And what this teaches us Post Traumatic Stress Disorder
Tags: Therapy/ CBT/ EMDR/ PTSD/ Trauma/ video games
Trigger warning: The following article discusses death, torture and trauma in ways that some may find difficult to read. Images depicting video game violence are also present
Post traumatic Stress Disorder (PTSD) is an awful illness. You would not wish it on anyone.
Think of the worst thing that’s ever happened to you. We all have experienced some pretty terrible things in our lives. But now increase the awfulness by a factor of 10. Perhaps even a factor of 100 and now you get to the sort of experiences people have had who develop PTSD.
Seeing loved ones beaten and killed before your eyes. Torture at the hands of people who don’t care if you live or die. Losing your baby during childbirth. The worst kinds of abuse you can imagine. The horror of war; can you imagine the smell after a nearby bomb explodes that kills your best friends?
These are common experiences for people who suffer from PTSD and they not only flip your world upside down, they leave such deep mental injuries that you can scarcely recognise the person you become.
A walk to a coffee shop to grab a drink with friends becomes a terrifying ordeal where your head is presenting you with all the awful things people might do to you if you dare to walk down the street. A knock at the door sets you in floods of tears as the loud banging reminds your head of what such noises meant for you in the past. It then causes the worst moments of your life to replay for you in front of your eyes. But it’s not just a memory that floats by; it is a horrifying crystal-clear reproduction of worst events of your life. On top of this, not only do you see them; you smell them again, taste them again physically and emotionally feel them again. If your body hurt then so will it hurt again now. If you were abused, then you feel that abuse again.
You hate to be around people, yet hate how lonely and disconnected you feel. You struggle to feel joy, love; such emotions are replaced by almost constant fear and anger.
It is a truly terrible state of being.
So when I ask why don’t videogames cause PTSD this is not a flippant query for clicks, I am deadly serious. As a professional psychotherapist and video game lover I truly think it is worth exploring.
In my previous article on ‘Fear and DOOM’ I talk about how I felt genuinely scared as I played through the original iteration of Romero and co.’s game. I would encourage you to read the article in-full for context, but the headline is that the reason we can feel fear is that part of the brain fails to distinguish between what is real and what is not real but just a video game. In DOOM horrifying hordes of demons rush at you to be the first to send you to an untimely grave. You gun them down in showers of blood; if you run out of bullets then you can pull out your chainsaw and literally tear them limb from limb. Truly horrifying concepts if we relate them to our real lives.
The graphics and depictions are rudimentary by today’s standards but characters like ‘Doom Slayer’ are shown in much more visceral images now. The Slayer himself will be ripping and tearing his way back on to our screens in ‘DOOM: The Dark Ages’ in 2025. So many games don’t just depict violence to enemies, but violence to us as the player character. In ‘Wolfenstein II: The New Colossus’ we see ourselves get decapitated. In modern Resident Evil titles the game over screen is usually some variant of our life being finished in some of the most gruesome ways imaginable; eaten, having our throat torn or bitten out, having our flesh pulled from our body. In Alien Isolation, we are hunted by a horrifying xenomorph and stabbed through the face by it. We are tortured in oh so many ways in Call of Duty, as Jacob Geller shows us in his recent YouTube essay on the topic.
All the worst things we could see and imagine happening to ourselves video games will gladly show you. And if you are unconvinced that such images can genuinely affect how you feel then just type something like “Resident Evil 2 remake all death scenes” and watch any of the top videos that come up. In writing this I watched one for five minutes and could feel my heart racing, my muscles becoming tense and my stomach turning. Your body and brain responds to this stuff.
So, if our brain can fail to distinguish what is real from what is not and what is just a game, and seeing horrors of torture, abuse death and dying are some of the primary triggers for PTSD then why do we not develop the disorder from these?*
I find this a fascinating question and one I believe that does have an answer; an answer that helps us to understand why PTSD develops and gain insight into how it can be treated. This is not an illness we need to be afflicted by for the rest of our life following trauma but one that has research-backed treatments, such as Cognitive Behaviour Therapy and Eye movement desensitization and reprocessing (EMDR). I see people in my treatment sessions go from inconsolable sobbing; hating the shell of their former selves that they have become to sobbing with relief that they can re-find themselves and move on with their life realising that they can find peace and re-claim their life after trauma. It is a wonderful experience and I feel honoured to be able to help people in this way.
