In an era defined by techno-gadgets that put the cyber world in the palm of your hand, a debate is growing about how to handle so-called “Internet addiction,” a problem that gets a lot of attention in the press but has yet to receive much attention from U.S. researchers. The issue is resurfacing in step with the American Psychiatry Association’s periodic revision of its Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of diagnostic standards for psychiatric conditions.
Some psychiatrists have proposed that Internet addiction—or compulsive computer use, online or off—should be included in the fifth edition of the manual (dubbed DSM-V) and thus officially recognized as a psychiatric condition with specific diagnostic and management criteria. In an editorial last year in the American Journal of Psychiatry, Oregon psychiatrist Jerald Block argued that “Internet addiction appears to be a common disorder that merits inclusion” in the updated manual, due out in 2012.
Conceptually, Block said Internet addiction is a “compulsive-impulsive spectrum disorder” with at least three subtypes (excessive video gaming, sexual preoccupations and e-mail/texting). He defined its key features in terms used to describe alcohol or drug addiction: excessive use; withdrawal symptoms when a computer is unavailable; tolerance, defined as a need for more computer time and/or better, faster equipment; and negative repercussions to one’s life.
Others worry that elevating Internet addiction to a mental disorder is another step in the “medicalization” of normal behavior, a criticism that has been aimed at DSM developers practically since the manual was first published in 1952 (homosexuality was once a DSM disorder, for example, and controversies currently surround the classification of gender identity disorder and pathological bias, among others.)
In blog posts in March 2008 and January 2009 to PsychCentral.com, psychologist John Grohol has lambasted the idea, citing a “continuing lack of scientific validity” to support the inclusion of Internet addiction as a discrete mental disorder. In an irreverent post on May 28 for The Daily Beast titled “8 New Ways You Might be Insane,” writer Constantino Diaz-Duran included Internet addiction in a list of purported mental illnesses being considered by DSM-V committees, along with compulsive shopping, sex addiction, embitterment disorder and pathological hoarding, among others.
Cheeky headlines aside, in some countries, Internet addiction is no joke. South Korea, which has the world’s highest percentage of Internet users and among the world’s fastest broadband speeds, considers Internet addiction a public health threat and has instituted a national intervention policy that includes school-based preventive education and counselors trained to identify the problem in young people. In China, with nearly 300 million Internet users, the government has taken steps to limit online gaming among minors and has set up more than 300 boot-camp-like rehab centers for afflicted youth. Thailand and Vietnam also have imposed limits on video gaming.
In the United States, there is little data on the prevalence of Internet addiction, in part because there are no universally accepted criteria for where to draw the line between normal and pathological use. Kimberly Young, a psychologist who founded the Center for Internet Addiction Recovery in Bradford, Pa.., has developed an Internet Addiction Test that gauges the impact of computer use on a user’s social and academic or work performance, but the test’s sensitivity for differentiating people “at risk” vs. those with an actual problem has been challenged in scientific studies. And last fall, Chinese psychologist Tao Ran caused a stir when he published diagnostic criteria defining Internet addiction as computer use that exceeds 6 hours per day.
The lack of rigorous science on the prevalence or clinical symptoms of Internet addiction in the United States is likely to be a primary factor in whether it is included as a discrete condition in DSM-V.
“In order to include something in DSM-V, there needs to be sufficient scientific evidence about the importance and credibility of the particular disorder,” says Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), who has been involved in the DSM-V working groups that are discussing whether Internet addiction should be considered under the rubric of behavioral addictions. “That type of information as it pertains to the U.S. is not there for Internet addiction.”
To be defined as a mental illness, she says, a behavior must “produce disruption in your everyday activity to a degree that is pathological—it’s really interfering with your well-being.” Equally important is whether something can be done about the behavior.
“To just hang a label on someone with a certain diagnosis that is not in any way going to influence how you treat that person or what you can do to help makes no sense,” she says. No scientific evidence exists to support any particular treatment for Internet addiction, she says.
Based on her own research in compulsive eating, Volkow does believe that there are commonalities between the so-called behavioral addictions and substance abuse, in that the same neural circuits seem to be affected. Disruption in prefrontal areas of the brain that normally exert cognitive control over emotions and desires is a common feature of drugs of abuse and behavioral addictions, for example.
Impairment in memory circuits that underlie motivational drive and conditioned behaviors likely represent another common pathway, she said. A few brain imaging studies of video game playing have shown activation of the same motivation areas of the brain that light up with cocaine use, for instance.
Ronald Pies, a psychiatry professor at SUNY-Upstate in Syracuse, N.Y., believes it’s premature to consider Internet addiction as a discrete disorder. Too many questions remain, he said, especially with regard to psychiatric conditions such as anxiety, depression or obsessive-compulsive disorder that often co-occur with pathological computer use, creating a dilemma about which came first.
At the same time, he said, the potential for serious emotional and physical complications necessitates that the syndrome “should not be written off as another attempt by psychiatry to ‘medicalize’ unfortunate or self-destructive behaviors.”