he loved being in the park when few people were there and he always found a few Pokémon hiding in the trees or on a rock. His reality testing was poor. He was not afraid of being accosted by anyone. When I mentioned the possibility that he could be hurt or his smartphone stolen by muggers, he nodded, but did not take me seriously. He heard voices talking to him and believed the voices were Pokémon characters. Sometimes he even saw some of the characters that were not really there when he tried to capture them. Since he had both visual and auditory hallucinations, I began to think either that he was taking drugs, or that he might have bipolar disorder. He completely denied any drug use. He said he did not even drink alcohol. Blood tests and a urine screen confirmed what he claimed, since they were negative for everything. He had had CT scans and MRIs when he was hospitalized, which ruled out any physical brain anomalies.
The virtual world was perfect for Jake, since he did not have to interact with real people. He was paranoid of most people because he was afraid they would mock or belittle him.
For centuries, philosophers have argued many different theories about what constitutes “reality.” Let us just say that reality is an agreed upon construct that most of us share about the physical world. Lack of reality or being out of touch with reality or having psychosis is detrimental to our patients because it usually causes them stress and alienation from our world and trouble with people around them. Most of us psychiatrists work hard to control psychosis in our patients. I wonder if Pokémon Go will sabotage our efforts, especially with patients like Jake.
I offered to change Jake’s antipsychotic to a less sedating one, if he promised not to go into Central Park alone after midnight. He agreed to try Latuda after I informed him that he might lose some weight with this antipsychotic. He also pointed out that he was getting more exercise as a result of running after the Pokémon characters, so there is a positive aspect to playing the game after all. When I last heard from him, he was going into the park with a group of other Pokémon Go players before midnight, and he was still taking his medicine.
*Not his real name
Carol W. Berman, M.D. is a clinical assistant professor of psychiatry at NYU Medical Center. She has published three books. Her most recent book, Surviving Dementia: A Clinical and Personal Perspective is available now. For more information, please visit: carolwberman.com