internet addiction

Internet Addiction Disorder Presented by Dr. Atiqul Haq Mazumder

Issues for DSM-V: Internet Addiction Internet addiction appears to be a common disorder that merits inclusion in DSM-V .

Conceptually, the diagnosis is a compulsive-impulsive spectrum disorder that involves online and/or offline computer usage (1, 2) and consists of at least three subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging (3). .

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) negative repercussions, including arguments, lying, poor achievement, social isolation, and fatigue (3, 4). . .

Some of the most interesting research on Internet addiction has been published in South Korea. After a series of 10 cardiopulmonary-related deaths in Internet cafés (5) and a game-related murder (6)

“ South Korea considers Internet addiction one of its most serious public health issues(7).”

210,000 South Korean children (2.1%; ages 6–19) are afflicted and require treatment (5) About 80% of those needing treatment may need psychotropic medications, and perhaps 20% to 24% require hospitalization (7)

Since the average South Korean high school student spends about 23 hours each week gaming (8), another 1.2 million are believed to be at risk for addiction and to require basic counseling.

In particular, therapists worry about the increasing number of individuals dropping out from school or work to spend time on computers (5).

As of June 2007, South Korea has trained 1,043 counselors in the treatment of Internet addiction and enlisted over 190 hospitals and treatment centers (7). Preventive measures are now being introduced into schools (9).

13.7% of Chinese adolescent Internet users meet Internet addiction diagnostic criteria—about 10 million teenagers. As a result, in 2007 China began restricting computer game use; current laws now discourage more than 3 hours of daily game use (10).

In the United States, accurate estimates of the prevalence of the disorder are lacking (11, 12). About 86% of Internet addiction cases have some other DSM-IV diagnosis present. In one study, the average patient had 1.5 other diagnoses (7)

Unfortunately, Internet addiction is resistant to treatment, entails significant risks (16), and has high relapse rates. Moreover, it also makes comorbid disorders less responsive to therapy (3).

Am J Psychiatry 165:3, March 2008 307 EDITORIAL ajp.psychiatryonline.org References

References 1. Dell’Osso B, Altamura AC, Allen A, Marazziti D, Hollander E: Epidemiologic and clinical updates on impulse control disorders: a critical review. Eur Arch Psychiatry Clin Neurosci 2006; 256:464–475 2. Hollander E, Stein DJ (eds): Clinical Manual of Impulse-Control Disorders. Arlington, Va, American Psychiatric Publishing, 2006 3. Block JJ: Pathological computer use in the USA, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction. Seoul, Korea, National Youth Commission, 2007, p 433 4. Beard KW, Wolf EM: Modification in the proposed diagnostic criteria for Internet addiction. Cyberpsychol Behav 2001; 4:377–383 5. Choi YH: Advancement of IT and seriousness of youth Internet addiction, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction. Seoul, Korea, National Youth Commission, 2007, p 20 6. Koh YS: Development and application of K-Scale as diagnostic scale for Korean Internet addiction, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction. Seoul, Korea, National Youth Commission, 2007, p 294 7. Ahn DH: Korean policy on treatment and rehabilitation for adolescents’ Internet addiction, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction. Seoul, Korea, National Youth Commission, 2007, p 49 8. Kim BN: From Internet to “family-net”: Internet addict vs. digital leader, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction. Seoul, Korea, National Youth Commission, 2007, p 196 9. Ju YA: School-based programs for Internet addiction prevention and intervention, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction. Seoul, Korea, National Youth Commission, 2007, p 243 10. The more they play, the more they lose. People’s Daily Online, April 10, 2007 11. Aboujaoude E, Koran LM, Gamel N, Large MD, Serpe RT: Potential markers for problematic Internet use: a telephone survey of 2,513 adults. CNS Spectr 2006; 11:750–755 12. Block JJ: Prevalence underestimated in problematic Internet use study (letter). CNS Spectr 2007; 12:14 13. Lee HC: Internet addiction treatment model: cognitive and behavioral approach, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction. Seoul, Korea, National Youth Commission, 2007, p 138 14. Block JJ: Pathological computer game use. Psychiatric Times, March 1, 2007, p 49 15. Ko CH: The case of online gaming addiction without other comorbid psychiatric disorders, in 2007 International Symposium on the Counseling and Treatment of Youth Internet Addiction, Seoul, Korea, National Youth Commission, 2007, p 401 16. Block JJ: Lessons from Columbine: virtual and real rage. Am J Forensic Psychiatry 2007; 28:5–33

