PUBG-related suicides during the COVID-19 pandemic: Three cases from Pakistan.

INTRODUCTION: The present case report presents the most extreme negative aspects of gaming, namely PUBG-related suicide during the coronavirus disease-2019 pandemic in Pakistan. CASE
PRESENTATION: Three suicide cases of extreme gamers occurred within a few days of each other in Lahore, Pakistan. All three were young males aged 16-20 years and their suicides appear to be related to PUBG addiction. It is likely that all three individuals experienced other predisposing factors relating to psychological instability. PRACTICAL IMPLICATIONS: For vulnerable groups such as adolescents and emerging adults who have psychological predispositions and/or other comorbidities, engrossing videogames which take up many hours a day such as PUBG may pose a risk which in the most extreme cases may be fatal.

INTRODUCTION

Most research demonstrates that videogame playing has positive influences on players' psychological health, and can have beneficial social, educational, therapeutic, and cognitive benefits. , The coronavirus disease‐2019 (COVID‐19) pandemic has significantly disrupted normal daily activities worldwide. Stay‐at‐home orders and quarantines have led to increased utilization of digital entertainment, including online gaming and associated online activities (e.g., videogame streaming). While most of this technology utilization is positive, it should be noted that significant increases in gaming may not always be advantageous and that a small minority of individuals, including teenagers, may be at risk of gaming disorder. Among those affected, problematic gaming is associated with disturbance in sleep patterns, physical health problems, and harms to mental health. , For an even smaller minority, gaming disorder may lead to a gaming addiction where gaming becomes the only activity in a person's life and is done to the neglect of everything else. In May 2019, the World Health Organization officially recognized gaming disorder as a mental health disorder.

One game that has been associated with gaming disorder and gaming addiction is PlayerUnknown's Battlegrounds (PUBG). PUBG is a multiplayer online “battle royale” endurance game where players are parachuted onto an island and must find weapons and then kill everybody else on the island to win. Some of the well‐known consequences of playing PUBG to the neglect of everything else include exhaustion, eye strain, headaches, obesity, insomnia, poor quality of sleep, withdrawal symptoms (irritability and rage), drug abuse, and suicide. Some scholars claim the game has a negative influence on children and youth and that it promotes cruelty, violence, and aggression. , In extreme cases, there have been case reports of self‐harm and suicide, among PUBG players who have been asked by their parents to stop playing the game. Here, we briefly present three further PUBG‐related suicides that occurred during the COVID‐19 pandemic. These three suicide cases all occurred within a few days of each other and all in Lahore (Pakistan). All three were young males aged 16–20 years and their suicides appear to be related to PUBG addiction.

CASE 1: (SOURCE BAAGHI TV AND PARHLO; JUNE 22, 2020)

A 20‐year‐old male from Saddar Bazaar (Lahore) committed suicide. He was a 2nd‐year student at Forman Christian College. The report claimed he was addicted to PUBG, playing the videogame almost all of the time. A day before committing suicide, he argued with his father about the amount of gaming he was engaged in. His father reprimanded him and prohibited him from playing the game. He got angry with his father because of his actions and committed suicide by hanging from a fan in his bedroom.

CASE 2: (SOURCE DAWN NEWS; 24 JUNE, 2020)

A 16‐year‐old teenager from Hingerwal (Lahore) committed suicide by hanging himself from a ceiling fan after he missed a PUBG mission in the game that had been assigned to him. The teenager used to play game for many hours on daily basis, and was said by those who knew him to be addicted to the game. He committed suicide after not being able to complete the task while playing the game. Police found his mobile phone near him in his room with the PUBG application still running. His parents had told him many times to stop playing the game. On the day of the suicide, the teenager was alone and he had locked the door of his room while playing game and then killed himself.

