Aviv Weinstein, Ph.D. and Michel Lejoyeux, Ph.D.,
The American Journal of Drug and Alcohol Abuse, Early Online:1–7, 2010
Excerpts from full study
INTRODUCTION
Problem Definition
Problematic Internet use, or addiction, is characterized by excessive or poorly controlled preoccupations, urges or behaviors regarding Internet use that lead to impairment or distress. The condition has attracted increasing attention in the popular media and among researchers, and this attention has paralleled the growth in computer use and Internet access (1). Phenomenologically, there appear to be at least three subtypes: excessive gaming, sexual preoccupations (cybersex), and e-mail/text messaging.
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Addicts may use the Internet for extended periods, isolating themselves from other forms of social contact, and focus almost entirely on the Internet rather than broader life events.
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It is not clear whether Internet addiction usually represents a manifestation of an underlying disorder, or is truly a discrete disease entity. The frequent appearance of Internet addiction in the context of numerous comorbid conditions raises complex questions of causality. It has been argued (5) that, based on the limited available data regarding course, prognosis, temporal stability, and response to treatment, it appears premature to consider Internet addiction as a discrete disease entity. However, growing research suggests that some individuals with Internet addiction are at significant risk and merit professional care and treatment. Carefully controlled studies are required to settle these controversies. This review searched articles published between 2000 and 2009 in Medline and PubMed, using the key word “Internet addiction” over the topics of diagnosis, phenomenology, epidemiology, and treatment.
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DIAGNOSIS AND PREVALENCE
The diagnosis of Internet addiction (dependence) remains problematic. It does not appear in any official diagnostic system, including DSM-IV, and there are no widely accepted diagnostic criteria.Four components have been suggested as essential to the diagnosis (6): 1) excessive Internet use, often associated with a loss of sense of time or a neglect of basic drives, 2) withdrawal, including feelings of anger, tension, and/or depression when the computer is inaccessible, 3) tolerance, including the need for better computer equipment,more software, or more hours of use, and 4) adverse consequences, including arguments, lying, poor school or vocational achievement, social isolation, and fatigue.
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There are currently no diagnostic instruments for Internet addiction that show adequate reliability and validity across countries. A recent systematic analysis of the various diagnostic instruments found that previous studies utilized inconsistent criteria to define Internet addicts, applied recruiting methods that may cause serious sampling bias, and examined data using primarily exploratory rather than confirmatory data analysis techniques to investigate the degree of association rather than causal relationships among variables (7). Thus, prevalence data on pathological Internet use are limited by methodological difficulties concerning the diagnosis and the heterogeneity of diagnostic instruments. This makes it difficult to compare prevalence rates across countries.
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There are also general concerns related to using self-reports, having dishonest answers, participants may not understand various questions or misinterpret the various test items. Additionally, there is also a problem of selection bias with the participant pool obtained from Web sites or undergraduate courses and no adequate control group. The use of a Web page may influence how people responded as well as the number of valid responses obtained. Finally, a person may show addictive behaviors toward one application, but not others.
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The main difficulty with these studies is that they use vague terms to describe levels of Internet use, such as “ borderline,” “ excessive,” “ at risk,” and “ addictive,” which are not operationally defined or clinically validated. The prevalence rates of Internet addiction have been examined elsewhere (12, 36).
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COMORBIDITY
Cross-sectional studies on samples of patients report high comorbidity of Internet addiction with psychiatric disorders, such as affective disorders, anxiety disorders (including generalized anxiety disorder, social anxiety disorder), and attention deficit hyperactivity disorder (ADHD). It has been suggested (37) that the relationship between loneliness and preference for online social interaction is spurious and that social anxiety is the confounding variable.
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NEUROBIOLOGY AND BRAIN IMAGING
Currently, there have been very few studies on the neurobiology of Internet addiction. There were reported studies on computer and videogame addiction (see Weinstein, elsewhere in this issue). Among the first brain imaging studies (13) has reported 10 participants with online gaming addiction who were presented with gaming pictures and the paired mosaic pictures while undergoing functional magnetic resonance imaging (fMRI) scanning. In the addicted group, right orbito-frontal cortex, right nucleus accumbens, bilateral anterior cingulate and medial frontal cortex, right dorsolateral prefrontal cortex, and right caudate nucleus were activated in contrast to the control group. The activation of the regions-of-interest (ROI) was positively correlated with self-reported gaming urge and recalling of gaming experience provoked by the pictures. The results demonstrated that the neural substrates of cue-induced gaming urge/craving in online gaming addiction was similar to that of the cue-induced craving in substance dependence. Thus, the results suggested that the gaming urge/craving in online gaming addiction and craving in substance dependence might share the same neurobiological mechanism.