AS THEIR WORLD IS BASED ON CONTINUOUS PARTIAL ATTENTION

Internet Addiction is an impulsive-control problem and five subtypes have been defined:

1.Cybersexual Addiction – Individuals who suffer from Cybersex/Internet pornography addiction are typically engaged in viewing, downloading, and trading online pornography or involved in adult fantasy role-play chat rooms.

2.Cyber-Relational Addiction – Individuals who suffer from an addiction to chat rooms, IM, or social networking sites become over-involved in online relationships or may engage in virtual adultery. Online friends quickly become more important to the individual often at the expense of real life relationships with family and friends. In many instances, this will lead to marital discord and family instability

3.Net Compulsions – Addictions to online gaming, online gambling, and eBay are fast becoming new mental problems in the post-Internet Era. With the instant access to virtual casinos, interactive games, and eBay, addicts loose excessive amounts of money and even disrupt other job-related duties or significant relationships.

4.Information Overload – The wealth of data available on the World Wide Web has created a new type of compulsive behavior regarding excessive web surfing and database searches. Individuals will spend greater amounts of time searching and collecting data from the web and organizing information. Obsessive compulsive tendencies and reduced work productivity are typically associated with this behavior.

5.Computer Addiction – In the 80s, computer games such as Solitaire and Minesweeper were programmed into computers and researchers found that obsessive computer game playing became problematic in organizational settings as employees spent most days playing rather than working. These games are not interactive nor played online.

71% of office workers abuse the Internet during work hours visiting social networking sites, shopping online, reading personal email, or visiting pornography, gaming, or gambling sites.

Individuals who suffer from depression, anxiety-disorders, social phobia, and other compulsive disorders are more likely to develop Internet addiction.

Children who suffer from Internet addiction are more likely to suffer from depression, experience academic and social problems at school, and are at greater risk to develop physical illnesses, obesity, and carpel tunnel syndrome.

According to the Stanford University School of Medicine Study, 1 out of 8 Americans suffer from Internet Addiction, 14% of respondents found it hard to abstain from Internet use for several days; 5.9% said excessive Internet use affected their relationships; 8.2% said the Internet was a means of escape from the real world.

According to the Chinese Government, approximately 13 % of Chinese teenagers suffer from Internet addiction and they have banned the opening of Internet cafes for the year 2007.

The Government of China funded a military-style boot camp to combat the disease. Patients are males between 14 and 19 years old. This China boot camp reports a 70% recovery rate and over 1,500 young who have received treatment at this facility operating since 2004.

In Germany, estimates suggest that close to 1 million people are addicted to the Internet, or about 3 percent of the German online population. In 2003, the German social security services instituted the first camp in the seaside town of Boltenhagen, northern Germany. It is the first camp of its kind in Europe and aims to wean children off computers.

In Amsterdam, the first Detoxification Center to treat video game addiction opened in 2006.

The Indian Institute of Technology (IIT) in Mumbai adopted a measure to cut the students' use of Internet in the school dormitories after the suicide of an IIT student in October of 2005 due to Internet abuse.

The term “Internet Addictive Disorder,” (IAD) was coined by a New York psychiatrist , Ivan Goldberg in 1996.

The term Pathological Internet Use (PIU) was assigned in 1996, by Kimberly Young, a psychologist of University of Pittsburgh, Bradford

Davis (2001) distinguishes two types of pathological Internet use, as to their utility. Specific Pathological Internet Use (SPIU) refers to those dependent on content specific functions of the Internet (e.g. online stock trading, auctions, and sexual material).