CASE 3: (SOURCE: DAWN NEWS; JULY 1, 2020)

An 18‐year‐old male residing at the Punjab Housing Society (Lahore) committed suicide by hanging himself from a fan in a room of his rented house. The victim's brother who he lived with confirmed to police that his brother was addicted to playing the PUBG videogame. It was reported that the victim had made a video call to an unidentified girl before taking life. The victim also left a suicide note in which he described PUBG as a “killer online game.” According to one news report:

“The letter read that excessive violence could trigger aggressive thoughts, causing violent behavior; addiction to complete the mission caused pain, agony and anxiety, resulting in depression and stress; the players spent more time in playing the PUBG, which meant they ended up becoming less socially active and sitting in front of the screen for too long caused disruption in sleep pattern, resulting in deterioration of physical and mental health”

DISCUSSION

Being in lockdown and other preventive measures have been implemented throughout the world in an attempt to minimize the spread of COVID‐19. , Millions of individuals have been restricted to their homes with lots of spare time to fill. Engaging in activities like gaming via smartphones has become more frequent. Gaming can be unhealthy for a minority of individuals who use it as coping mechanism and escapism from reality. Consequently, online gamers in the lockdown period may be impacting psychologically because of the persistence of excessive gaming. The present‐report highlights what appears to be the first online gaming suicides during the COVID‐19 pandemic globally and the first gaming‐related suicide cases in Pakistan.

The three cases highlighted here appeared to be addicted to the PUBG game (based on corroborative reports), and their failure to stop playing the game and/or failures within the game appears to have been the precipitating factor that led them to suicide. Previous cases of negative consequences, self‐harm, and suicide among Indian youths addicted to PUBG cases have previously been reported. Various consequences of problematic PUBG gaming led to (i) exam failure by a formerly studious teenager who had a distinction in his Secondary School Certificate but ended up writing how to download and play PUBG in his exam questions; (ii) running away from home because of being brainwashed by online PUBG team‐mates; (iii) hospitalization of a fitness trainer who lost his mental balance and started hitting himself and got being injured after completing one of the PUBG game rounds; (iv) drinking acid instead of water by mistake while being engrossed playing PUBG; (v) dying of neck pain nerve damage after playing PUBG for 45 continuous days', and (vi) being hit and killed by a train because of being so engrossed in playing the PUBG game at a railway station.

The same study also provided evidence of a suicide attempt and suicide completion because of PUBG. More specifically, a 14‐year‐old boy allegedly attempted suicide by consuming poison in a fit of anger after his mother took away his mobile phone in an attempt to stop him playing PUBG. Another boy hung himself because his parents refused to buy a new smartphone for playing the PUBG after an argument with his family members. In another case from Bangladesh, Mamun and Griffiths reported that an 18‐year‐old student committed suicide with issues related to gaming although there were other multiple suicide factors including (i) not getting the highest marks in an exam (which may have been because of excessive gaming); (ii) being very stressed about an upcoming exam; (iii) not being happy with his physical appearance (i.e., weight and skin color); (iv) suffering from some mental health problems including depression (probably because of his poor exam performance and dislike of his physical appearances); and (v) being addicted to playing videogames. His suicide note read “even in death, I will be hero” which was a reference to one of his videogame avatars ( ; p. e101951).

During lockdown, there appears to have been an increase in use of digital entertainment consumption including viewing online video content, videogame streaming, e‐sport viewing, and playing online games. The Telecommunication Company reported a 75% increase in online gaming activities in the US and a 70% increase in Fortnite‐gaming‐related internet traffic in Italy. Large gaming increases during the pandemic have also been reported by various Indian gaming companies. Additionally, psychoactive substances and other escape‐based activities (e.g., gambling, gaming, pornography consumption) can be used to relieve tension, anxiety, and depressive moods. , However, for a small minority with addictive behaviors, negative consequences may occur if they are unable to ingest psychoactive substances or engage in escape‐based activities. For some, such negative consequences may start with pain and hopelessness, and then physiological, and/or psychological states which have the capacity to facilitate suicidal ideation if such disruptions persist continuously. , There may also be impulsive suicide occurrences (where people commit suicide without prior suicide planning) due to not succeeding and/or failing in their gaming, a situation which appears to have occurred in at least one of the previous cases.

IMPLICATIONS FOR PSYCHIATRIC NURSING PRACTICE

In the modern era, Internet use has become an important and essential part of daily life. Some online activities can lead to potentially addictive and harmful behaviors. Online gaming can be addictive, although there are debates as to whether gaming addiction can be as harmful as substance addictions. For some, excessive use of online activities is used as a way of coping with negative psychological states such as anxiety, depression, and stress, , psychological states that are also predisposing risk factors for suicide, particularly depression. , Despite the many positive benefits of online gaming, it may pose a risk for vulnerable groups such as adolescents and emerging adults who have other predispositions and/or comorbidities, and in very extreme cases may also be a factor in suicidal ideation.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.