Tokai University School of Medicine, Isehara City, Japan
We define Chronic Alternate-World Disorder ( CAWD ) as “ A state in which a person is no longer able to distinguish the real world from virtual space, due to his or her isolation in virtual space for an extended period of time with no contact with the actual world. ” The case report is about a patient who hijacked a jumbo jetliner in order to fly the airplane on his own, after developing CAWD from the use of flight-simulator virtual reality system. We believe symptomatic cases of CAWD will increase as virtual-reality (VR) spread throughout our society. In view of this, our objective is to propose precautionary and preventive measures for providers of VR system for patients with schizophrenia or personality disorders, from psychiatric and sociological perspectives
Key words: Chronic Alternate-World Disorder (CAWD), flight simulator, Virtual space, Virtual-reality (VR) system.
Our purpose in making this report is to define, for the first time, Chronic Alternate-World Disorder (CAWD ) as a symptomatic behavior in which a person becomes fanatically engrossed in a virtual-reality ( VR ) world to the extent that he or she can no longer distinguish between the actual world and virtual reality. It is also our purpose to report on our investigation and provide an analysis and discussion of what we believe to be a case of CAWD.
2. Definitions and word meaning
2.1 Chronic Alternate-World Disorder (CAWD)
Alternate-World Disorder is an abnormal reaction to the living body’s inability to deal with VR devices and/or VR space. For example, in a case of Acute Alternate-World Disorder, a person using a flight simulator world also experience temporary nausea due to loss of balance between the sense of sight and the sense of equilibrium .
On this basis, we offer the following definition of CAWD: “A state in which a person is no longer able to distinguish the real world from virtual space, due to his or her isolation in virtual space for an extended period of time with no contact with the actual world” (definition by Ichimura & Nakajima).
Symptoms of this condition include the inability to distinguish VR space from the real world, which becomes a chronic state even when the person is out of VR space. When this chronic state continues, it is commonly referred to as a “cognitive disorder” and it stems from a mental predisposition other than that caused by organic psychosis (psychic trauma / injuries, inflammation, tumor, degeneration, vascular disorder, and drug use).
2.2 Schizophrenia 
The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted affect. Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits may evolve in course of time. The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-direction. The most intimate thoughts, feelings, and acts are often felt to be known to or shared by others, and explanatory delusions may develop, to the effect that natural or supernatural forces are at work to influence the afflicted individual’s thoughts and actions in ways that are often bizarre. The individual may see himself or herself as the pivot of all that happens. Hallucinations, especially auditory, are common and may comment on the individual’s behaviour or thoughts. Perception is frequently disturbed in other ways: colours or sounds may seem unduly vivid or altered in quality, and irrelevant features of ordinary things may appear more important than the whole object or situation. Perplexity is also common early on and frequently leads to a belief that everyday situations possess a special, usually sinister, meaning intended uniquely for the individual. In the characteristic schizophrenic disturbance of thinking, peripheral and irrelevant features of a total concept, which are inhibited in normal directed mental activity, are brought to the fore and utilized in place of those that are relevant and appropriate to the situation. Thus thinking becomes vague, elliptical, and obscure, and its expression in speech sometimes incomprehensible. Breaks and interpolations in the train of thought are frequent, and thoughts may seem to be withdrawn by some outside agency. Mood is characteristically shallow, capricious, or incongruous. Ambivalence and disturbance of volition may appear as inertia, negativism, or stupor. Catatonia may be present. The onset may be acute, with seriously disturbed behaviour, or insidious, with a gradual development of odd ideas and conduct. The course of the disorder shows equally great variation and is by no means inevitably chronic or deteriorating. In a proportion of cases, which may vary in different cultures and populations, the outcome is complete, or nearly complete, recovery. The sexes are approximately equally affected by the onset tends to be later in women.
Although no strictly pathognomonic symptoms can be identified, for practical purposes it is useful to divide the above symptoms into groups that have special importance for the diagnosis and often occur together, such as:
(a) thought echo, thought insertion or withdrawal, and thought broadcasting;
(b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;
(c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;
(d) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world);
(e) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;
(f) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;
(g) catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;
(h) “negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;
(i) a significant and consistent change in overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.
2.2.2 Diagnostic Guidelines
The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed as (a) to (d) above, or symptoms from at least two of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more. Conditions meeting such symptomatic requirements but of duration less than 1 month (whether treated or not) should be diagnosed in the first instance as acute schizophrenia-like psychotic disorder and are classified as schizophrenia if the symptoms persist for longer periods.
