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.)
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.)