Generalized Pathological Internet Use (GPIU) is used to describe general, multi-dimensional use without a clear objective (e.g. wasting time, surfing, chatting, e-mailing)

A study done by the department of Psychiatry, Kaohsiung Medical University Hospital, Kaosiung, Taiwan shows that: Internet addiction is associated with harmful alcohol use. - Psychiatry Clin Neurosci. 2009 Apr;63(2):218-24.

A study in USA showed that: Dissociative symptoms are related to severity and impact of IAD. - Comprehensive Psychiatry xx (2009) xxx–xxx

A study done to investigate the beliefs and attitudes of Swiss general psychiatrists toward Internet addiction showed that: Out of 94 psychiatrists -

a) DISBELIEVERS (N = 20) rejected the concept of Internet addiction and its importance, not considering it a real clinical problem and consequently not considering the existence of a specific treatment.

b) The NOSOLOGY BELIEVERS (N = 66) and NOSOLOGY/TREATMENT BELIEVERS (N = 8) assumed that Internet addiction is a real problem.

c) NOSOLOGY/TREATMENT BELIEVERS asserted the availability of effective treatment (mainly psychological) d) NOSOLOGY BELIEVERS were less affirmative regarding treatment. - Psychiatr Q. 2009 Jun;80(2):117-23. Epub 2009 Mar 27.

Another study showed that: Excessive Internet user (EIU), also described as Internet addicted or pathological Internet user have deficits in decision-making function. - CNS Spectr. 2009 Feb;14(2):75-81 .

Another study showed that: Stimulants such as methylphenidate (MPH), given to treat ADHD, and video game play have been found to increase synaptic dopamine. - Compr Psychiatry. 2009 May-Jun;50(3):251-6. Epub 2008 Oct 15.

A survey of university freshmen showed that male gender, habit of skipping breakfast, mental health morbidity, deficient social support; and neurotic personality characteristics are

major risk factors in Taiwan. -Psychiatry Research 167 (2009) 294–299 w.

A survey of university freshmen in China showed that a single-parent family, the age of first exposure to Internet use, the age of the student, city residence, and homesickness were significantly associated with Internet addiction (p < 0.01). - Psychiatry Res. 2009 May 30; 167(3):294-9. Epub 2009 Apr 23.

A study in Australia showed that higher frequency of use, lack of perseverance (an aspect of impulsivity), and online group membership significantly predicted problematic Internet use. -Cyberpsychol Behav. 2009 May 17.

Another study showed that: adolescents with Internet addiction exhibit more impulsivity than controls in China. -Internet Addiction • May 04, 2008

A survey in Korea showed that among the adolescents 1.6% was diagnosed as Internet addicts, while 38.0% was classified as possible Internet addicts. The prevalence of Internet addiction did not vary with gender.

The levels of depression and suicide ideation were highest in the Internet-addicts group. - International Journal of Nursing Studies 43 (2006) 185–192

A confirmatory study in Hong Kong to evaluate Young’s Internet Addiction Test showed that: academic performance was negatively correlated with the Internet addiction scores. - Computers in Human Behavior 24 (2008) 2597–2619

Another study showed that: Among 12-18 year-old adolescents in Finland 85% used the Internet. Among daily users 4.6% of boys and 4.7% of girls are internet addicted. - Addiction Research & Theory, Volume 12, Issue 1 February 2004 , pages 89 - 96

A study in Korea reveals a significant association between Internet addiction and depressive symptoms in adolescents - Psychopathology 2007;40:424-430 (DOI: 10.1159/000107426 )

Another study in Korea revealed that adolescents with Internet addiction were more likely to have aggressive behaviors during the previous year. - Journal of Adolescent Health- (2009) 1–8

A study in Taiwan showed that Internet addiction was associated with symptoms of ADHD and depressive disorders. However, hostility was associated with Internet addiction only in males. - Journal of Adolescent Health 41 (2007) 93–98

A study in Greece showed that Internet addicted students are more prone to experience loneliness, withdrawal, depression and rejection from others. And