2.3 Personality Disorder 
A personality disorder is a severe disturbance in the characterological constitution and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption. Personality disorder tends to appear in late childhood or adolescence and continues to be manifest into adulthood. It is therefore unlikely that the diagnosis of personality disorder will be appropriate before the age of 16 or 17 years. General diagnostic guidelines applying to all personality disorders are presented below.
2.3.2 Diagnostic Guidelines
Conditions not directly attributable to gross brain damage or disease, or to another psychiatric disorder, meeting the following criteria:
(a) markedly disharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
(b) the abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
(c) the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
(d) the above manifestations always appear during childhood or adolescence and continue into adulthood;
(e) the disorder leads to considerable personal distress but this may only become apparent late in its course;
(f) the disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.
2.4 Virtual Reality
Virtual reality (VR) is a technology which allows a user to interact with a computer-simulated environment, be it real or imaged one. Most current virtual reality environments are primary visual experiences, displayed either on a computer screen or through special stereoscopic displays, but some simulations include additional sensory information, such as sound through speakers or headphones. Some advanced, haptic systems now include tactile information, generally known as force feedback, in medical and gaming applications. Users can interact with a virtual environment or a virtual artifact either through the use of standard input devices such as a keyboard and mouse, or through multimodal devices such as a wired glove, the Polhemus boom arm, and omnidirectional treadmill. The simulated environment can be similar to the real world, for example, simulations for pilot or combat training, or it can differ significantly from reality, as in VR games. In practice, it is currently very difficult to create a high-fidelity VR experience, due largely to technical limitations on processing power, image resolution and communication bandwidth. However, those limitations are expected to eventually be overcome as processor, imaging and data communication technologies become more powerful and cost-effective over time.
Generally speaking, the following definitions are applied to the narrow usage of the term VR [3, 4].
(1) Handles 3D
(2) Recreates time
(3) Enable one to protect oneself into VR or to become narcissistic
3. Case Report (Japan Times, 1999)1 & (Mainichi Shinbun, 1999)2
3.1 Patient’s history
Patient was born in Tokyo. He graduated from prestigious private junior and senior high school and national university. In his student years, he held a part-time job as a porter at Haneda Airport. He wrote his graduation thesis on “Transportation Economics” and it was his dream to become a pilot. Failing to pass the hiring exams of three major Japanese airlines and airfreight companies, including Japan Airlines and All Nippon Airways made him disappointed and frustrated. He later took a job at JR (Japan Railways) Cargo where he decorated his company-supplied dormitory room with model airplanes, aviation posters and stickers. Such behavior only served to increase his desire to fly and be around airplanes. He quit his job with JR Cargo after working for them for approximately two years, saying, “The job I have right now isn’t what I really want to do.” At around that time, he first became obsessed with a flight-simulation game on his personal computer. His flight simulator was set up in his room on the second floor of his house. He frequented a nearby video-game arcade to play flight-simulation games, in an effort to improve his ability to use the control stick (joystick).
His record showed that he received psychiatric outpatient therapy in the past, but his ailment was not specified. According to statements given by his neighbors, high-pitched laughter could be heard coming from his house at night.
Four days prior to his commission of the hijacking, he purchased a kitchen knife, which was taken away by his father. At last, on July 23rd, 1999, he had also flown on actual aircraft over 70 times.
He intruded into the cockpit and commanded the Copilot “Get out! You’re in my way.” He himself seated on the Copilot’s seat, took hold of the control stick, and commanded the Captain to head for Yokota airbase from the plane’s present location above Ohshima. At 11:53 AM above Sagami Bay, he demanded to sit on the Captain’s seat, saying, “It’s harder to fly a real plane than in those games.” The Captain unwilling to comply, said, “Do you want to sit in my seat? I don’t think I can let you do that…… There are many other planes up here, so it could be dangerous. ” He acknowledged the Captain’s advice and obediently replied, “Yes, I understand.” At 11:54 AM, Captain told him, “I would like to increase our altitude so that we don’t crash into anything.” He obediently acknowledged the Captain’s words and said, “Yes, I understand.” But 22 seconds after this conversation, he fatally stabbed the Captain in the neck.
3.3 Patient’s comments after incident
After the incident, the patient commented as follows. “I could not be satisfied with games any longer.” He calmly stated, “I had done it so well on games, I thought that if anybody could land the aircraft, I could.” He also said in his deposition, “I’m sorry about the Captain. If we had crashed, I would have done a terrible thing to the passengers and residents of the area. ” “ I wanted to do a VFR ( Visual Flight Rule ) flight at low altitude, but the Captain didn’t want to tell me how to disengage the autopilot and I couldn’t fly the plane the way I wanted to…… So I stabbed the Captain. ” “I chose to land at Yokota instead of Haneda because the landing strip is longer.” “I wanted to fly underneath the Rainbow Bridge.”