In understanding why videogames do not trigger PTSD we first need to explore why PTSD can develop. This is another important factor. We have explored the type of events that can trigger PTSD for people, but it is important to note that only about 1 in 3 of people experiencing such horrors will go on to develop PTSD; it is not a blanket, sure-fire thing that severe trauma can lead to the disorder developing. You might argue, therefore, that it is something about the person; there is something about them- their psychology or genetic make-up- that pre-disposes them to it. Though that might not be entirely inaccurate there is something more important here. When we talk to soldiers returning from war who have seen all the worst parts of a Call of Duty playthrough in their real world lives it is not generally their whole tour of duty that they talk about in relation to their PTSD but a few inciting events amidst the many horrors. It seems that certain situations stand out among the many traumatic incidents for them that trigger PTSD.
When we explore why this is it becomes quite clear. Memories have emotions attached to them. Again, as I explored in my ‘Fear and DOOM’ article, we see emotions like fear are mediated quite unconsciously in the brain; a scary thing happens, and the brain makes you feel scared as part of the involuntary fight or flight response. This helps you to run or fight but either way hopefully survive. The brain is quite good at responding to scary situations and processing these big, powerful emotions. But there is another major factor that relates to our emotional response in the moment and after the fact as we reflect on our memory and that is our thoughts. Our thoughts imbue the incident and memory with meaning and meaning is very powerful. It can take a big, powerful emotion and make it awful and unbearable. And, when the emotion becomes this big then it ceases to be able to be processed.
Cognitively speaking, the main differentiating point of why PTSD would develop compared to why it would not is what the traumatic event means to us. Which is to say, what were the main takeaway messages for the brain from the event. We need to get into the weeds a bit here to truly make sense of this in relation to the main question of why videogames do not cause PTSD.
The brain can derive meanings from the traumatic incident in a number of ways. Firstly, our "rational", thinking brain- the bit we all identify with in our head as being "us"- is nearly always reflecting on events in real time and deriving meaning.
"There's no escape"
"I'm going to die"
"My baby is going to die"
"This is unbearable"!
These are all the types of thoughts our rational head can present us in such situations.
Our unconscious, emotion-driven brain (what therapists may sometimes call our less-evolved "lizard brain") is also trying to derive meaning. This meaning may be somewhat wordless, perhaps just a felt sense, though we can put words to it and they are often the same as the conscious part of the brain.
Finally, there are our thoughts after the traumatic event, often directly in the aftermath though not always. Here, our conscious brain is trying to derive meaning of why what happened did happen or why events played out in the way that they did. We may have such thoughts as:
"it was all my fault"
"I wanted this"
“I should have done more/ acted differently”.
"they would still be alive if I had..."
"I'm an awful person".
These thoughts can cause powerful emotions like horror, guilt and shame.
Now, all the thoughts I've just mentioned might be caused by videogames. The first time I sacrificed and harvested a Little Sister in Bioshock I did have an in-the-moment sense that they were going to die (spoilers; they did). I also did feel guilt and believe that they would still be alive if it were not for me. And, I did feel like a pretty bad person. The experience I summarised for PTSD then is pretty similar to what can occur in videogames.
Harvesting a Little Sister in 'Bioshock' does not look particularly pleasant. The game does not want this to feel good.
Once again, in my article on 'Fear and DOOM' (maybe you should read it…) I discussed how the conscious brain can talk to the unconscious brain. When the unconscious brain is mistaking the events in the game as real things to be really scared of the conscious brain can tell it that it's not real. This can happen for all events in games. So, I harvest the Little Sister in Bioshock and feel bad, but then my conscious brain kicks in and reminds my emotional brain “it’s okay, it’s just a video game”.
At this point then it probably seems pretty obvious that the conscious brain is not able to chime in and say “it’s okay, it’s just a video game” for real world events and you would be right. The horrifying events leading to PTSD for an individual are all too real and sufferers of the disorder cannot fail to be aware of that as the events continue to play through their head in glorious, visceral, sensory-encompassing 4K.
