Curr Psychiatry Rep (2015) 17: 71 DOI 10.1007/s11920-015-0609-6

GENETIC DISORDERS (W BERRETTINI, SECTION EDITOR)

The Effects of Video Games on Cognition and Brain Structure: Potential Implications for Neuropsychiatric Disorders Tahireh A. Shams 1,2 & George Foussias 3,4,5 & John A. Zawadzki 4,5 & Victoria S. Marshe 1,4,5 & Ishraq Siddiqui 4,5 & Daniel J. Müller 1,3,4,5 & Albert H. C. Wong 4,5

Published online: 29 July 2015 # Springer Science+Business Media New York 2015

Abstract Video games are now a ubiquitous form of entertainment that has occasionally attracted negative attention. Video games have also been used to test cognitive function, as therapeutic interventions for neuropsychiatric disorders, and to explore mechanisms of experience-dependent structural brain changes. Here, we review current research on video games published from January 2011 to April 2014 with a focus on studies relating to mental health, cognition, and brain imaging. Overall, there is evidence that specific types of video games can alter brain structure or improve certain aspects of cognitive functioning. Video games can also be useful as neuropsychological assessment tools. While research in this area is still at a very early stage, there are interesting results that encourage further work in this field, and hold promise for utilizing this technology as a powerful therapeutic and experimental tool.

This article is part of the Topical Collection on Genetic Disorders Daniel J. Müller and Albert H. C. Wong contributed equally to this work. * Daniel J. Müller [email protected] 1

Pharmacogenetics Research Clinic, Centre for Addiction and Mental Health, Toronto, ON, Canada

2

Department of Science, Ryerson University, Toronto, ON, Canada

3

Department of Psychiatry, University of Toronto, Toronto, ON, Canada

4

Institute of Medical Science, University of Toronto, Toronto, ON, Canada

5

Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, 250 College Street, Toronto, ON M5T 1R8, Canada

Keywords Video game . Computer game . Virtual reality . Cognition . Psychiatry . Treatment . Rehabilitation . MRI . Brain structural imaging . Plasticity

Introduction Video games are a very popular and often controversial contemporary pastime. Concerns about the negative effects of computer games have included addiction [1] and the influence of violent [2] or misogynist [3] content [4–7]. In contrast, there have also been studies on the therapeutic and rehabilitative potential of video games for a variety of nervous system disorders [8–11]. There has been interest in the effect of video games on brain structure and cognitive function in both experimental and therapeutic contexts. An emerging question is how the type of game play affects the brain and what cognitive changes may result. The negative impact of video games has included a number of domains. For instance, violent video games have been implicated in sleep disruption [12] and decreased response to negative stimuli [13]. The violent and criminal content of some game narratives have prompted concern that players may emulate game scenarios in real life. Some studies have reported that adolescents are more likely to carry weapons to school after playing violent video games [14] and to engage in risky driving behavior after playing street-racing games [15]. Other studies have revealed increased self-identification and emotional self-involvement with personal avatars in long-term online gamers [16]. Video games are especially popular among adolescents and young adults. According to a recent demographic survey of 4028 high school students aged 14–18 in Connecticut, approximately 50 % of participants reported playing video games for at least 1 h per week, with the majority of this group

