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David Baxter

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Time to log off: New diagnostic criteria for problematic Internet use
Current Psychiatry Online
Vol. 2, No. 4 / April 2003
Dawn Heron, MD
Nathan A. Shapira, MD, PhD
Department of Psychiatry, University of Florida, Gainesville

The MOUSE screening tool helps identify five behaviors that spell too many hours online.

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.

We propose a screening tool called ?MOUSE? and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:
  • How does problematic Internet use present?
  • Is it an addiction or an impulse control disorder?
  • 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:
  • an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function1
  • and employment and relationships are jeopardized by the hours spent online2.
Case: Computer gamer out of control
Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.

He is taking no medications. The only clinically significant family history is his father?s apparent OCD, undiagnosed and untreated.

Mr. A?s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.

Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week?nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:
  • 35% in chat forums, communicating with gaming partners he has never met
  • 25% in multi-player, video/strategy games
  • 15% using e-mail
  • and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).
He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.

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.3 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.4,5

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.5-8 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.1

As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.8

Diagnostic criteria. Although Mr. A?s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),9 which we define as:
  • uncontrollable
  • markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
  • and not solely present during mania or hypomania.
Teasing out comorbid disorders
As in Mr. A?s case, 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.10-12

Although some researchers feel that the many comorbid and complicating factors cannot be teased out,13 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 al1,14 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, Black11 found:
  • 33% had a mood disorder
  • 38% had a substance use disorder
  • 19% had an anxiety disorder
  • 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.1,11

Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al15 hypothesized that the Internet use caused the depression. Pratarelli et al16 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:
  • have obsessive characteristics
  • prefer online interactions to real-life interactions
  • use the Internet ?to feel better,? alleviate depression, and become sexually aroused.16
Personality traits. In another study, Orzack12 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:?
  1. boredom
  2. private self-consciousness
  3. loneliness
  4. social anxiety
  5. shyness
  6. low self-esteem
Diagnosing Internet overuse
Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions?easily recalled by the mnemonic MOUSE?can help you screen for problematic Internet use (Table 2).

History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.17 Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.

To determine how the Internet may alter the patient?s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a ?feelings diary? may help the patient sort through his or her emotions.17

Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.17 They tend to take pride in their computer skills2 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.?).

Comorbidities. Given the high incidence of psychiatric comorbidity,1 it is important to complete a thorough psychiatric evaluation and treat any underlying illness. Whether the illness is primary or comorbid, it is likely exacerbating the symptoms of problematic Internet use.

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) is 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:
  • use external timers to keep track of time online
  • set goals of brief, frequent sessions online
  • carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected.17
Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use.12 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.

Treatment declined. Mr. A declined treatment for his problematic Internet use. As in many other psychiatric illnesses, insight into impulse control disorders tends to be limited. We can address the problem directly and offer to help patients change their online behaviors, but we cannot force them into treatment if they are not endangering themselves or others.

References
1Shapira NA, Goldsmith TG, Keck PE, Jr., Khosla UM, McElroy SL. Psychiatric features of individuals with problematic Internet use. J Affect Disord 2000;57:267-72.
2Beard KW, Wolf EM. Modification in the proposed diagnostic criteria for Internet addiction. Cyberpsychol Behav 2001;4:377-83.
3Goldberg I. Internet addiction. Available at http://www.cybernothing.org/jdfalk/media-coverage/archive/msg01305.html. Accessed Feb. 26, 2003.
4Griffiths MD. Internet addiction: an issue for clinical psychology? Clin Psychol Forum 1996;97:32-6.
5Young KS. Psychology of computer use: XL. Addictive use of the Internet: a case that breaks the stereotype. Psychol Rep 1996;79:899-902.
6Treuer T, F?bi?n Z, F?redi J. Internet addiction associated with features of impulse control disorder: is it a real psychiatric disorder? J Affect Disord 2001;66:283.
7Young KS. Caught in the net: how to recognize the signs of Internet addiction-and a winning strategy for recovery. New York: John Wiley & Sons, Inc. 1998:8.
8Young KS, Rogers RC. The relationship between depression and Internet addiction. Cyberpsychol Behav 1998;1:25-8.
9Shapira NA, Lessig MC, Goldsmith TD, et al. Problematic Internet use: proposed classification and diagnostic criteria. Depress Anxiety (in press, 2003).
10Griffiths MD. Internet addiction: Fact or fiction? Psychologist 1999;12:246-50.
11Black DW, Belsare G, Schlosser S. Clinical features, psychiatric comorbidity, and health-related quality of life in persons reporting compulsive computer use behavior. J Clin Psychiatry 1999;60:839-44.
12Orzack MH. How to recognize and treat computer.com addictions. Directions in Mental Health Counseling 1999;9:13-20.
13Stein DJ. Internet addiction, Internet psychotherapy (letter; comment). Am J Psychiatry 1997;154(6):890.
14Shapira NA. Unpublished data, 2000.
15Kraut R, Lundmark V, Patterson M, Kiesler S, Mukopadhyay T, Scherlis W. Internet paradox: A social technology that reduces social involvement and psychological well-being? Am Psychol 1998;53:1017-31.
16Pratarelli ME, Browne BL. Confirmatory factor analysis of Internet use and addiction. Cyberpsychol Behav 2002;5:53-64.
17Young KS. Internet addiction: symptoms, evaluation and treatment. Innovations in Clin Pract 1999;17:19-31.

