Internet Addiction Guide
By John M. Grohol, Psy.D.
May 27, 1999, Last updated: Dec 28, 2017
A resource for objective, useful information
about Internet addiction, a theorized disorder.
Is the Internet Addiction Test valid?
What is Internet Addiction Disorder (IAD)?
Researchers still can't tell you exactly what Internet Addiction Disorder is, also know by the term "Pathological Internet Use" (PIU). Much of the original research was based upon the weakest type of research methodology, namely exploratory surveys with no clear hypothesis, agreed-upon definition of the term, or theoretical conceptualization. Coming from an atheoretical approach has some benefits, but also is not typically recognized as being a strong way to approach a new disorder. More recent research has expanded upon the original surveys and anecdotal case study reports. However, as I will illustrate below later, even these studies don't support the conclusions the authors claim.
The original research into this disorder began with exploratory surveys, which cannot establish causal relationships between specific behaviors and their cause. While surveys can help establish descriptions of how people feel about themselves and their behaviors, they cannot draw conclusions about whether a specific technology, such as the Internet, has actually caused those behaviors. Those conclusions that are drawn are purely speculative and subjective made by the researchers themselves. Researchers have a name for this logical fallacy, ignoring a common cause. It's one of the oldest fallacies in science, and one still regularly perpetrated in psychological research today.
Do some people have problems with spending too much time online? Sure they do. Some people also spend too much time reading, watching television, and working, and ignore family, friendships, and social activities. But do we have TV addiction disorder, book addiction, and work addiction being suggested as legitimate mental disorders in the same category as schizophrenia and depression? I think not. It's the tendency of some mental health professionals and researchers to want to label everything they see as potentially harmful with a new diagnostic category. Unfortunately, this causes more harm than it helps people. (The road to "discovering" IAD is filled with many logical fallacies, not the least of which is the confusion between cause and effect.)
What most people online who think they are addicted are probably suffering from is the desire to not want to deal with other problems in their lives. Those problems may be a mental disorder (depression, anxiety, etc.), a serious health problem or disability, or a relationship problem. It is no different than turning on the TV so you won't have to talk to your spouse, or going "out with the boys" for a few drinks so you don't have to spend time at home. Nothing is different except the modality.
What some very few people who spend time online without any other problems present may suffer from is compulsive over-use. Compulsive behaviors, however, are already covered by existing diagnostic categories and treatment would be similar. It's not the technology (whether it be the Internet, a book, the telephone, or the television) that is important or addicting -- it's the behavior. And behaviors are easily treatable by traditional cognitive-behavior techniques in psychotherapy.
Case studies, the alternative to surveys used for many conclusions drawn about online overuse, are just as problematic. How can we really draw any reasonable conclusions about millions of people online based upon one or two case studies? Yet media stories, and some researchers, covering this issue usually use a case study to help "illustrate" the problem. All a case study does is influence our emotional reactions to the issue; it does nothing to help us further understand the actual problem and the many potential explanations for it. Case studies on an issue like this are usually a red flag that help frame the issue in an emotional light, leaving hard, scientific data out of the picture. It is a common diversionary tactic.
Why Does the Research Leave Something to Be Desired?
Well, the obvious answer is that many of the original researchers into the phenomenon known as IAD were actually clinicians who decided to conduct a survey. Usually doctoral training is sufficient to create and test a survey, yet the psychometric properties of these surveys are never released. (Perhaps because they were never conducted in the first place? We simply do not know.)
The obvious confounds are never controlled for in most of these surveys. Questions about pre-existing or a history of mental disorders (e.g., depression, anxiety), health problems or disabilities, or relationship problems are absent from these surveys. Since this is one of the most obvious alternative explanations for some of the data being obtained (for example, see Storm King's article, Is the Internet Addictive, or Are Addicts Using the Internet? below), it is very surprising these questions are left off. It taints all the data and make the data virtually useless.
Other factors are simply not controlled for. The current Internet population is nearly 50/50 in terms of proportion of men to women. Yet people are still drawing conclusions about this same group of people based upon survey samples that have 70-80% men, comprised mostly of white Americans. Researchers barely mention these discrepancies, all of which will again skew the results.
Research done in a particular area should also agree about certain very basic things after a time. Years have gone by and there are more than a few studies out there looking at Internet addiction. Yet none of them agree on a single definition for this problem, and all of them vary widely in their reported results of how much time an "addict" spends online. If they can't even get these basics down, it is not surprising the research quality still suffers.
More research has been done since the original surveys were released in 1996. This newer research has been conducted by more independent researchers with clearer hypotheses and stronger, less biased population sets. More about these studies will be discussed in updates to this article.
Where Did Internet Addiction Come From?
Good question. It came from, believe it or not, the criteria for pathological gambling, a single, anti-social behavior that has very little social redeeming value. Researchers in this area believe they can simply copy this criteria and apply it to the hundreds of behaviors carried out everyday on the Internet, a largely pro-social, interactive, and information-driven medium. Do these two dissimilar areas have much in common beyond their face value? I don't see it.
I don't know of any other disorder currently being researched where the researchers, showing all the originality of a trash romance novel writer, simply "borrowed" the diagnostic symptom criteria for an unrelated disorder, made a few changes, and declared the existence of a new disorder. If this sounds absurd, it's because it is.
And this speaks to the larger problem these researchers grapple with... Most have no theory driving their assumptions (see Walther, 1999 for a further discussion of this issue). They see a client in pain (and in fact, I've sat in many presentations by these clinicians where they start it off with just such an example), and figure, "Hey, the Internet caused this pain. I'm going to go out and study what makes this possible on the Internet." There's no theory (well, sometimes there's theory after-the-fact), and while some quasi-theoretical explanations are slowly emerging, it is putting the chicken far before the egg.
Do You Spend Too Much Time Online?
In relation to what or whom?