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being younger males. The girls who played video games were more likely to smoke, use caffeine, carry weapons, be in violent altercations, and to have a higher BMI [17]. These negative associations may have been seen only in girls because video gaming is more prevalent in boys, and thus is correlated with a particular subset of girls who may be selected for being more aggressive. A separate cross-sectional study of 373 Dutch high school students aged 12–16 found that those with lower levels of education were more likely to play video games with an active component (Bexer-games^) than those in higher levels [18]. They also found a higher prevalence of sedentary video game play for several hours per week in boys and older students versus girls or younger students. Another study examined 430 Spanish online multiplayer playing game players [19]. They reported that the players were predominantly males and had a mean age of approximately 26 years with a mean time spent playing of approximately 23 h per week. This result was in line with previous findings from other countries [20, 21]. Social contact and exploration of the different possibilities in the game were the strongest motivations for playing this type of game. In general, single player video games seem to hold greater appeal for males, and online multiplayer games appeal to a greater age range of players. Video games have also been studied for interventional and rehabilitation purposes, particularly virtual reality (VR) and interactive gaming. These rehabilitation approaches have been investigated in various populations, including children with degenerative ataxia, ischemic stroke, patients with traumatic and acquired brain injury, as well as autistic children [22••, 23–26]. There have been mixed results for the therapeutic effects of video games, but improvement in ataxia, balance in patients with acquired brain injury, postural coordination in those with traumatic brain injury, and upper limb function after stroke have all been shown to be positively influenced by VR games [23, 24, 26]. For autistic children, it is hypothesized that video game training can aid in the improvement of memory, facial recognition, motor skills, and social integration [22••]. In children with acquired brain injury, the clinical feasibility of VR rehabilitation has been questioned [27]. Interventional video games have also been proposed as strategies for improving healthy diet choices and promoting physical activity in children and adults [28, 29]. One of the main concerns with VRbased computer therapies for brain disorders has been generalizability beyond the game environment to real-world functioning. In line with this, some recent studies of commercial brain training games have found limited transferability of skills acquired during training [30, 31]. Many areas of neuroscience and medicine have used video games as tools in their research, including studies of neuroplasticity, brain activation in response to stimuli, learning and memory, physical ability in elderly populations, neuron competition, effectiveness of electroencephalography in

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measuring visual fatigue, internet game addiction, and remedies for motion sickness [32–41]. As evidenced above, video game studies span a wide range of areas and clinical applications. This review will focus on a subset of this literature: specifically studies relating to mental health, cognition, and brain imaging with an emphasis on work published since 2011.

Methods We reviewed original articles on video game studies published in PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) before April 2014. Selected key words were Bvideo games,^ Bcognition,^ Bnavigation,^ Bbrain,^ Bschizophrenia,^ and Bmental health^. We excluded conference abstracts, reviews, and studies focusing on EEG/ECG measures. We chose to focus on studies relating to mental health, cognition, and brain imaging, so we will not comprehensively review studies on motor function, rehabilitation, or interventional games outside of the three categories of focus. This review will also focus on studies that include a video game component, not video-related tasks in general. In total, we identified 27 prospective studies and nine retrospective studies that will be reviewed in detail here (see Table 1). We begin with studies on the effects of video gaming on brain structure, focusing first on prospective investigations followed by retrospective studies. We will then examine studies investigating the effect of video games on cognition in both healthy patients and patients with mental illness, similarly categorized into prospective and retrospective studies.

Results Prospective Studies—Structural and Functional Brain Effects A number of structural imaging studies have found that video game play can alter brain structure, especially gray matter volume. These studies have typically analyzed a particular video game or video game type. The most commonly studied category in the last few years has been complex strategy games such as Super Mario 64 or Space Fortress (Developed in 1989 [42]). There is evidence that regional differences in brain volume can predict learning in tasks that require the use of perceptual, cognitive, and motor processes. Basak et al. (2011) used voxel-based morphometry to assess brain volume differences that predicted skill acquisition in complex tasks, such as the strategy-based video game Rise of Nations [43]. In their study of 20 volunteers who participated in 15 one-and-a-half-hour sessions over 5–6 weeks, they found that variance of gray

Dynasty Warriors 5 (violent game) and Super Mario 64 (non-violent game)

