More threads by David Baxter PhD

David Baxter PhD

Late Founder
Time to log off: New diagnostic criteria for problematic Internet use
Dawn Heron, MD, & Nathan A. Shapira, MD, PhD
Current Psychiatry Online
Vol. 2, No. 4 / April 2003

Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses... This article discusses the new criteria and answers three questions:
o How does problematic Internet use present?
o Is it an addiction or an impulse control disorder?
o How can we help those afflicted with this problem?

When Internet use goes over the line
Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:
o an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function
o and employment and relationships are jeopardized by the hours spent online

Internet overuse: An 'addiction'?
Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke. He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.

Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder. Shapira et al. studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.

As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.

Diagnostic criteria. [The] proposed criteria for Problematic Internet Use is behavior which shows the following characteristics:
o uncontrollable
o markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
o not solely present during mania or hypomania

Teasing out comorbid disorders
Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.

Although some researchers feel that the many comorbid and complicating factors cannot be teased out, most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.

A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.

Shapira et al. found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black found:
o 33% had a mood disorder
o 38% had a substance use disorder
o 19% had an anxiety disorder
o 52% met criteria for at least one personality disorder

On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.

Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al. hypothesized that the Internet use caused the depression. Pratarelli et al. noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.

In a survey of college students, individuals with "Internet addiction" were found to:
o have obsessive characteristics
o prefer online interactions to real-life interactions
o use the Internet "to feel better", alleviate depression, and become sexually aroused

Personality traits. In another study, Orzack found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of "Internet addiction disorder":
o boredom
o private self-consciousness
o loneliness
o social anxiety
o shyness
o low self-esteem

History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.

How does the Internet alter the individual’s moods? How does he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the person sort through emotions which are related to internet use.

Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy. They tend to take pride in their computer skills and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use ("I’m using it for work, academics, travel, research, etc.").

Changing problematic behaviors
Psychotherapy. Once you find the motives and possible causes of Internet overuse, what is the best form of treatment? This question warrants further study, but cognitive-behavioral therapy (CBT) seems to be the primary treatment at this time.

The goal of CBT is for patients to disrupt their problematic computer use and reconstruct their routines with other activities. They can:
o use external timers to keep track of time online
o set goals of brief, frequent sessions online
o carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected

Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use. Support groups and family therapy can help repair damaged relationships and engage friends and family in the treatment plan.

Drug therapy. No studies have looked at drug therapy for problematic Internet use, beyond treating comorbid psychiatric illnesses.

(Note: This is not quite true - there is at least one report of the use of SSRI's to treat compulsive internet pornography use, although it is not clear whether the effectiveness was due to the reduction in libido which sometimes occurs as a side-effect of these medications, or whether it was due to reduction in symptoms of anxiety/stress or depression which may have been present as "comorbid disorders" - David Baxter.)
I've had a variable sleep cycle of 48-72 hr wake cycles with 14 to 26 hr sleep cycles as an ongoing problem for around 10 years.

It began when I left school under duress and started correspondance education. Coming off the back of social destruction, betrayal, relationship breakdown and mild substance abuse I sought a sanctuary from the daily violence of my educational and social environments.

My insomnia progressed with other pyschological disorders as I grew more insular and isolated. It effected my relationships negatively to the point of total destruction and progressed into obsessive behaviour that I became dependant on as a justification for a reason to live.

I missed birthdays, christmas, anniversaries and other events. In fact the longer it went on the more problems occured and the more dependant I became on my obsession to justify my existance and I became more depressed and sleepless as a result of pursuing that self gratification for survival.

I suffer from depression, anxiety, insomnia, stress, paranoia and I may be mildly pyschotic. I can't afford to buy x product or seek specialist counselling anymore (I've tried some alteranative therapies such as hypnosis). I would like to try anything or cheaper variants of recommended approaches.
I've just completed 2 years of free full time counselling and the effect has been fairly negligible. After the counselling was finished I tried to branch out from my isolation.

I had an intense but failed short term relationship. It seemed to help more than 2 years of therapy but due to my problems and the fact that the only people I can relate to have pyschological problems of their own it was impossible to maintain. I just don't know what I can do to help myself get back into a normal stream of life.

I will attempt next to apply a visionary capability of positive or active thought as was recommended to me. I will see if I can effect change through altering my subconcious thought process to actions that I will try to rationally and logically comprehend as the right ones.
I'm not a big fan of drugs for treating pyschological illness and I have always refused anti-depressants when I've been prescribed them.

Any ideas on the social aspects of treatment?
Because I feel like that's a real obstacle to change. A catch 22 of social isolation and that making me more depressed so I isolated myself again.

How does one get back into normal association with people and make friends when one is wierd and out of every social loop?
I've joined a gym, I go out, I try. I just have no idea how to relate.

David Baxter PhD

Late Founder
My first question is why have you "refused anti-depressants when I've been prescribed them"? Don't you think there might have been a valid reason for prescribing them? Especially when right after that you say, "that's a real obstacle to change. A catch 22 of social isolation and that making me more depressed so I isolated myself again."?

If you really want your life to change, perhaps the first step is listening to the advice of people who are trying to help you. It seems you have at least come to the point where you are wondering if there is any real likelihood of doing it all on your own and that's a step forward, but the next step is to stop rejecting options that can help you make those changes.
I wanted to retain myself and not put on a mask for others.
I'd feel like I was being dishonest about who I was if I was heavily dependant on medication to enable myself to be sociable. I realise how frustrating that would be to someone who is trying to help me.
It's a personal fault and part of my psyche that I want to overcome challenges on my own.
Still I am seeking help for change, it's an internal confliction.

David Baxter PhD

Late Founder
Anti-depressants don't mask anything, don't change your pesonality, don't stop you feeling anything. What they do is boost your resources for coping with stressors in your life and help to prevent your brain (neurochemistry) from overreacting to things -- basically, it helps you to modulate or moderate your emotional reactions.

It's not a medication like a tranquilizer or a narcotic or sedative. It's restoring your neurochemistry to a more normal balance so that cognitively and affectively you are better able to cope with and react to and manage stressors and other events in your life.

I understand that some people don't like taking medications, not even aspirin. On the other hand, trying to do it alone makes your task significantly more difficult; if you're already depressed, this can make the difference between success and failure.

I'm open to trying them now. I conquered my idealism.

Mostly I'm an emotional extremist, so I am blank emotionally 95% of the time and the other 5% I have to vent in a creative way or I become destructive.
I've learned thorough control, I would be slightly worried about the change, I'm willing to try however.

David Baxter PhD

Late Founder
I wonder if that "blank e,otionally 95% of the time" isn't really dysthymia or depression...

Also see the information on omega-3 essential fatty acids in the "alternative therapies" section.
I probably spend too much time on the internet. Before that I watched too much tv. I just do not want to be alone with myself at all ever. Never.

But I can also go on vacation for days and leave it alone and it doesn't bother me at all.

Interesting article.


Too much time on the internet? I don't know if I spend TOO much time (a few hours a day), but for years I have had FOUR neopets which I have fed and cared for and played AT A MINIMUM the same spelling type game every day for years. I looked after them, shopped for them, attended auctions for them, bought them medicine....basically a virtual family! Today I put my first neopet up for adoption. I can only get rid of them at the rate of one pet per day. I intend to stop my reliance on this site for my daily fix of entertainment because it has become quite a chore!
Replying is not possible. This forum is only available as an archive.