Time alone cannot be an indicator of being addicted or engaging in compulsive behavior. Time must be taken in context with other factors, such as whether you're a college student (who, as a whole, proportionally spend a greater amount of time online), whether it's a part of your job, whether you have any pre-existing conditions (such as another mental disorder; a person with depression is more likely to spend more time online than someone who doesn't, for instance, often in a virtual support group environment), whether you have problems or issues in your life which may be causing you to spend more time online (e.g., using it to "get away" from life's problems, a bad marriage, difficult social relations), etc. So talking about whether you spend too much time online without this important context is useless.
What Makes the Internet So Addictive?
Well, as I have shown above, the research is exploratory at this time, so suppositions such as what makes the Internet so "addictive" are no better than guesses. Since other researchers online have made their guesses known, here are mine.
Since the aspects of the Internet where people are spending the greatest amount of time online have to do with social interactions, it would appear that socialization is what makes the Internet so "addicting." That's right -- plain old hanging out with other people and talking with them. Whether it's via e-mail, a discussion forum, chat, or a game online (such as a MUD), people are spending this time exchanging information, support, and chit-chat with other people like themselves.
Would we ever characterize any time spent in the real world with friends as "addicting?" Of course not. Teenagers talk on the phone for hours on end, with people they see everyday! Do we say they are addicted to the telephone? Of course not. People lose hours at a time, immersed in a book, ignoring friends and family, and often not even picking up the phone when it rings. Do we say they are addicted to the book? Of course not. If some clinicians and researchers are now going to start defining addiction as social interactions, then every real-world social relationship I have is an addictive one.
Socializing -- talking -- is a very "addictive" behavior, if one applies the same criteria to it as researchers looking at Internet addiction do. Does the fact that we're now socializing with the help of some technology (can you say, "telephone"?) change the basic process of socialization? Perhaps, a bit. But not so significantly as to warrant a disorder. Checking e-mail, as Greenfield claims, is not the same as pulling a slot-machine's handle. One is social seeking behavior, the other is reward seeking behavior. They are two very different things, as any behaviorist will tell you. It's too bad the researchers can't make this differentiation, because it shows a significant lack of understanding of basic behavioral theory.
In addition to those previously discussed, here is an alternative hypothesis that no research to date has seriously considered -- that the behaviors we are observing are phasic. That is, for most people with "Internet addiction," they are likely newcomers to the Internet. They are going through the first stage of acclimating themselves to a new environment -- by fully immersing themselves in it. Since this environment is so much larger than anything we've ever seen before, some people get "stuck" in the acclimation ( or enchantment) stage for a longer period of time than is typical for acclimating to new technologies, products, or services. Walther (1999) made a similar observation based upon the work of Roberts, Smith, and Pollack (1996). The Roberts et al. study found that online chat activity was phasic -- people first were enchanted by the activity (characterized by some as obsession), followed by disillusionment with chatting and a decline in usage, and then a balance was reached where the level of chat activity normalized.
I hypothesize that this type of model can be more globally applied to online usage in general:
Some people simply get caught in Stage I and never move beyond it. They may need some help to get to Stage III.
For existing online users, my model allows for overuse as well, since the overuse is defined by finding a new online activity. I would argue, though, that existing users have a much more easier time successfully navigating through these stages for new activities they find online than newcomers to the Internet. It is possible, however, for an existing user to find a new activity (such as an attractive chat room or newsgroup or Website) that could lead them back into this model.
Note one important distinction about my model... It makes the assumption that since all online activity is phasic to some degree, all people will eventually get to Stage III on their own. Just like a teenager learns to not spend hours on the telephone every night on their own (eventually!), most adults online will also learn how to responsibly integrate the Internet into their lives. For some, this integration simply takes longer than others.
What Do I Do If I Think I Have It?
First, don't panic. Second, just because there is a debate about the validity of this diagnostic category amongst professionals doesn't mean there isn't help for it. In fact, as I mentioned earlier, help is readily available for this problem without needing to create all this hoopla about a new diagnosis.
If you have a life problem, or are grappling with a disorder such as depression, seek professional treatment for it. Once you admit and address the problem, other pieces of your life will fall back into place.
Psychologists have studied compulsive behaviors and their treatments for years now, and nearly any well-trained mental health professional will be able to help you learn to slowly curve the time spent online, and address the problems or concerns in your life that may have contributed to your online overuse, or were caused by it. No need for a specialist or an online support group.
In the past couple of years, there have been a handful of additional studies which have looked at this issue. The results have been inconclusive and contradictory.
You can read my analysis of a study done a year ago about the psychometric validity (or lack thereof) of the Internet Addiction Test. Needless to say, the research which could validate this disorder remains to be published. All but one of the studies that I'm aware of haven't looked at the effects of time on the reported problems of subjects. Without a short longitudinal study (1 year), one cannot answer whether this problem is situational and phasic or something more serious.
Well, as the years pass and more and more research is published claiming to support this theorized disorder, I'm happy to revisit some of the outstanding issues and blatant logical fallacies that researchers into maladaptive Internet use continue to make. You'd think that after a decade of research on this issue, someone would learn.
Here are two more recent updates regarding Internet research, as we pass over two decades of research into this supposed disorder. Is Internet Addiction Really the 'New' Mental Disorder? (of course not) and a 2016 update: The Relentless Drum Beats on about Problematic Internet Use aka 'Internet Addiction'.
Czincz's 2009 critique of the problems with the research into this phenomenon remain true today:
The three main problems with the existing research on PIU are the challenges regarding the general conceptualization of PIU, the dearth of methodologically sound studies, and the lack of a widely accepted assessment measure with adequate psychometric properties. There continues to be a lack of consensus in the research regarding the definitional and diagnostic base for PIU, which has lead to inconsistencies across studies and posed challenges for the identification of optimal treatment options. [...]
Most research on PIU to date is not methodologically sound due to difficulties with sampling and research design. The majority of studies involve self-identified convenience samples of problematic users or student samples, which significantly biases the results (Byun et al., 2009; Warden et al, 2004). [...]