Internet over-use affects academic performance and is associated with substance consumption. - Abstracts for Poster session III / European Psychiatry 23 (2008)

Instruments designed to measure Internet addiction without specifying the dimensions:

Goldberg (1995) Internet addiction disorder diagnostic criteria (IADDC)

Brenner (1997) Internet-Related Addictive Behavior Inventory (IRABI)

Young (1998a) Internet Addiction Test (IAT)

Young (1998b) Young’s Diagnostic Questionnaire (YDQ)

Griffiths (2000) Addiction components criteria

Morahan-Martin and Schumacher (2000) Pathological Use Scale (PUS)

Davis et al. (2002) Online Cognition Scale (OCS)(IAST)

Lin and Tsai (2002) Internet addiction scale for Taiwanese high school students (IAST)

Full set of items in IAT scale

Q1 How often do you find that you stay online longer than you intended?

Q2 How often do you neglect household chores to spend more time online?

Q3 How often do you prefer the excitement of the Internet to intimacy/relationships with your partner/ friends?

Q4 How often do you form new relationships with fellow online users?

Q5 How often do others in your life complain to you about the amount of time you spend online?

Q6 How often do your grades or school work suffer because of the amount of time you spend online?

Q7 How often do you check your e-mail before something else that you need to do?

Q8 How often does your job performance or productivity suffer because of the Internet?

Q9 How often do you become defensive or secretive when anyone asks you what you do online?

Q10 How often do you block out disturbing thoughts about your life with soothing thoughts of the Internet?

Q11 How often do you find yourself anticipating when you will go online again?

Q12 How often do you fear that life without the Internet would be boring, empty, and joyless?

Q13 How often do you snap, yell, or act annoyed if someone bothers you while you are online?

Q14 How often do you lose sleep due to late-night logins?

Q15 How often do you feel preoccupied with the Internet when offline, or fantasize about being online?

Q16 How often do you find yourself saying ‘‘just a few more minutes” when online?

Q17 How often do you try to cut down the amount of time you spend online and fail?

Q18 How often do you try to hide how long you’ve been online?

Q19 How often do you choose to spend more time online over going out with others?

Q20 How often do you feel depressed, moody or nervous when you are offline, which goes away once you are back online?

0 = Not Applicable 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Often 5 = Always

20 - 49 points: You are an average on-line user. You may surf the Web a bit too long at times, but you have control over your usage.

50 -79 points: You are experiencing occasional or frequent problems because of the Internet. You should consider their full impact on your life.

80 - 100 points: Your Internet usage is causing significant problems in your life.

You should evaluate the impact of the Internet on your life and address the problems directly caused by your Internet usage.

Young’s Diagnostic Questionnaire (YDQ): Eight criteria to diagnose IAD

1. Do you feel preoccupied with the Internet (think about on-line activity or anticipate the next on-line session)? 2. Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction? 3. Have you repeatedly made unsuccessful efforts to control, cut back or stop Internet use?

4. Do you feel restless, moody, depressed, or irritable when attempting to cut down on or stop Internet use? 5. Do you stay on-line consistently longer than originally intended? 6. Have you jeopardized or risked the loss of a significant relationship, job, educational or career opportunity because of the Internet?

7. Have you lied to family members, therapist, or others to conceal the extent of involvement with the Internet? 8. Do you use the Internet as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)?

Answering "yes" to five or more questions may mean you suffer from Internet addiction over a six month period and when not better accounted for by a manic episode .

Proposed DC-IA-C: Distinguishing characteristics of Internet addiction

Diagnostic Criteria of Internet Addiction for college (DC-IA-C) is based on the characteristics of adult ADHD

A maladaptive pattern of Internet use, leading to clinically significant impairment or distress, occurring at any time within the same 3-month period A. Six (or more) of the following symptoms have been present 1. Preoccupation with Internet activities. 2. Recurrent failure to resist the impulse to use the Internet.