But…
But, where we often die in the game we do not die in real life. We worry at the time of a traumatic incident- like a near-fatal car crash- that we were going to, but we don’t. We are instead alive to tell the tale and develop PTSD because of it and what is happening in PTSD is that the brain is re-living the memory and responding again like we really are moments from death, but we are not; this is not an accurate response to the world anymore.
Or where perhaps the worst thing did happen for someone like torture, or a loved one dying the meaning that their head is giving them in reality is not all that accurate.
“I could have done more…”
“I should have acted differently…”
But, in the moment, with the information you had available to you at the time, before you have had months or years to think about it and play it out in hundreds of different ways could you really have done more or acted differently. Almost certainly not.
In a slightly different way to what happens with video games, your head is mistaking what is real with what is not real. It may not be a video game but you did not actually die, or you could not have actually done more. So, why do we develop such a response to these moments like we see in PTSD?
The answer to this comes from the notion I have mentioned already when I said that those meanings the brain derives can take a big emotion and make it unbearable and unable to be processed. A video game can cause the same thoughts, feelings and physical sensations but just not on the same scale. When you would hope the conscious brain would kick in to say “it’s okay you didn’t die; it was terrible what happened, but you couldn’t have done more, it’s not your fault” it just can’t. The awfulness of the emotion stops us from being able to talk ourselves down and see the truth of the matter. Instead, every time the memory comes into our head we recoil in horror and push it away. And because the brain isn’t properly reviewing the memory and the meanings it has been given then those meanings just persist as truths; truths about the situation, truths about us.
This leads to the strangely paradoxical situation of a bad situation not killing us but each time the event comes back into our heads our brain responds like we are really back there, and we really could be moments from death. We did no die but continue to constantly be feeling like we are going to. The brain still thinks it’s moments away from death now; we still live with the shame of knowing we should have done more or acted differently.
So, video games don’t cause PTSD because even though awful things happen the emotional response to them just isn’t on the same scale and the brain is able to review the memory of it, see the truth about it (i.e. it’s not real) and process the memory.
In real-life traumatic events when a certain situation is given a particular meaning in the moment or later it causes emotions so unpleasant that we can no longer contemplate the memory but instead hide away from it. This leads to the meanings remaining true even though they often are not. The memory does not get processed but instead lives in a state of purgatory in our brains getting regularly replayed in various awful ways from then on.
Hopefully, this explains fully why video games do not cause PTSD for us. Hopefully now we can also see why something like Cognitive Behaviour Therapy can treat PTSD. The therapist helps the person be able to contemplate the memory, see it for what it truly is, identify the meanings and see how they are inaccurate (if they are, which is usually the case to varying extents). In doing this, the emotion attached to the memory is reduced and in achieving this it lets the brain finally be able to process the memory properly.
That is not to say that the memory stops being unpleasant; we are still talking about likely the worst moments of people’s lives so when they think about these things it is still not nice. But, it stops being PTSD; it stops replaying in such an awful visceral way. If you think about any event good or bad memory and hold it in your head you likely have a sense of events, you may get a pretty good picture of it and remember what was said, what you ate etc., but you don’t recall every feeling, smell, sound and other sensation of it; it’s just a hazy picture in your mind of something that once happened. And that’s what we see happening in PTSD; the traumatic event goes from being this visceral re-living when it comes to mind to just a very bad hazy picture of something awful that once happened. But the brain now knows that it is not happening now, and stops responding like it is. And when we achieve this, so many of the symptoms of PTSD can start to reduce. There is more to treatment than this, and Eye movement desensitization and reprocessing (EMDR) works a bit differently, but this is often such a big part of what we know works.
If you, or someone you know suffers from PTSD- or you suspect it might be the case- I would strongly encourage you to consider engaging with a therapist who is trained in an evidence-based psychological treatment for PTSD. In the UK, we would suggest that the therapy you seek is CBT or EMDR, but other countries may suggest differently.
That’s how I feel about this. You might feel different and that is OK.
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*There have been previous reports that developers of modern Mortal Kombat games have been diagnosed with PTSD from the work that they have done. This article does not particularly address that. I haven't intended to side step it but it is a complicated idea that couldn't be easily addressed here, and I may not have good answers to anyway. I might perhaps write about it in the future.
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