There is no assessment measure of PIU that is both psychometrically sound and widely accepted. Most of the existing measures have adapted diagnostic criteria from other psychological disorders to PIU and lack adequate psychometric properties. [...]
More Online Resources
I and other professionals have talked about the problems facing the concept of IAD before. We're not saying anything new here. Until there is stronger, more conclusive research in this area, though, you should shy away from anyone looking to treat this problem, since it is a problem that seems to exist more in some professionals' concept of dysfunction than in reality.Here are some further links you should check out on this issue:
- Take the Online Addiction Quiz
From the Center for Online Addiction
- Computer and Cyberspace Addiction
An interesting 2004 article on this phenomenon from pioneer cyberspace researcher John Suler, Ph.D.
- Psych Central Editorial
This editorial by Dr. Grohol, written in 1997, examined the usefulness and validity of Internet Addiction Disorder as a diagnosis and something to treat.
- Psych Central's Internet Addiction Resources
A listing of Internet resources related to this topic.
- Pathological Internet Use
An article by Leonard Holmes, Ph.D. about "Pathological Internet Use." See also What is Normal Internet Use? by the same author.
- Why is This Thing Eating My Life? Computer and Cyberspace Addiction
This article, and another one like it, were written by online researcher, John Suler, Ph.D. Another interesting perspective.
- Is the Internet Addictive, or Are Addicts Using the Internet?
One of many possible alternative explanations for this phenomenon.
- How Much is Too Much When Spending Time Online?
My own ramblings about the problems with this disorder in October, 1997.
- Communication Addiction Disorder: Concern over Media, Behavior and Effects (PDF)
Joseph B. Walther Rensselaer Polytechnic Institute, August, 1999
(BTW, if you don't get it, this paper is parodying Internet Addiction Disorder.)
- Center for On-Line Addiction
Dr. Kimberly Young's Center (one of the researchers behind the push for this diagnostic category), which, co-incidentally, offers books, workshops for professionals, and online (?!) counseling to treat this "disorder."
- The Cause of Internet Addiction?
Christopher McPeck, who holds a BS in Computer Science, has an interesting theory as to this phenomenon's potential cause.
- Roberts, L. D., Smith, L. M., & Pollack, C. (1996, September). A model of social interaction via computer-mediated communication in real-time text-based virtual environments. Paper presented at the annual meeting of the Australian Psychological Society, Sydney, Australia.
Last updated: 29 Dec 2017
Last reviewed: By John M. Grohol, Psy.D. on 29 Dec 2017
Published on PsychCentral.com. All rights reserved.
Internet addiction disorder, also known as problematic Internet use or pathological Internet use, refers to excessive Internet use that interferes with daily life. Addiction, defined by Webster Dictionary as a "compulsive need for and use of a habit-forming substance characterized by tolerance and by well-defined physiological symptoms upon withdrawal", was traditionally used to depict a person's dependence on the substance. More recently, the concept has been applied to behavioral dependence including internet use. The problem of Internet addiction evolves together with the development and spread of Internet. As adolescents (12–17 years) and emerging adults (18–29 years) access the Internet more than any other age groups and undertake a higher risk of overuse of the Internet, the problem of Internet addiction disorder is most relevant to young people.
Excessive use of Internet has been found by various studies to disrupt individuals' time use and have a series of health consequences. But the existence of Internet addiction as a mental disorder is not yet well recognized. The current version of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) noted that Internet gaming disorder is a condition that requires more research in order to be considered as a full disorder in 2013.
The notion of "Internet Addictive Disorder" was initially conjured up by Dr. Ivan K. Goldberg in 1995 as a joke to parody the complexity and rigidity of American Psychiatric Association's (APA) "Diagnostic and Statistical Manual of Mental Disorders (DSM)." In his first narration, Internet addictive disorder was described as having the symptoms of "important social or occupational activities that are given up or reduced because of Internet use," "fantasies or dreams about the Internet," and "voluntary or involuntary typing movements of the fingers."
The definition of Internet addiction disorder has troubled researcher ever since its inception. In general, no standardized definition has been provided despite that the phenomenon has received extensive public and scholar recognition. Below are some of the commonly used definitions.
In 1998, Dr. Jonathan J. Kandell defined Internet addiction as "a psychological dependence on the Internet, regardless of the type of activity once logged on."
English psychologist Mark D. Griffiths (1998) conceived Internet addiction as a subtype of broader technology addiction, and also a subtype of behavioral addictions.
Dr. Keith W. Beard (2005) articulates that "an individual is addicted when an individual’s psychological state, which includes both mental and emotional states, as well as their scholastic, occupational and social interactions, is impaired by the overuse of [Internet]".
As a result of its complex nature, some scholars do not provide a definition of Internet addiction disorder and throughout time, different terms are used to describe the same phenomenon of excessive Internet use. Internet addiction disorder is used interchangeably with problematic Internet use, pathological Internet use, and Internet addictive disorder. In some cases, this behavior is also referred to as Internet overuse, problematic computer use, compulsive Internet use, Internet abuse, harmful use of the Internet, and Internet dependency.
Diagnosis of Internet addiction disorder is empirically difficult. Various screening instruments have been employed to detect Internet addiction disorder. Current diagnoses are faced with multiple obstacles.
Given the newness of the Internet and the inconsistent definition of Internet addiction disorder, practical diagnosis is far from clearcut. With the first research initiated by Kimberly S. Young in 1996, the scientific study of Internet addiction has merely existed for 20 years. A few obstacles are present in creating an applicable diagnostic method for Internet addiction disorder.
- Wide and extensive use of the Internet: Diagnosing Internet addiction is often more complex than substance addiction as internet use has largely evolved into be an integral or necessary part of human lives. The addictive or problematic use of the internet is thus easily masked or justified. Also, the Internet is largely a pro-social, interactive, and information-driven medium, while other established addiction behaviors such as gambling are often seen as a single, anti-social behavior that has very little socially redeeming value. Many so-called Internet addicts do not suffer from the same damage to health and relationships that are common to established addictions.
