Summary by Richard N. Rosenthal, MD
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Based on “Principles of Addiction Medicine” Chapter by Richard N. Rosenthal, MD, and Zebulon Taintor, MD
Microprocessors are ubiquitous, serving as prosthetic brains, guides, knowledge sources, and calculators; while they help us manage many aspects of our lives, and provide much stimulation, they don’t manage our time, our motivations, and our involvements. Some of us become dependent on the stimulation they provide, with significant negative life consequences, not that different from addiction to substances.
The Internet has five major uses that affect clinicians and their patients: (1) source of information on disease, diagnosis, treatments, and therapists; (2) source of support and self-help groups; (3) provision of advice, diagnosis, and counseling whereby the person being helped has not met the helper except over the Internet; (4) helps obtain addictive substances, both prescription and nonprescription; and (5) enhances opportunities for people to do things (sex, gambling, etc.) with intrinsic addiction vulnerability. “Internet addiction,” however, covers only part of patients’ problems using devices built around microprocessors. These problems are due to the interaction of the novel technology and the people using it, compared to intrinsic mental disorders such as depression and schizophrenia.
HISTORICAL PERSPECTIVE
The Internet was established in 1969 at the University of Southern California as a way of linking computers for national defense uses. Computers have always offered opportunities to impair functioning, even pre-Internet. Problematic, if not necessarily pathologic, non–work-related Internet use in the workplace arose quickly after the Internet became functional in the business community. The first articles about Internet addiction appeared in the mid-1990s.
Some portion of problematic microprocessor use may be more due to social adaptation to new technology than due to psychopathology. Internet social utilities such as social networks, commercial dating sites, special interest blogs, chats, and others have made forming new relationships with fellow online users a mainstream activity, when once it represented eccentric or problem behavior. Identity and the Internet is emerging as a separate field of study. One creates an identity often quite opposite from one’s regular self in virtual world applications.
DIAGNOSTIC DILEMMAS
Addiction as used in popular media describes a much less serious phenomenon than what clinicians mean by “addiction.” In considering whether the microprocessors are a bona fide substrate for addictive processes, it is important to present some caveats:
- Using the computer, cell phone, or videogame is not intrinsically illegal and is generally normal, prosocial, encouraged behavior.
- When people experience new and powerful tools, there is a learning curve to information acquisition, time management, and social behavior.
- High engagement in microprocessor use is not necessarily pathologic.
- Calling maladaptive microprocessor-related behavior pathology rather than bad habit may medicalize a social problem.
Important questions arise in the context of considering whether Internet addiction is a discrete disorder and whether it is an addiction or some other type of disorder:
- Are most surveys that present high rates of pathologic Internet use suffering from selection bias?
- Is the term Internet addiction overstated and overgeneralized?
- Is it the technology or that which it enables that people may become addicted to?
- Does the Internet, as a conduit for other disorders such as pathologic gambling or compulsive sexual behavior, become a substrate for addictive process?
- Is Internet addiction a component of another disorder, or if a discrete disorder, does it frequently co-occur with other mental disorders?
Internet addiction disorder (IAD) was codified by Young in 1998 as an eight-item polythetic diagnostic set modeled on pathologic gambling, and neuroimaging studies show altered regional cerebral activity and structural changes generally consistent with studies of drug and other behavioral addiction. Individuals with IAD have increased glucose metabolism in the right orbitofrontal cortex, left caudate, and right insula and decreased metabolism in the bilateral postcentral gyrus, left precentral gyrus, and bilateral occipital regions and decreased dorsal striatal D2 receptor availability in men, which is inversely correlated with IAD severity, consistent with a reward deficiency model for SUD. Men with high severity IAD have greater activity in the anterior and posterior cingulate cortices, consistent with impaired inhibitory control and response inhibition. Long-term IAD may lead to structural brain changes and altered function, although a causal relationship has not yet been established. Decreased gray matter volumes in the bilateral dorsolateral prefrontal cortex have been demonstrated in adolescents with IAD that were significantly correlated with Internet addiction duration.
A monothetic approach may create a narrow construct in which to categorize and evaluate if Internet addiction is a real disorder. All criteria must be endorsed in a monothetic approach (compared to the DSM approach) in order to make a diagnosis. It should have high sensitivity for diagnosing true positives. A monothetic approach with good construct and predictive validity should allow a clinically useful criterion set that reduces false negatives. Clinicians who treat patients with chemical addictions will recognize the symptom set in their patients, and thus the economy in the approach:
- Salience: The drug or behavior has gained primacy in a person’s life, as a cognitive change, dominating the person’s mental life, or behaviorally, dominating a person’s activity compulsively.
- Mood modification: The substance or behavior gives one a rewarding high or alleviates a negative mood state.
- Tolerance: One must increase the amount or intensity of the substance or behavior in order to achieve the desired effect.
- Withdrawal symptoms: After stopping or reducing the substance or behavior, the person demonstrates either physical symptoms or dysphoria characterized by irritability, mood lability, depressive symptoms, etc.
- Conflict: One has conflicts regarding the use of the substance or behavior that manifests as interpersonal (e.g., marital strife) or intrapsychic (e.g., guilt).