Retrospective

Various

Various

Space Fortress

Space Fortress

Space Fortress

Strategy/navigation games Strategy/navigation games

Strategy/navigation games

Unreal

Strategy/navigation games

Space Fortress

75 Volunteers

Super Mario 64

Strategy/navigation games

Strategy/navigation games

20 Volunteers

Need for Speed: Electronic Arts

Racing games

fMRI, voxel-based morphometry technique: MRI, MID task during fMRI and the CGT

Frequent gamers: ≥9 h per week of game play Infrequent 14

154 Volunteers (76 frequent gamers, 76 infrequent gamers)

SPECT

Two different games for 30 min each

Mean age approx. 24

fMRI

fMRI

fMRI

fMRI

fMRI

30 Volunteers

Fifteen 2-h sessions over several weeks

Ten 2-h training sessions with approx 3–5 sessions per week

Two 1-h sessions per day for 5 days Fifteen 2-h training sessions over 8–10 weeks

Variable, however long tasks took to complete

Voxel-based morphometry technique: MRI and cognitive tests

DTI: diffusion MRI framework sensitive to tissue microstructure

16 Blaps^ broken up into 4 training sessions: total time approx. 2 h

30 min per day for 2 months

Voxel-based morphometry technique: MRI

Measurement

Fifteen 1.5-h training sessions over 5–6 weeks

Time spent playing

Mean age approx. 21

Mean age approx. 22

18–30

18–29

Mean age approx. 28

Mean age approx. 24

Mean age approx. 26

62–75

Age

45 Volunteers

39 Volunteers (completed training but only 29 were imaged)

50 Volunteers: Exp 1 14 Volunteers: Exp 2

48 Volunteers

70 Volunteers

20 volunteers

Rise of Nations

Strategy/navigation games

Sample

Game

Summary of reviewed studies investigating the effects of video games on cognition in patients with mental illness and healthy volunteers

Category

Table 1

[43]

• Variance in gray matter volume of the medial prefrontal cortex (Brodmann area 6), cerebellum, and the right ventral anterior cingulated cortex (ACC, Brodmann area 24), and the DLPFC predicted variance in learning of the game • Changes in diffusion in the fornix and hippocampus correlated with behavioral measures of improvement in learning tasks • Indication of short-term white matter plasticity in humans • Significant increase in gray matter volume in the right HC, right DLPFC, and bilateral cerebellum in the video game group compared to the control group • HC increase correlated with changes from egocentric to allocentric navigation strategy • Gray matter increases in HC and DLPFC correlated with participants’ desire for video gaming • Use of spatial landmarks to navigate correlated with increased activation of the right hippocampus • Use of a non-spatial strategy showed sustained increased activity in the caudate nucleus during navigation • Both groups showed activation in the posterior parietal and frontal cortices • Individual learning differences were predicted by differences in phasic activation • Reduction in brain activation in areas related to visuo-spatial attention and goal-directed movement was correlated with improved performance on untrained tasks • Changes in brain network interaction with variable priority training indicative of more flexible skill learning and retrieval • Fixed priority training showed brain network interactions indicative of procedural learning and skill implementation • Provides first evidence for interaction of brain networks via different learning strategies • Differences in activation of the SPL and caudate predicted performance variability in untrained working memory tasks • CBF was significantly decreased in the prefrontal cortex and significantly increased the temporal and occipital cortices for both games • Number of characters killed in the violent game correlated significantly with decreased CBF in the anterior cingulate cortex • Provides support for the hypothesis that anterior cingulate cortex may play a role in violent behavior regulation • Frequent gamers had higher left striatal gray matter volume and enhanced activity during feedback of loss in the MID task than non-

[53]

[52]

[51•]

[50]

[49]

[48]

[47]

[45••]

[44]

Ref

Results summary

Curr Psychiatry Rep (2015) 17: 71 Page 3 of 15 71

Game

Retrospective

Retrospective

Retrospective

Retrospective

Retrospective

Category

Various

Various

Action games

Action games

Various

Table 1 (continued)

17 Volunteers (8 male pathological game players and 9 controls)

26 Male volunteers (12 video game players, 14 non-video game players)

50 Male volunteers (including 17 action video game experts)

62 Male volunteers

20 Online gaming addicts, 17 pro-gamers, and 18 healthy controls

Sample

fMRI

Video game players: ≥5 h per week avg. of action video game play Non-video game players: 30 game playing hours per week) versus nine occasional (≤5 game playing hours per week) adolescent male (mean age approximately 16) video game players to assess time perceptions [81]. The authors report that due to chronic video game play, efficient time perception in players may be more inherent than cognitively controlled.