- High comorbidity: Internet addiction is often accompanied by other psychiatric disorders such as personality disorder and mental retardation. It is found that Internet addiction is accompanied by other DSM-IV diagnosis 86% of the time. In one study conducted in South Korea, 30% of the identified Internet addicts have accompanying symptoms such as anxiety or depression and another 30% have a second disorder such as attention deficit hyperactivity disorder (ADHD). Another study in South Korea found an average of 1.5 other diagnoses among adolescent internet addicts. Further, it is noted in the United States that many patients only resort to medical help when he/she is in trouble with other disorders. For many individuals, overuse or inappropriate use of the Internet is a manifestation of their depression, social anxiety disorders, impulse control disorders, or pathological gambling. It generally remains unclear from existing literature whether other psychiatric disorders is the cause or manifest of Internet addiction.
Despite the advocacy of categorizing Internet addiction as an established illness, neither DSM-IV (1995) nor DSM-V (2013) considers Internet addiction as a mental disorder. It is worth noting, though, a subcategory of IAD, Internet gaming disorder is listed in DSM-V as a condition that requires more research in order to be considered as a full disorder in May 2013. The WHO's draft 11th Revision of the International Classification of Diseases (ICD-11) scheduled for publication in 2018 also include gaming disorder. There is still considerable controversy over whether IAD should be included in the DSM-V and recognized as a mental disease in general.
Most of the criteria utilized by research are adaptations of listed mental disorders (e.g., pathological gambling) in the Diagnostic and Statistical Manual of Mental Disorders(DSM) handbook.
Dr. Ivan K. Goldberg, who first broached the concept of Internet addiction, adopted a few criteria for IAD on the basis of DSM-IV, including “hoping to increase time on the network” and “dreaming about the network.” By adapting the DSM-IV criteria for pathological gambling, Dr. Kimberly S. Young (1998) proposed one of the first integrated sets of criteria, Diagnostic Questionnaire (YDQ), to detect Internet addiction. A person who fulfills any five of the eight adapted criteria would be regarded as Internet addicted:
- Preoccupation with the Internet;
- A need for increased time spent online to achieve the same amount of satisfaction;
- Repeated efforts to curtail Internet use;
- Irritability, depression, or mood lability when Internet use is limited;
- Staying online longer than anticipated;
- Putting a job or relationship in jeopardy to use the Internet;
- Lying to others about how much time is spent online; and
- Using the Internet as a means of regulating mood.
While Young's YDQ assessment for IA has the advantage of simplicity and ease of use, Keith W. Beard and Eve M. Wolf (2001) further asserted that all of the first five (in the order above) and at least one of the final three criteria (in the order above) be met to delineate Internet addiction in order for a more appropriate and objective assessment.
Young further extended her 8-question YDQ assessment to the now most widely used Internet Addiction Test (IAT), which consists of 20 items with each on a 5-point Likert scale. Questions included on the IAT expand upon Young's earlier 8-question assessment in greater detail and include questions such as "Do you become defensive or secretive when anyone asks you what you do online?" and "Do you find yourself anticipating when you go online again?". A complete list of questions can be found in Dr. Kimberly S. Young's 1998 book Caught in the Net: How to Recognize the Signs of Internet Addiction and A Winning Strategy for Recovery and Drs. Laura Widyanto and Mary McMurran's 2004 article titled The Psychometric Properties of the Internet Addiction Test. The Test score ranges from 20 to 100 and a higher value indicates a more problematic use of the Internet:
- 20–39 = average Internet users,
- 40–69 = potentially problematic Internet users, and
- 70–100 = problematic Internet users.
Over time, a considerable number of screening instruments have been developed to diagnose Internet addiction, including the Internet Addiction Test (IAT), the Internet-Related Addictive Behavior Inventory (IRABI), the Chinese Internet Addiction Inventory (CIAI), the Korean Internet Addiction Self-Assessment Scale (KS Scale), the Compulsive Internet Use Scale (CIUS), the Generalized Problematic Internet Use Scale (GPIUS), the Internet Consequences Scale (ICONS), and the Problematic Internet Use Scale (PIUS). Among others, the Internet Addiction Test (IAT) by Young (1998) exhibits good internal reliability and validity and has been used and validated worldwide as a screening instrument.
Although the various screening methods are developed from diverse contexts, four dimensions manifest themselves across all instruments:
- Excessive use: compulsive Internet use and excessive online time-use;
- Withdrawal symptoms: withdrawal symptoms including feelings such as depression and anger, given restricted Internet use;
- Tolerance: the need for better equipment, increased internet use, and more applications/software;
- Negative repercussions: Internet use caused negative consequences in various aspects, including problematic performance in social, academic, or work domains.
More recently, researchers Mark D. Griffiths (2000) and Dr. Jason C. Northrup and colleagues (2015) claim that Internet per se is simply the medium and that the people are in effect addicted to processes facilitated by the Internet. Based on Young's Internet Addiction Test (IAT), Northrup and associates further decompose the internet addiction measure into four addictive processes: Online video game playing, online social networking, online sexual activity, and web surfing. The Internet Process Addiction Test (IPAT) is created to measure the processes to which individuals are addicted.
Screening methods that heavily rely on DSM criteria have been accused of lacking consensus by some studies, finding that screening results generated from prior measures rooted in DSM criteria are inconsistent with each other. As a consequence of studies being conducted in divergent contexts, studies constantly modify scales for their own purposes, thereby imposing a further challenge to the standardization in assessing Internet addiction disorder.
Some scholars and practitioners also attempt to define Internet addiction by a single question, typically the time-use of the Internet. The extent to which Internet use can cause negative health consequences is, however, not clear from such a measure. The latter of which is critical to whether IAD should be defined as a mental disorder.