- Relapse: After some abstinence, the use or behavior is reinstated at the same intensity.
The DSM-V workgroup had contemplated problematic Internet use as a compulsive–impulsive disorder in the group of impulse control disorders, and Pathologic Internet Use could be conceived as an ICD. Pathologic Internet Use is modeled after pathologic gambling, a DSM-IV ICD, but Gambling Disorder has been moved to the DSM-5 substance related and addiction disorders section. ICD hallmarks are repeated failure to resist impulses that are harmful to self or others and tension or arousal before and pleasure or relief during the act, followed by guilt or self-reproach. However, Internet addiction has addiction-specific symptoms, such as development of euphoria, craving, and tolerance in addition to some ICD symptoms (Internet preoccupation, compulsive use, loss of control) Pathologic Internet use has also been proposed as an OCD spectrum disorder, but the preoccupation is ego-syntonic and pleasurable, whereas intrusions and compulsions are ego-dystonic in OCD. Internet Addiction has been narrowed in DSM-5 to Internet Gaming Disorder and placed in the appendix, but the placement of Gambling Disorder in the substance-related disorders suggests other behavioral addictions may ultimately be validated for that group.
Building a bottom-up construct of most frequent symptoms from factor analysis of a group is another approach to developing stable and valid criteria for Internet addiction. Factor analysis of surveys of college students Addiction factor (salience items), loads upon all items of the monothetic model behavioral addiction criteria and is primary and causal to Sex (downloading graphic material), and excessive Internet Use factors. High computer engagement is also part of the structure of “computer addiction” but is not necessarily in and of itself pathologic, such as a mother’s relationship with her newborn. So, consistent with the DSM approach that symptoms are insufficient for diagnosis without impairment, impairment in a person’s daily functioning over and above symptoms of high engagement, should be necessary for a diagnosis of Internet Addiction.
Chemical addictions occur at high rates with other mental disorders in the population and there is a strong correlation of pathologic Internet use with ADHD and depression.
ASSESSMENT
Functional impairment is a good proxy for a clinically relevant misuse of microprocessors. One can discuss the intensity and impact of use of microprocessor-containing devices and assign general risk categories based upon the information provided. A simple screening cutoff can begin to establish whether use is “normal” or problematic:
- Use: A reasonable time spent accomplishing specific goals using microprocessors, such as getting back your dog that strayed because the staff at the pound found the chip under his skin. High engagement does not necessarily mean pathology.
- Problem use: The use is causing clinically significant impairment. The patient repeatedly takes on undue risk, gets into legal problems, continues the use in spite of recurring social or interpersonal problems related to use, or the use interferes with fulfilling major role obligations
- Dependence: The patient experiences inability to get along without it. Here the problem is the level of functioning. There may be a false sense of being in control and “able to stop any time” when one cannot.
Nervousness, aggression, agitation, insomnia, anorexia, tremulousness, and depression have been noted after microprocessor deprivation, but microprocessor activity withdrawal has not been well documented for inclusion into the DSM.
INTERNET CHARACTERISTICS
The Internet has advantages over other agents with high liability for abuse and dependence, including the following:
- Always available: 24/7, lending itself to impulsive access and marathon sessions
- Convenient: No need to leave home or work.
- Inexpensive: Now just the cost of the hookup and there are no dealers to pay.
- Rewarding: Content-rich Web sites calculated to please with interactivity, and novelty.
- Controllable: The user can go wherever desired and leave at will.
- Validating: One can find content according to one’s interests and tastes, and verify as legitimate since others feel similarly.
- Escapist: Sites of interest to the potentially addicted offer a welcoming reality where all sex partners are attractive and interested, bets are likely to be won, women can act like men, and introverts can act like extroverts
The Internet may differentially support addictive process, as Internet communication is anonymous, isolated from normative feedback, and provides easy access to reinforcing stimuli. Risks of Internet addiction might be ameliorated through education and training.
TREATMENT MODEL
Motivation is key. If rewards are the issue, others must be found. If obsessive–compulsive concerns are more important, efforts and medication are directed at developing different habits and thought patterns. Recovery is about learning to avoid triggers for impulsive Internet use, making use of social support for healthy reinforcers found in everyday life, and relearning how to use microprocessors in nonpathologic ways.
TREATMENT PLANNING
The addiction field is used to epidemics of powerfully rewarding substances that die down and become endemic. Incidence estimates for Internet addiction range from 1% to 3% of the American population.
Rating scales serve as diagnostic aids and can help patients to realize the extent of their problems by offering objective data for feedback in motivational approaches. The 20-question Internet Addiction Test (IAT) (http://netaddiction.com/resources/internet_addiction_test.htm) is best established and covers six factors: salience, excessive use, neglecting work, anticipation, lack of control, and neglecting social life on a 100-point scale with ranges of 20 to 49 indicating average online use, and 50 to 79 indicating occasional or frequent problems. Many of the items correspond to similar items in the DSM-IV diagnostic categories of substance abuse and substance dependence.
INDICATIONS FOR TREATMENT
Patients and families understand and feel impairment, so responses to the scale above and issues of morbidity and mortality can help all concerned understand indications for treatment.