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WHY DO PEOPLE BECOME ADDICTED TO THE
INTERNET?
Internet-dependent scored significantly lower on most measures that reflected successful resolution of these crises, and scored higher on the measures that reflected unsuccessful resolution of these crises (48).
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Compulsive cybersex has become a significant component of Internet addiction for many men and women who have fallen prey to the accessibility, affordability, and anonymity of online sexual behaviors (49). Some patients develop problems with compulsive cybersex due to predisposition or accidental conditioning experiences, while other compulsive users have underlying trauma, depression, or addiction. Both men and women with cybersex problems exhibit maladaptive coping, conditioned behavior, dissociative reenactment of life trauma, courtship disorder, intimacy dysfunction, and addictive behavior (49). The problematic Internet use group showed higher scores in the Self- Directedness and Cooperativeness profiles and lower scores in the Novelty Seeking and Self-Transcendence profiles of the JTCI, compared with the nonproblematic Internet use group, after controlling for the ADHD symptoms.
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These maladaptive coping mechanisms seem overlap with sexual addiction (see Thibaut elsewhere in this issue), but they are using the specific media of the Internet. In the case of compulsive cybersex, the content of display, more specifically pornography, is a specific form of sexual computer-assisted behavioral addiction. Therapists report a growing number of patients addicted to this activity, a form of both Internet addiction and sexual addiction, with the standard problems associated with addictive behavior.
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DISCUSSION
Internet addiction, i.e., excessive use of the Internet with resulting adverse consequences, does not appear in any official diagnostic system, including DSM-IV. Block has argued that Internet addiction is a common disorder that merits inclusion in DSM-V (5). Conceptually, the diagnosis is a compulsive-impulsive spectrum disorder that involves online and/or offline computer usage. At least three subtypes have been identified: excessive gaming, sexual preoccupations, and e-mail/text messaging. All of the variants share the following four components: 1) excessive use, often associated with a loss of sense of time or a neglect of basic drives, 2) withdrawal, including feelings of anger, tension, and/or depression when the computer is inaccessible, 3) tolerance, including the need for better computer equipment, more software, or more hours of use, and 4) adverse consequences, including arguments, lying, poor achievement, social isolation, and fatigue. Others have argued that Internet addiction is not a true addiction and may be no more than a symptom of other, existing disorders such as anxiety, depression, ADHD or impulse control disorders (70). Little data are available to resolve this question, and the pathophysiological mechanisms underlying Internet addiction remain unknown. This relative ignorance also extends to treatment. The few published treatment studies for Internet addiction are based on interventions and strategies used in the treatment of substance use disorders. Thus, it is impossible to recommend any evidence-based treatment of Internet addiction.
Abstract
Background: Problematic Internet addiction or excessive Internet use is characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding computer use and Internet access that lead to impairment or distress. Currently, there is no recognition of internet addiction within the spectrum of addictive disorders and, therefore, no corresponding diagnosis. It has, however, been proposed for inclusion in the next version of the Diagnostic and Statistical Manual of Mental Disorder (DSM).
Objective: To review the literature on Internet addiction over the topics of diagnosis, phenomenology, epidemiology, and treatment.
Methods: Review of published literature between 2000–2009 in Medline and PubMed using the term “internet addiction.
Results: Surveys in the United States and Europe have indicated prevalence rate between 1.5% and 8.2%, although the diagnostic criteria and assessment questionnaires used for diagnosis vary between countries. Cross-sectional studies on samples of patients report high comorbidity of Internet addiction with psychiatric disorders, especially affective disorders (including depression), anxiety disorders (generalized anxiety disorder, social anxiety disorder), and attention deficit hyperactivity disorder (ADHD). Several factors are predictive of problematic Internet use, including personality traits, parenting and familial factors, alcohol use, and social anxiety.
Conclusions and Scientific Significance: Although Internet-addicted individuals have difficulty suppressing their excessive online behaviors in real life, little is known about the patho-physiological and cognitive mechanisms responsible for Internet addiction. Due to the lack of methodologically adequate research, it is currently impossible to recommend any evidence-based treatment of Internet addiction.
Internet Addiction or Excessive Internet Use – Abstract on line
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