As many scholars have pointed out, the Internet serves merely as a medium through which tasks of divergent nature can be accomplished. Treating disparate addictive behaviors under the same umbrella term is highly problematic.
Dr. Kimberly S. Young (1999) asserts that Internet addiction is a broad term which can be decomposed into several subtypes of behavior and impulse control problems, namely,
- Cybersexual addiction: compulsive use of adult websites for cybersex and cyberporn;
- Cyber-relationship addiction: Over-involvement in online relationships;
- Net compulsions: Obsessive online gambling, shopping or day-trading;
- Information overload: Compulsive web surfing or database searches;
- Computer addiction: Obsessive computer game playing.
For a more detailed description of related disorders please refer to the RelatedDisorder section below.
|Research-based Prevalence Rate of Internet Addiction|
|Country or Region||Rate or Population||Sample||Year||Instrument|
|Global||6%||A meta-analysis-based estimate||1994 - 2012||YDQ & IAT|
|Hong Kong||17 - 26.7%||Over 3000 high school students||2009 - 2015||IAT|
|Taiwan||13.8%||1708 high school students||n.a.||YDQ|
|South Korea||2.1%||An estimate based on Korean population aged 6-19 years||2006|
|Japan||2.0%||853 adolescents aged 12-15 years||2014||IAT|
|Europe||4.4%||11956 adolescents in 11 European countries||2009 - 2010||YDQ|
|Germany||1.5 million||An estimate based on German population||n.a.|
|Spain||16.3%||40955 school adolescents aged 12-17 years||2016||PIUS-a|
|Norway||0.7%||3399 individuals aged 16-74 years||2007||YDQ|
|UK||18.3%||371 college students||n.a.||PIUS|
Different samples, methodologies, and screening instruments are employed across studies and therefore one should take caution interpreting and comparing the above-listed figures.
It is argued that interpersonal difficulties such as introversion, social problems, and poor face-to-face communication skills, often lead to internet addiction. Internet-based relationships offer a safe alternative for people with aforementioned difficulties to escape from the potential rejections and anxieties of interpersonal real-life contact.
A lack of social support
Individuals who lack sufficient social connection and social support are found to run a higher risk of Internet addiction. They resort to virtual relationships and support to alleviate their loneliness. As a matter of fact, the most prevalent applications among Internet addicts are chat rooms, interactive games, instant messaging, or social media. Some empirical studies reveal that conflict between parents and children and not living with mother significantly associated with IA after one year. Protective factors such as quality communication between parents and children and positive youth development are demonstrated, in turn, to reduce the risk of IA.
Prior addictive or psychiatric history are found to influence the likelihood of being addicted to the Internet. Some individuals with prior psychiatric problems such as depression and anxiety turn to compulsive behaviors to avoid the unpleasant emotions and situation of their psychiatric problems and regard being addicted to the Internet a safer alternative to substance addictive tendency. But it is generally unclear from existing research which is the cause and which is the effect partially due to the fact that comorbidity is common among Internet addicts.
Internet addicts with no previous significant addictive or psychiatric history are argued to develop an addiction to the some of the features of Internet use: anonymity, easy accessibility, and its interactive nature.
Most recent research has focused on the biological causes of Internet addiction. For a systematic review of the kind, please refer to the 2017 Springer book edited by Christian Montag and Martin Reuter: Internet Addiction: Neuroscientific Approaches and Therapeutical Implications Including Smartphone Addiction (2nd edition).
Parental educational level, age at first use of the Internet, and the frequency of using social networking sites and gaming sites are found to be positively associated with excessive Internet use among adolescents in some European countries.
Mental health consequences
A longitudinal study of Chinese high school students (2010) suggests that individuals with moderate to severe risk of Internet addiction are 2.5 times more likely to develop depressive symptoms than their IA-free counterparts.
Brain function consequences
Using an age- and gender-matched Chinese adolescent sample, Yan Zhou and associates (2009) demonstrate that IA adolescents have a lower brain gray matter density (GMD) in the "left anterior cingulate cortex, left posterior cingulate cortex, left insula, and left lingual gyrus" than adolescents in the control group, indicating the presence of brain structural changes in Internet addicts.
Similar results have been confirmed by CB Weng and colleagues (2011) with a group of 17-year-olds who were diagnosed online game addiction (OGA) and another group without addiction. In their study, adolescents who were addicted had "lower gray matter volume in left orbitofrontal cortex, left medial prefrontal cortex, bilateral insula, left posterior cingulate cortex, and left supplementary motor area.
The best-documented evidence of Internet addiction so far is time-disruption, which subsequently results in interference with regular social life, including academic, professional performance and daily routines. Some studies also reveal that IA can lead to disruption of social relationships in Europe and Taiwan. It is, however, also noted by others that IA is beneficial for peer relations in Taiwan.
Internet addiction has raised great public concern in Asia and some countries consider Internet addiction as one of the major issues that threats public health, in particular among adolescents.
Internet addiction is commonly referred to as "electronic opium" or "electronic heroin" in China. The government of the People's Republic of China is the first country to formally classify Internet addiction a clinical disorder by recognizing Clinical Diagnostic Criteria for Internet Addiction in 2008. The government has enacted several policies to regulate adolescents' Internet use, including limiting daily gaming time to 3 hours and requiring users' identification in online video games.
Being almost universally connected to the Internet and boasting online gaming as a professional sport, South Korea deems Internet addiction one of the most serious social issues and describes it as a "national crisis". Nearly 80% of the South Korean population have smartphones. According to government data, about 2 million of the country's population (less than 50 million) have Internet addiction problem, and approximately 68,000 10-19-year-old teenagers are addicted to the Internet, accounting for roughly 10 percent of the teenage population. Even the very young generation are faced with the same problem: Approximately 40 % of South Korean children between age 3 to 5 are using smartphones over three times per week. According to experts, if children are constantly stimulated by smartphones during infancy period, their brain will struggle to balance growth and the risk of Internet addiction.
