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JOURNAL OF ADDICTIVE DISORDERS
SUMMARY
An examination of whether the Internet is a “pathological agent” and should be included as a disorder separate from other psychiatric diagnoses, including discussion of Internet overuse, the distinction between addictions, compulsions and impulses, technology as a non-chemical addiction, symptoms suggesting addiction potential of the Internet, the prevalence and demographic profile of addicts, uniqueness of the etiology, contrary theories, and placement of the pathological Internet use within the DSM IV.
ARTICLE
Defining Internet Overuse
In 1994, Dr. Kimberly S. Young, an Associate Professor of Psychology at the University of Pittsburgh, Bradford, received an urgent telephone call from a friend (Young, 1998). Between sobs, the woman told her that she was about to divorce her husband. When asked why, the woman replied, “ he’s addicted to the Internet.” Having piqued her interest, Dr. Young devised a simple eight-question survey from criteria used to assess alcoholism and compulsive gambling. She posted the questionnaire on several Internet user groups on a given day in November 1994, she says, “expecting a handful of responses, and none as dramatic as her friend’s story.” (Young, 1998, p. 4) The following day she had received 40 responses from all over the world, with many claiming they were addicted to the Internet. From this simple survey, followed by her subsequent research, publications, and her presentation at the 104th annual meeting of the American Psychological Association in 1996, (Young, 1996a), there rose a social issue being pursued by dozens of researchers and writers from that time to present day. Several authors have attempted to apply meaningful and accurate definitions to this phenomenon. In this paper, the relevant theory and research will be reviewed, first to develop as good an understanding of this issue as possible. Second, to chronicle the diverse ways of approaching the issue, the writers and researchers in the field have struggled with. Finally, an attempt, based on the literature, will be made to determine if placement of Internet overuse as a legitimate disorder is justified, and (if so) what kind of disorder it should be considered.
Several attempts have been made to name to appropriately title Internet overuse. These attempts are chronicled as follows:
1 This copyrighted material may be copied in whole or in part, provided that the material used is properly referenced, and that the following citation is used in full: VanGelder, S.C. (2003). INTERNET ADDICTION: Is the Internet a “pathological agent” includable as a disorder separate from other psychiatric diagnoses? Journal of Addictive Disorders. Retrieved from http://breining.edu.
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Internet Addiction Disorder
The term “Internet Addictive Disorder,” (IAD) was coined by a New York psychiatrist by the name of Ivan Goldberg in 1996. (Griffiths, 1999; Kandell, 1998; Wang, 2001) He posted a set of criteria on an online message board for a professional web page as a joke. The criteria, paralleling that of substance dependence as defined by the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition (1994), replaced the term “Internet,” for a given substance. While Goldberg described his intention as a parody, it is noted in literature that IAD was taken seriously by some.
Pathological Internet Use
The term Pathological Internet Use (PIU) was assigned in 1996, by Kimberly Young, based on results highly suggestive of a common etiology with pathological gambling. (Young, 1998) PIU was later reinforced by Davis, (2001) who pointed out that the DSM-IV favors the term dependence for substances, and pathology for disorders like gambling. Young refers to the addictive potential of the Internet, yet avoids the term as it pertains to diagnosis for the above reason.
Specific or Generalized Pathological Internet Use
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) These definitions will be discussed in more detail, when exploring social-cognitive theory.
Internet Dependence and Internet Behavior Dependence
Sherer and Bost, (1997, cited by Griffiths, 1999, 2000) conducted a study of Internet Dependence using criteria parallel to that of substance dependence as defined in the DSM-IV. Hall and Parsons, (2001) expanded the definition of Internet Dependence to that of Internet Behavior Dependence (IBD). They placed emphasis on the affects of the Internet on cognitive, behavioral, and affective functioning. They do not endorse a pathological etiology to the problem, but rather, a compensation mechanism for other areas in the person’s life.
For the purposes of simplicity and to avoid getting lost in terms used to define excessive Internet use, the term “Internet addiction” will be applied to the subject phenomenon in this paper. There will be justifications for and against the use of the term addiction mentioned in the citations. The term Internet addiction will be used during review of literature for the purpose of uniformity.