4. Analysis and discussion
4.1 Our impression of this case
Our impression of this case is as follows. Symptoms of psychosis in a family member may appear in an other family member who haven’t been afflicted with psychosis. This type of psychiatric disorder is known as “induced psychosis.” Due to widespread application of VR technology in our society, we believe that CAWD will spread among patients with schizophrenia or personality disorders, and it is plausible that CAWD will show different symptoms than those seen with conventional cases of induced psychosis.
4.2 Psychiatric analysis of the case report
While it appears that he went to great lengths to develop a detailed plan, its execution was haphazard and game-like. As a result of his obsession with his flight simulator and his resultant difficulty distinguishing between virtual reality and the real world, the life of the Captain was lost and the lives of 503 passengers were put in jeopardy. As the writers of this paper did not directly examine the patient who is the subject of the case report, it is difficult to make statements with any amount of certainty. However, the following can be said:
(1) There is reason to believe that he was receiving outpatient therapy for some form of psychosis.
(2) He was without a steady job, which might be due to abulia.
(3) There is a reason to doubt that he had auditory hallucinations, judging from his high-pitched laughter at night.
(4) His only interest was his flight simulator, which might manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.
(5) The patient developed the symptoms before the age of 30.
Judging from those symptoms, we can surmise that schizophrenia was the most probable disorder. It can also be said that the incident occurred at a time when the patient’s psychosis was progressing.
The significance of the described case report lies in the fact that electronic instruments such as VR devices, which are proliferating in our society, influenced the nature of the incident. It is our observation that, in this case, these devices had a significant influence on the events leading to the development of psychosis.
4.3 Diagnostic criteria for CAWD
It is necessary to establish basic criteria for separating schizophrenia and personality disorders, among patients who have been diagnosed with CAWD.
(1) Inability to distinguish virtual reality from the real world.
(2) Inability to distinguish oneself from others.
(3) Lack of awareness of one’s own abnormality.
(4) CAWD symptoms developed prior to the age of 30.
If even one of items (1)-(3) above applies to a schizophrenia patient, there is a significant possibility that CAWD has developed. For schizophrenia, it is important to consider the age factor described in item (4), as that disease also tends to develop prior to the age of 30. On the other hand, if the patient shows no symptoms corresponding to items (1)-(3) above prior to the development of CAWD, he or she may either be in the early stages of schizophrenia or suffering from a personality disorder. Regarding the patient who is the subject of the case report, we are only able to make conjectures, but we believe he showed at least one of symptoms (1)-(3) above prior to developing CAWD. Therefore, we strongly suspect schizophrenia in this case.
4.4 Roots of the social environment
In this paper, we have defined the state of “communicating” with electronic devices such as VR devices, games, and personal computers (including for Internet use), without coming into direct contact with people, as being part of the “non-contact society.”
Video games are extremely popular among Japanese children today. This doesn’t simply imply that they like to play video games, but that they would become social outcasts if they could not discuss video games among their peers and friends. The fear of being left out is what compels them to play video games so as to be able to discuss them. However, when they play in groups, and they are less likely to become adept at outdoor team sports (such as baseball and soccer), even among friends who discuss video games. The fear of being left out reflects the anxiety of today’s children regarding personal relationships, and the fact that they are not adept at striking up or maintaining personal relationships. Furthermore, at the root of this phenomenon lies the inability of parents to discipline their children, the disintegration of the family system, and inconsistencies in the Japanese educational system. As a result, children become engrossed in computers and video games to escape real society (the motivation for playing games) [2, 5]. This directly results in the development of a non-contact society among Japanese children today, and we believe that the makings of future CAWD patients are hidden within this society.
CAWD as a symptomatic behavior in which a person becomes fanatically engrossed in a VR world, to extent that he or she can no longer distinguish between the actual world and VR. With the widespread use of VR, we believe that the number of cases of CAWD will increase. VR suppliers, parents, and educators must examine way to prevent the use of VR among schizophrenia and personality disorder patients, devise measures for preventing the development of CAWD, and establish warning signs and systems for CAWD.
Flight Simulator 98 is a registered trademark of Microsoft Corporation. Densha de Go! (Let’s go ride on the Train!: An electric-train operator’s simulator ) is a registered trademark of Taito Corporation. This paper in no way specified or alluded to the perpetrator’s ailment or background. We have examined generally and personally based on published information (Mainichi Shinbun newspaper article). We would like to express our deep appreciation to Mainichi Shinbun for its accurate journalism.
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1) Japan Times (1999, August, 11) ANA hijacker deemed fir for trail
2) Mainichi Shinbun. (1999, July, 29).