And because of the Internet addiction, so many tragedies happened in South Korea: A mother, tired of playing online games, killed her 3-year-old son. A couple, obsessed with online child-raising games, left their young daughter die of malnutrition. A 15-year-old teenager killed his mother for not letting himself play online games and then committed suicide. One Internet gaming addict stabbed his sister after playing violent games. Another addict killed one and injured seven others.
In response, the South Korea government has launched the first Internet prevention center in the world, the Jump Up Internet Rescue School, where the most severely addicted teens are treated with full governmental financial aid. As of 2007, the government has built a network of 140 Internet-addiction counseling centers besides treatment programs at around 100 hospitals. Typically, counselor- and instructor-led music therapy and equine therapy and other real-life group activities including military-style obstacle courses and therapeutic workshops on pottery and drumming are used to divert IAs' attention and interest from screens.
In 2011, the Korean government introduced the "Shutdown Law", also known as the "Cinderella Act", to prevent children under 16 years old from playing online games from midnight (12:00) to 6 a.m.
Current interventions and strategies used as treatments for Internet addiction stem from those practiced in substance abuse disorder. In the absence of "methodologically adequate research", treatment programs are not well corroborated. Psychosocial treatment is the approach most often applied. In practice, rehab centers usually devise a combination of multiple therapies.
The cognitive-behavioral therapy with Internet addicts (CBT-IA) is developed in analogy to therapies for impulse control disorder.
Several key aspects are embedded in this therapy:
- Learning time management strategies;
- Recognizing the benefits and potential harms of the Internet;
- Increasing self-awareness and awareness of others and one’s surroundings;
- Identifying “triggers” of Internet “binge behavior,” such as particular Internet applications, emotional states, maladaptive cognitions, and life events;
- Learning to manage emotions and control impulses related to accessing the Internet, such as muscles or breathing relaxation training;
- Improving interpersonal communication and interaction skills;
- Improving coping styles; and
- Cultivating interests in alternative activities.
Three phases are implemented in the CBT-IA therapy:
- Behavior modification to control Internet use: Examine both computer behavior and non-computer behavior and manage Internet addicts' time online and offline;
- Cognitive restructuring to challenge and modify cognitive distortions: Identify, challenge, and modify the rationalizations that justify excessive Internet use;
- Harm reduction therapy to address co-morbid issues: Address any co-morbid factors associated with Internet addiction, sustain recovery, and prevent relapse.
Symptom management of CBT-IA treatment has been found to sustain 6 months post-treatment.
RESTORE RECOVERYTM is a training program that aims to standardize the CBT-IA application and assist practitioners' practice in assessing and treating Internet addiction disorder.
The motivational interviewing approach is developed based on therapies for alcohol abusers. This therapy is a directive, patient-centered counseling style for eliciting behavior change through helping patients explore and resolve ambivalence with a respectful therapeutic manner. It does not, however, provide patients with solutions or problem solving until patients' decision to change behaviors.
Several key elements are embedded in this therapy:
- Asking open-ended questions;
- Giving affirmations;
- Reflective listening.
Other psychosocial treatment therapies include reality therapy, Naikan cognitive psychotherapy, group therapy, family therapy, and multimodal psychotherapy.
Transcutaneous Electrical Nerve Stimulation
Scholars have also evaluated the effect of 2/100-Hz transcutaneous electrical nerve stimulation (TENS) on Internet addicts. Two Chinese studies found that 2/100- Hz TENS, which adjusts the release of central neurotransmitter, can effectively reduce the online time of adolescent Internet addicts and mitigate IA syndrome.
Given that multiple psychiatric disorders frequently coexist with Internet addiction disorder, pharmacological therapies are used to address the shared mechanism. Several studies have been carried out in this respect. One study also suggests that desires exhibited in online gaming addiction (IGD) might have the same neurobiological mechanism as that of substance dependence. Although some evidence has emerged, the general efficacy of pharmacologic therapy in treating IA is yet to be established.
Treatment: inpatient care and retreat centers
The South Korean government has opened more than 140 psychological counseling centers over the whole country to help teenagers get rid of their Internet addiction. Among them, the most notable is the "special training camp" which combines military training, physical training, and psychological rehabilitation training. "Networms" aged 16 to 18, spend 12 days in a special life. They rode horses, practiced fight, made pottery, and even played drums. No Internet access during the camp, only one hour of mobile phone every day and no game.
Equine therapy is a kind of behavior therapy in South Korea, which uses the relationship between horses and people to keep Internet addicts away from the computer and network, so as to help addicts quit Internet overuse. In addition to learning how to ride a horse, the Internet addiction teenagers also accept a variety of professional advisory services. But they think riding could give them the biggest help because these young people have set up a kind of emotional connection, they would pat their horses, and then run to the snow. Several successful cases have been noted by the news since the inception of equine therapy. It is also found that equine therapy is beneficial for quitting other mental health disorder including substance use disorder.
To provide therapeutic help to patients with emotional and behavioral disorders, the Korean equestrian association has offered two treatment centers, treating a total of 50 people daily as of 2013. The association plans to expand 30 more centers around the country by 2022 to meet growing demand for Internet addiction treatment.
The Chinese government established the first Internet Addiction Treatment Center (a semi-military camp operated by the military, IATC) in Beijing in 2004. A strict definition of Internet addiction is applied to screen Internet addicts: daily use of the Internet for 6 hours in 3 consecutive months. Patients in the treatment camp have to follow a strict, semi-military training. In their strictly designed training schedule time (6:30 AM - 9:30 PM), patients perform tasks such as military drills, therapy sessions, reading, and sports. Various other legal and illegal camps have emerged in the recent decades in reaction to the dramatically increased Internet-addicted adolescents. According to the Chinese Adolescents Internet Addiction Report, 13.2% of the adolescents in the country are addicted to the Internet in 2005, 9.72% in 2007, and 14.1% in 2009. Controversially, adolescents who are potentially Internet addicts are sent to such camps when and only when their parents feel their kids are addicted to the Internet. And when parents resort to camps, no further consent from their kids are needed.