Conclusion The use of video games as assessment and therapeutic tools in psychology and psychiatry is still a relatively new idea. This review attempts to capture some of the major areas of research using video games, realizing that there is likely to be a rapid increase in the use of such technology in neuroscience and

Curr Psychiatry Rep (2015) 17: 71

clinical medicine. Even with the limited number of studies published to date, there is a great variety of ways in which video games are used and the ways in which their effects on brain and behavior have been assessed. Overall, it is clear that video games can indeed alter brain structure and function, just like real-world experiences. There is also a clear potential for refining video games for focused therapeutic applications and as novel tools for assessing cognitive and emotional functioning. In summary, there is consistent evidence that video game play can alter gray matter volumes [54, 45••, 56] and some evidence for their effect on the plasticity of white matter as well [44]. Several of the studies discussed above replicated an increase in gray matter volume in the hippocampus [55, 45••] as well as the dorsolateral prefrontal cortex and cerebellum [43, 45••] with video gaming. There is also general agreement among a number of reports that regional brain activation patterns can be affected by video game play [57, 53, 49]. Changes in interaction of brain networks [50] and cerebral blood flow [52] due to video game play has also been observed. Such findings are consistent with the notion of considerable brain plasticity in response to concentrated activity. In the context of psychiatry, studies indicating brain volume reduction following antipsychotic exposure have recently received much attention [82•]. It would be interesting to investigate whether video game-based therapy could counteract this effect. In studies of the cognitive effects of video gaming, there is evidence for increased working memory [71, 67••, 68], increased processing speed [65, 67••, 68, 81, 63], and increased attention/attentional biases [63, 80] across a variety of game types including brain training games and exer-games. There is also evidence that virtual reality platform games can be used to measure cognitive performance in patients with schizophrenia [75•, 77••], as a diagnostic aid [75•], and as a therapeutic tool for reduction of positive symptoms [76]. In patients with impulse-control disorders, a pilot study for the therapeutic use of a custom video game has shown promising results for increased self-control and coping strategies in this population [78•]. There are a number of positive results that suggest video games could be a promising therapeutic approach. Nevertheless, there are practical considerations depending on the clinical population [27]. On a positive note, these potential obstacles seem to be isolated to the use of commercial games that are not created specifically for the purpose of rehabilitation, such as the negative feedback from the game being counterproductive to therapy. In summary, while there were positive results from many studies for the use of commercial video games therapeutically, it would seem that in order to eliminate most concerns involved in clinical implementation, specialized video games (such as in [77••]) would be a better choice. This notion is consistent with the report that specialized video games induced significant improvement across more

Curr Psychiatry Rep (2015) 17: 71

cognitive domains than commercially available games [60]. Nonetheless, well-designed clinical trials are needed to determine the practical, clinical usage of video games. While the findings published to date are interesting and promising, there remain more unanswered questions than answers. This review discussed the cognitive, structural, and functional effects of video games, but there are many other studies that discuss the positive motivational, emotional, and social effects; these are summarized in a recent review [83••]. On a practical clinical level, it remains to be seen whether video games will prove to be effective and tractable treatment tools for neuropsychiatric disorders or useful assessment tools for cognitive function or diagnosis. Substantially more research is undoubtedly required, but optimism about the future applications of video games seems warranted, considering the rapid advancement of both the hardware and software platforms that run such games, as well as the increasing appreciation that these games can be harnessed for more than just entertainment.

Compliance with Ethics Guidelines Conflict of Interest Tahireh A. Shams, George Foussias, John A. Zawadzki, Victoria S. Marshe, Ishraq Siddiqui, Daniel J. Müller, and Albert H. C. Wong declare that they have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

References Papers of particular interest have been highlighted as: • Of importance •• Of major importance

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