3. Tolerance: a marked increase in the duration of Internet use needed to achieve satisfaction. 4. Withdrawal, as manifested by either of the following i. Symptoms of dysphoric mood, anxiety, irritability, and boredom after several days without Internet activity. ii. Use of Internet to relieve or avoid withdrawal symptoms.

5. Use of Internet for a period longer than intended. 6. Persistent desire and/or unsuccessful attempts to cut down or reduce Internet use. 7. Excessive time spent on Internet activities and leaving the Internet.

8. Excessive effort spent on activities necessary to obtain access to the Internet. 9. Continued heavy Internet use despite knowledge of having a persistent or recurrent physical or psychological problem likely to have been caused or exacerbated by Internet use.

B. Functional impairment: one (or more) of the following symptoms have been present 1. Recurrent Internet use resulting in a failure to fulfill major role obligations at work, school, and home. 2. Important social or recreational activities are given up or reduced because of Internet use.

3. Recurrent legal problems because of Internet behavior. (eg, arrest for disorderly conduct in a game). C. The Internet addictive behavior is not better accounted for by psychotic disorder, bipolar I disorder, or other disorder, which is classified in impulse control disorder and paraphilia in DSM-IV-TR.

Comprehensive Psychiatry xx (2009) xxx–xxx ARTICLE IN PRESS

Possible Causes of Internet Addiction Psychodynamic Perspective In the psychodynamic perspective, the cause of addiction attributes to childhood unresolved traumatic experience, presence of particular personality traits as well as inherited vulnerability.

Sociocultural Perspective There are huge numbers of theory that ensure addiction is dependent on a wide variety of factors including age, sex, socioeconomic status, ethnicity, religion, and location.

Behavioral Perspective Theories of Internet addiction based on behavioral perspective largely depend on B. F. Skinner's theory of operant conditioning and the notion of reward and reinforcement.

Since, Cybersex, virtual relationship, online gambling, Internet browsing, shopping comprise of several awards in terms of psychological comfort, affection, excitement and moreover, a sense of escape from hard reality itself.

Biomedical Perspective Theories of Internet addiction based on biomedical perspective focus hereditary and innate factors including a thorough understanding of chemical imbalance occurring in the brain and the dysfunctional neurotransmitters.

What are the particular dynamics that make university campuses ripe for Internet overuse?

Triggers for Internet Addiction Substance Abuse: Over half of Internet addicts suffer from other addictions, mainly to drugs, alcohol, smoking, and sex.

Mental Illness: Trends show that Internet addicts suffer from emotional problems such as depression and anxiety-related disorders and often use the fantasy world of the Internet to psychologically escape unpleasant feelings or stressful situations.

Relationship Troubles: In almost 75% of cases, Internet addicts use applications such as chat rooms, instant messaging, or online gaming as a safe way of establishing new relationships and more confidently relating to others.

Free and unlimited Internet access Huge blocks of unstructured time Newly experienced freedom from parental control No monitoring or censoring of what they say or do on-line Full encouragement from faculty and administrators Adolescent training in similar activities The desire to escape college stressors Social intimidation and alienation A higher legal drinking age

NEGATIVE EFFECTS OF ADDICTIVE INTERNET USAGE

Physical:  Sleep deprivation  Excessive fatigue  Decreased immune system  lack of proper exercise  Poor personal hygiene  back or eye strain

Physical:  Dry eyes  Eating irregularities, such as skipping meals  Carpal Tunnel syndrome (pain, numbness, and burning in your hands that can radiate up the wrists, elbows, and shoulders) 

Familial:  Relationship problems with family  Neglect of daily chores  Increased family conflicts

Academic:  Drop In grades  Missed classes  Decline in study habits

Others:  Lack of real-life social relationships  Cyber bullying  Sexual predators  Exposure to pornographic materials

Treatments: If a person presents with depression and/or family dysfunction, these issues should be addressed. More than half of Internet addicts report a history of depression, about one third report anxiety disorder, and a little over half report a history of drug abuse. Antidepressants and family therapy can address underlying psychiatric issues in the individual and his or her family.Cognitive behavioral therapy is the primary therapy at this time.