As of March 2007, the Internet Addiction Treatment Center (IATC) in Beijing has treated over 1500 addicts, overwhelmingly teenagers aged between 14 and 19 years old. It claims that 70% of the Internet addicts were successfully cured. As of 2017, the center has admitted more than 6000 addicts.
It is estimated that there are 65 - 300 different internet-addiction rehab camps scattered around China. A 2009 survey conducted by the China Youth Internet Association indicates that 400 private rehabilitation centers are in China. In rehab camps, removal of Internet access, military training, corporal punishment, and electroshock therapy are typically utilized. While rigorous and controversial, no study so far has shown the efficacy of the camps.
The American-Israeli documentary Web Junkie directed by Hilla Medalia and Shosh Shlam specifically narrates the life in a legal Internet addiction treatment camp.
Fall City, Washington (near Seattle) is the location of the United States’ first rehabilitation clinic dedicated to Internet Addiction. The facility is called the Heavensfield Retreat Center, and it boasts a successful experimental program called ‘reSTART'. Founded in 2009, reSTART address this issue by first adopting the universal title of the disorder: Internet Addiction Disorder or the acronym IAD. The 45-day program takes a very direct approach to addressing IAD by creating opportunities to reestablish a balance within the patient’s lifestyle. Their main mission is to address reasons for the patient’s persistence in using the internet, despite its harmful effects. The downsides to this treatment include its exclusivity and price. The program takes up to 6 individuals per session and costs no less than $14500 USD.
Mistreatment in China
In the absence of guidance from China’s Health Ministry and a clear definition of Internet addiction, dubious treatment clinics have sprouted up in the country. As part of the treatment, some clinics and camps impose corporal punishment upon patients of Internet addiction and some conducted electroconvulsive therapy (ECT) against patients, the latter of which has caused wide public concern and controversy. A few salient mistreatment practices have been well-documented by news reports:
One of the most commonly resorted treatments for Internet-addicted adolescents in China is inpatient care, either in a legal or illegal camp. It is reported that many kids were sent to "correction" against their will. Some kids are seized and tied by staffs of the camp, some are drugged by their parents, and some are tricked into treatment.
In many camps and clinics, corporal punishment is frequently used to "correct" Internet addiction disorder. The types of corporal punishment practiced include, but not limited to, kilometers-long hikes, intense squats, standing, starving, and confinement. After a physical-abuse-caused death case of an adolescent Internet-addict was reported in 2009, the Chinese government has officially inhibited physical violence to "wean" teens from the Internet. But multiple abuse and death cases of Internet addicts have been reported after the ban.
Among Internet addiction rehab centers that use corporal punishment in treatment, Yuzhang Academy in Nanchang, Jiangxi Province, is the most heavily discussed. In 2017, the Academy was accused of using severe corporal punishment against students, the majority of which are Internet addicts. Former students claimed that the Academy hit problematic students with iron rulers, "whip them with finger-thick steel cables", and lock students in small cells week long. Several suicidal cases emerged under the great pressure.
In November 2017, the Academy stopped operating after extensive media exposure and police intervention.
In China, electroconvulsive therapy (ECT) is legally used for schizophrenia and mood disorders. Its off-label practices in treating adolescent Internet addicts has raised great public concern and stigmatized the legal use of ECT.
The most reported and controversial clinic treating Internet addiction disorder is perhaps the Linyi Psychiatric Hospital in Shandong Province. Its center for Internet addiction treatment was established in 2006 by Yongxin Yang. Various interviews of Yongxin Yang confirm that Yang has created a special therapy, xingnao ("brain-waking") therapy, to treat Internet addiction. As part of the therapy, electroconvulsive therapy is implemented with currents of 1-5 milliampere. As Yang put it, the electroconvulsive therapy only involves sending a small current through the brain and will not harm the recipient. As a psychiatric hospital, patients are deprived of personal liberty and are subject to electroconvulsive treatment at the will of hospital staffs. And before admission, parents have to sign contracts in which they deliver their guardianship of kids partially to the hospital and acknowledge that their kids will receive ECT. Frequently, ECT is employed as a punishment method upon patients who breaks any of the center's rules, including "eating chocolate, locking the bathroom door, taking pills before a meal and sitting on Yang's chair without permission". It is reported in a CCTV-12 segment that a DX-IIA electroconvulsive therapy machine is utilized to correct Internet addiction. The machine was, later on, revealed to be illegal, inapplicable to minor and can cause great pain and muscle spasm to recipients. Many former patients in the hospital later on stood out and reported that the ECT they received in the hospital was extremely painful, tore up their head, and even caused incontinence.
An Interview of the Internet addiction treatment center in Linyi Psychiatric Hospital is accessible via the following link.
Since neither the safety nor the effectiveness of the method was clear, the Chinese Ministry of Health banned electroconvulsive therapy in treating Internet addiction disorder in 2009.
In Yang's clinic, patients are forced to take psychiatric medication in addition to Jiewangyin, a type of medication invented by himself. Neither the effectiveness nor applicability of the medication has been assessed, however.
Physical abuse and death
At clinics and rehab centers, at least 12 cases of physical abuse have been revealed by media in the recent years including 7 deaths.
In 2009, a 15-year-old, Senshan Deng, was found dead 8 hours after being sent to an Internet-addiction center in Nanning, Guangxi Province. It is reported that the teenager was beaten by his trainers during his stay in the center.
In 2009, another 14-year-old teenager, Liang Pu, was taken to hospital with water in the lungs and kidney failure after a similar attack in Sichuan Province.
In 2014, a 19-year-old, Lingling Guo, died in an Internet-addiction center with multiple injuries on head and neck in Zhengzhou, Henan Province.