Related resources
Computer Addiction Services. Maressa Hecht Orzack, PhD.
www.computeraddiction.com; (617) 855-2908.
Center for Online Addiction. Kimberly S. Young, PhD.
www.netaddiction.com; (877) 292-3737.
 

Misha

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This site is giving me the equivelent of "med student syndrome"!!!
Which is even more reason for me to think my internet usage is problematic. I post an average of 10-20 messages each on 4 different forums daily. Which is at times self-defeating since the forums all serve VERY different purposes. This forum is probably the healthiest, and has helped me a lot.... or so it seems.
Irony: I am a member of an online forum to help me get over my addiction to another onlline forum (a post-proana forum to deal with involvement in the pro-ana movement).
Here is the thing: I am isolating myself anyways, and most of my computer use is at night when I can't sleep. If I am alone and feeling suicidal is it not better that I come to this site than do something stupid?
I do not know if my internet use is because I have a problem with internet use or if it is just an accessible source of information for me right now.
Slowly I am giving up my destructive (pro-ana) web use. Some days I only read the posts and do not post messages myself. But is replacing that with more "flat-screen" relationships equally destructive?
Let's face it.... I've been here a few days and I'm a "Senior Member...."
Any thoughts, ideas on how I can keep this a healthy experience?
 
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If I am alone and feeling suicidal is it not better that I come to this site than do something stupid?

I think it is much better to come here. I can so strongly relate to what you said. I have such a hard time at night and some nights I end up here just reading and being here. I think there's nothing wrong with that.

Some days I only read the posts and do not post messages myself. But is replacing that with more "flat-screen" relationships equally destructive?

I think you just have to take one step at a time and if this forum is helping at this time then that is fine, or if other forums (healthy ones) help, then I think it's fine. My personal opinion anyway.

I personally feel like I spend too much time online right now. I am hoping as I get well that I can develop offline friendships and interests. But for now this is very important to me. I'm isolated and alone and kind of lost and this is a good, safe place to be.

I do feel somewhat different when I spend more time offline. Better in some ways, worse in some ways. I DO NOT like being alone with my thoughts. I fall asleep with the tv on. Something always has to be on, music, tv, computer, internet.

I think this is an interesting topic and one I think about a lot and worry about.

I'm not sure I'm making sense. I wish I could give you some ideas about keeping this a healthy experience, but I'm not sure how to do it for myself either. :eek:
 

Misha

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Thanks Janet. I was thinking a bit after I posted (think before you post.... there's a novel idea for me....)
Anyways, I think a key to keeping it healthy is not making the relationships something they are not.
When I was in hospital last month I was banned from using the computer because of my pro-anorexic habits. I was devastated, thinking I had lost every friend I had. My dietician kept telling me, "no, they are not real friends." I didn't believe her. I had received so much "support" from them in my weight loss. Yet I felt this guilt for helping spur a disease that could kill them and orphan their children. And I began to wonder if they felt that guilt about me. When I came back to the site the population had almost completely turned over. And I was devastated. I realize this site is different, that my relationships here are based on health and not illness. Yet if I place value on these relationships that is not warrented by a two-dimensional relationship, I will fail to create real relationships in the real world.
The internet is just such a good tool. I think we're ok... maybe we both are worrying too much??
 

Misha

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Did that make any sense????

That said I am going to log off and write a letter to my 3D doctor for me to read to her on Tuesday.... I need to be as honest with her as I am here.
 
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I think what you said makes pefect sense.

I think it is interesting about the population of the pro-ana site you were on. How it was completely different.

I realize this site is different, that my relationships here are based on health and not illness. Yet if I place value on these relationships that is not warrented by a two-dimensional relationship, I will fail to create real relationships in the real world.

This part especially stood out to me. I agree. This forum is wonderful and right now I don't have much face to face interaction with people and I want that so much. So I'm hoping this is kind of a stepping stone.


The internet is just such a good tool. I think we're ok... maybe we both are worrying too much??

I think it is a good tool. I think we are ok. And probably worrying too much.

Good luck with your letter and I hope you can have a decent night's rest.
 

David Baxter

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I think coming here as an alternative to engaging in self-destructive behaviors is excellent, at least in the short-term. It's a transition from unhealthy to more healthy ways of coping. In due course, I would hope that you no longer need to isolate yourself and that you'll find a balance between online and offline ("3D" as you called it) life, but I can understand that in the interim this may be the safest place for you to be.
 

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