Young’s Recovery Strategies are as follows: Recognize What You’re Missing Young cites the Top 10 list of most commonly mentioned activities that suffer because of excessive Internet use: Time with partner or family. Daily chores. Sleep. Watching TV. Time with friends. Exercise. Hobbies. Sex. Social events

Assess Your On-line Time Keeping an actual log for a typical week on the Internet helps individuals to see the real extent and direction of their time use. This exercise makes it difficult for individuals to deny their involvement on-line: Chat rooms, Interactive games, e-mail, newsgroups, world wide web.

Use Time-Management Techniques Cultivate an alternative activity. Think of a hobby or activity or fun things in your life. Identify your usage pattern. To begin to shake the habit, practice the opposite. Find external stoppers. If this is not effective because you ignore them, use a real alarm clock to be set when you need to end the session.

Incorporate planned Internet time into your weekly schedule. Internet addiction does not require that a person go “cold turkey” and quit all usage. Set a reasonable goal, perhaps 20 hours a week on-line if you currently devote 40 hours. Instead of “One day at a time,” practice “One time a day.”

Find Support in the Real World Be intentional about reconnecting with loved ones and friends. Recognize Your Addictive Triggers Consider your own feelings when you head toward the computer.

Find Support in the Real World Be intentional about reconnecting with loved ones and friends. Recognize Your Addictive Triggers Consider your own feelings when you head toward the computer (e.g. bored, lonely, miserable, depressed, anxious, angry, stressed)

Carry Positive Reminder Cards Make a list of the five major problems caused by your addiction to the Internet. Make a separate list of the five major benefits of cutting down your Internet use. Transfer the two lists onto a 3-by-5inch-index card and keep it in your pocket, purse, or wallet.

Listen to the Voices of Denial “ Leave me alone; what I do on the computer is my business;” “ It’s not really extramarital or premature sex; it’s just words on the computer;” “ It will be all right if I just cool it on the chat rooms for a while;” “ So I miss a few hours sleep from the Net; that’s just wasted time anyway.”

Denial is to escape from : Loneliness Marital discontent Work-related stress Boredom Depression Financial problems Insecurity about physical appearance Anxiety Struggles with recovery from other addictions Limited social life

Confront Your Loneliness Transfer positive qualities that you discovered or developed on the Internet to “real life” experiences. Change your situation. Look at the circumstances of your life and how they may be contributing to your loneliness Explore the difficult feelings

Warning Signs of Terminal Love Change in sleep patterns Personality changes Loss of interest in sex A demand for privacy Household chores ignored Evidence of lying Declining investment in your relationships

Intervening with Addicted Spouse Set your specific goals and articulate it to your partner Find a good time to talk Decide what you most want to say Use no blaming “I” statement Listen empathetically Be prepared for a negative response Consider other alternatives

Warning Signs for children Excessive fatigue Academic problems Declining interest in hobbies Withdrawal from friends Disobedience and acting out

Intervening with Addicted Children Present a united front if you have a partner to help. Show your caring. Assign an Internet time log. Set reasonable rules. Make the computer visible. Encourage other activities. Support, don’t enable. Use outside resources when needed.

Help for the Addicted Employee Ask the right questions Determine whether your employee really wants Find a suitable recovery program or counselor Tighten control of Internet access

Help for the Addicted Friend Be a good role model Introduce them to some other people Get them involved in some non-computer related fun Support their desire for change Encourage them

Consider the Long-Term Consequences Avoid relapsing Be patient with yourself Give yourself credit for trying Tune in to your addictive triggers Get your loved ones on board

Dr. David Greenfield offers suggestions to help manage Internet use before it becomes a problem:

Consider taking a technology holiday Find other interests Exercise Watch less television Talk to your friends and family about what is happening in your life

Try counseling or psychotherapy to assist you in dealing with the addictive behavior Consider a support group Develop new relationships and friendships Talk to others about your overuse of the Internet Shorten your Internet sessions

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