In 2016, after escaping from an Internet addiction rehab center, a 16-year-old girl tied and starved her mother to death in revenge of the being sent to treatment in Heilongjiang Province.
In August 2017, an 18-year-old Internet addict, Li Ao, was found dead with 20 external scars and bruises two days after his parents sent him to a military-style boot camp in Fuyang city, Anhui Province.
Online gambling addiction
According to David Hodgins, a professor of psychology at the University of Calgary, online gambling is considered to be as serious as pathological gambling. It is known as an "isolated disorder" which means that those who have a gambling problem prefer to separate themselves from interruptions and distractions. Because gambling is available online, it increases the opportunity for problem gamblers to indulge in gambling without social influences swaying their decisions. This is why this disorder has become more a problem at this date in time and is why it is so difficult to overcome. The opportunity to gamble online is almost always available in this century opposed to only having the opportunity in a public forum at casinos for example. Online gambling has become quite popular especially with today's adolescents. Today's youth has a greater knowledge of modern software and search engines along with a greater need for extra money. So not only is it easier for them to find opportunities to gamble over any subject, but the incentive to be granted this money is desperately desired.
Online gaming addiction (Internet gaming disorder)
Main article: Video game addiction
Video game addiction is a known issue around the world. Incidence and severity grew in the 2000s, with the advent of broadband technology, games allowing for the creation of avatars, 'second life' games, and MMORPGs (massive multiplayer online role playing games). World of Warcraft has the largest MMORPG community on-line and there have been a number of studies about the addictive qualities of the game. Addicts of the game range from children to mature adults. A well-known example is Ryan van Cleave, a university professor whose life declined as he became involved in online gaming. Andrew Doan, MD, PhD, a physician with a research background in neuroscience, battled his own addictions with video games, investing over 20,000 hours of playing games over a period of nine years.
Online gaming addiction may be considered in terms of B.F. Skinner's theory of operant conditioning, which claims that the frequency of a given behaviour is directly linked to rewarding and punishment of that behavior. If a behaviour is rewarded, it is more likely to be repeated. If it is punished, it becomes suppressed.
Orzack, a clinical psychologist at McLean Hospital in Massachusetts claims that 40 percent of World of Warcraft (WoW) players are addicted. Orzack says that the best way to optimize the desired behaviour in the subject is to provide rewards for correct behaviour, and then adjust the number of times the subject is required to exhibit that behaviour before a reward is provided. For instance, if a rat must press a bar to receive food, then it will press faster and more often if it doesn't know how many times it needs to press the bar. An equivalent in World of Warcraft would be purple (epic) loot drops. Players in World of Warcraft will often spend weeks hunting for a special item which is based on a chance system, sometimes with only a 0.01% chance of it being dropped by a slain monster. The rarity of the item and difficulty of acquiring the item gives the player a status amongst their peers once they obtain the item.
Online Gamers Anonymous, an American non-profit organization formed in 2002, is a twelve-step, self-help, support and recovery organization for gamers and their loved ones who are suffering from the adverse effects of addictive computer gaming. It offers resources such as discussion forums, online chat meetings, Skype meetings and links to other resources.Internet and Technology Addicts Anonymous (ITAA) founded in 2009, is a 12-step program supporting users coping with digital distractions.
Jim Rossignol, a finance journalist who reports on Internet gaming has described how he overcame his own addiction, and channeled his compulsion into a desirable direction as a reporter of Internet gaming and gaming culture.
Communication addiction disorder (compulsive talking)
Main article: Communication addiction disorder
Communication addiction disorder (CAD) is a supposed behavioral disorder related to the necessity of being in constant communication with other people, even when there is no practical necessity for such communication. CAD had been linked to Internet addiction. Users become addicted to the social elements of the Internet, such as Facebook and YouTube. Users become addicted to one-on-one or group communication in the form of social support, relationships and entertainment. However interference with these activities can result in conflict and guilt. This kind of addiction is called social network addiction.
Social network addiction is a dependence of people by connection, updating and control of their and their friends social network page. The correlation between the social network use and a decreasing of offline social relationships is a complex issue, depending not only from the time spent on them but also from the motivation in using them. For some people in fact, the only important thing is to have a lot of friends in the network regardless if they are offline or only virtual; this is particularly true for teenagers as a reinforcement of egos. Sometimes teenagers use social networks to show their idealized image to the others. They generally start using social networks to improve face-to-face relationships. However, some of them use these tools as a showcase creating an idealized image to be accepted by groups and to reach a big number of friends. They spend a reduced time for face-to-face relationships, passing instead at least six hours per day on social networks. However, other studies claim that people are using social networks to communicate their real personality and not to promote their idealized identity.
Virtual reality addiction
Main article: Virtual reality addiction
Virtual reality addiction is an addiction to the use of virtual reality or virtual, immersive environments. Currently, interactive virtual media (such as social networks) are referred to as virtual reality, whereas future virtual reality refers to computer-simulated, immersive environments or worlds. Experts warn about the dangers of virtual reality, and compare the use of virtual reality (both in its current and future form) to the use of drugs, bringing with these comparisons the concern that, like drugs, users could possibly become addicted to virtual reality.
International Network Into Problematic Internet Usage
European Union under its Horizon 2020 umbrella has just launched a new United Kingdom-led four year European Cooperation in Science and Technology (COST) Action Programme (CA 16207), to advance networked interdisciplinary research into problematic internet usage across Europe and beyond. The first steps will be to reach consensus on the reliable definition of the problem, devise age-appropriate assessment instruments to measure its severity, plan studies to clarify its clinical course and impact on health and quality of life as well as to clarify the underpinning brain-based mechanisms to support the development of screening biomarkers to identify those who are vulnerable before the problematic use becomes too entrenched and ultimately to identify targets to guide the development of new and effective interventions. The Action welcomes research-active scientists working in the field. Actions website Net&Me is due to be launched by the end of Feb 2018.
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