Mortality
Murder and suicide have been reported (mostly in South Korea) after microprocessor deprivation, usually an adolescent killing the depriving parent or demonstrating through suicide that life without the microprocessor is not possible. IAT-identified Internet addiction has been significantly associated with depressive symptoms.
Morbidity
Real-life social relationships get less time, as more satisfying relationships are developed on the Internet. Clinicians may rate these relationships less favorably, like an alcoholic’s drinking buddies, so clinicians must assess cyber relationships in detail and without bias. Identity fragmentation may occur if one’s Internet persona is markedly different from one’s real-life persona. Impairment can result from prolonged sitting in front of screens, with increased obesity and less exercise, but inactivity is preferable to accidents that occur while multitasking. The American College of Emergency Physicians issued an alert against “text walking” as the number of vehicle hits, falls, and running into trees, lamp posts, and other people has become noticeable in emergency rooms.
PRETREATMENT ISSUES
Motivation—Rationale for Choice of Treatment
Motivation prior to engagement in treatment may be scant or absent. Patients minimalize, rationalize, or deny problems. A nonconfrontational discussion of impairment using the principles of motivational interviewing (MI), helps the patient to gain perspective. The facts of impact of the patient’s microprocessor overuse are elicited and then fed back to assist the patient to use his or her native analytic capacity and values in determining that the overuse is actually problematic or impairing and to help tip the decisional balance toward seeking help.
A departure from the abstinence-oriented approach of classic addiction treatment is therapeutic use of the Internet and microprocessors, aligned with moderation management concepts. Online support groups are thought to help, but there is no robust evidence of effects.
Selection and Preparation of Patients/Suitability
Microprocessor abusers are technically competent, often innovative, and well educated, which makes them typically suitable for treatment. There are high rates of current and lifetime co-occurring mental disorders that tend to have a negative impact upon recovery, and there is frequently secondary gain in abuse. Retreat into cyberspace may mask co-occurring social phobia and/or other anxiety disorders, much as alcohol abuse can mask social phobia.
TREATMENT AND TECHNIQUE
Similar to disorders of compulsive food intake, complete abstinence is not a feasible long-term treatment goal, as use of microprocessors is unavoidable in today’s world, and non-use is associated with significant vocational and social disadvantage. Restricting microprocessor access by significant others in control may increase motivation or result in destructive anger, so clinicians must expect to hear about and perhaps participate in decisions.
Since cognitive process maintains IAD, appropriate psychotherapeutic strategies would include cognitive restructuring focused on the Internet applications of choice, behavioral exercises, and graded exposure therapy with increasing duration of offline activity. Reintroduction into the real world must be done in stages to ease transitions, replacing the rewards of the microprocessor abuse with more natural and socially appropriate reinforcers. A desensitization process with iterative steps will support a sense of success and increased self-esteem. Consistent with community reinforcement principles, therapy is a rewarding process that helps the patient get in real life what was available only on the Internet. Treating co-occurring mood, anxiety, psychotic, and substance use disorders is helpful in supporting recovery and reintegration into the real world. Social skills training may also be helpful.
RELEVANT TREATMENT RESEARCH
Much of the available epidemiologic and treatment outcome research on Internet addiction has been based upon case studies and survey data, which is subject to selection bias.
Efficacy
Meta-analysis of the extant treatment research for IAD, suggests from pre-post analyses that there are effective treatments for IAD, time spent online, depression and anxiety. Pilots studies of pharmacotherapy for IAD have found success with escitalopram, and with sustained release bupropion. Treating comorbid psychiatric disorders may have utility as well. Methylphenidate treatment for ADHD (mean dose 30.5 mg/d) also reduced scores on hours of Internet use and the Internet Addiction Scale. However, if IAD follows suit with chemical addictions, then effective treatment of co-occurring other mental disorders will generally have effect sizes insufficient to treat the IAD.
Effectiveness-External Validity
There are no controlled studies of psychosocial treatments for IAD other than cognitive behavioral therapy (CBT), although there are case reports of the efficacy of typical addiction clinical interventions and self-help interventions. Probable validity for these approaches is derived from the applicability of the impulse-control/obsessive-compulsive model of addictions to microprocessor abuse, but will require controlled trials of standardized interventions in target populations using established and validated diagnostic criteria and outcomes measures.
KEY POINTS
1. Some portion of problematic microprocessor use may be more due to social adaptation to new technology than with psychopathology
2. As with other “behavioral addictions,” it remains to be demonstrated that Internet Addiction is itself a discrete disorder, is inclusive of other microprocessor-related disorders, or is a substrate for other behavioral disorders.
3. Although there is high comorbidity with mood and anxiety disorders and ADHD, Internet Addiction symptoms overlap but appear to be a separate from those disorders
4. Internet Gaming Disorder is included in the DSM-5 section 3 (appendix)
5. Treatment should entail MI engagement strategies and CBT, with graded reintegration into the outside world and its healthier pleasures.
6. Co-occurring other mental disorders should be identified and treated as they typically help reduce symptoms and lower the risk for relapse.
REVIEW QUESTIONS
1. Which of the following is true?
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