Understanding Addictions and Compulsions
Definition of Addictions vs. Compulsions vs. Impulses
Many psychologists are of the opinion that the term addiction should be reserved for physical substances known to create dependency. (Griffiths, 2000; Holden, 1997; Young, 1999) The term addiction is not used in the clinical criteria or diagnostic terminology in the DSM-IV. (Griffiths, 1999; Kandell, 1998; Wang, 2001; Young, 1996a; Young and Rodgers, 1998b) The terms dependency and abuse are used to describe degrees of pathology in use of chemical substances. (DSM-IV, 1994) Compulsions, as defined by the DSM-IV, (1994) are repetitive behaviors or mental acts, the goal of which is to reduce anxiety or stress, not to provide pleasure or gratification. Marks, (1990, p. 1391) points out that “behavioral addictions are often called compulsions to denote coercion from a discomfort that has to be allayed, whereas addiction more implies attraction towards something.” Marks describes the accepted definition
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of compulsion as a push toward relieving discomfort, while addiction as a pull toward a good feeling. He makes a case that push and pull occur simultaneously with both chemical and behavioral examples, (e.g. alcohol, sex) thereby lending evidence to no differentiation in the terms addiction or compulsion.
Impulse-Control Disorders, are considered by the DSM-IV, (1994) as an inability or failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or others. For most of these disorders, the user feels an increasing sense of tension or arousal before committing the act and then experiences pleasure, gratification, or relief afterward. The DSM-IV, (1994) notes such similarities to chemical substances but with clear distinction that the terms dependence and abuse are reserved for a drug, medication, or toxin. Beard and Wolf, (2001) make a viable argument that Internet use as well as other non-chemical behaviors are separate from chemically induced problems that may be entitled addiction, because of lack of such symptoms as physical withdrawal. They prefer the terms “problematic” or “maladaptive” as most appropriate to describe Internet overuse.
The Existence of Non-chemical Addictions
In the last two decades, psychologists and addiction counselors have begun to acknowledge that people can form addictions to more than physical substances. They point to common addictive behavior in such habits as compulsive gambling, chronic overeating, sexual compulsions, and obsessive television watching. (Marks, 1990; Young, 1998) Young, (1998, p. 17) takes the position that “in behavior-oriented addictions, those who get hooked are addicted to what they do and the feelings they experience when they’re doing it.” Also according to Young recent findings in science suggest that there is a possibility of experiencing habit-forming chemical reactions to non-chemical as well as chemical substances. Researchers point to the presence of dopamine release (the pleasure neurotransmitter) in the nucleus accumbens during non-chemically induced excitement, producing the same effect as alcohol and other drugs. (Bai, 2000; Mitchell, 2000; Young, 1998) “And when something makes our dopamine level rise, we naturally want more of it.” (Young, 1998, p. 220) “Today among a small but growing body of research, the term addiction has extended into the psychiatric lexicon that identifies problematic Internet use associated with significant social, psychological, and occupational impairment.” (Young, 1997, p. 2)
Technology as a Non-chemical Addiction
General Theory About the Addictiveness of Technologies
Each significant technological development fundamentally changes the way the world works,...just as the invention of the electric light bulb enabled a multitude of nocturnal activities to occur,...the world-wide web has spawned a revolution in communication, commerce and behavior. (Kandell, 1998) Technological addictions as a subset of a broader category of non-chemical addictions involve human-machine interaction, and can be either passive (e.g. television) or active (e.g. computer games). (Griffiths, 1999) Since movies in the 1929's, radio in the 1930's, and television in the 1940's and 1950's, such technologies have been criticized as affecting time management and behavior. (Stern, 1999) Television, according to Stern is evidenced to cause “parasocial” relationships with the characters on the television, being used to both combat and enhance loneliness. A total of nearly 9 years of an average American’s life is spent viewing television. (Grohol, 1999) Technology according to Stern, (1999) provides a highly effective medium by which maladaptive behaviors can be carried out (by breaking down social boundaries), not the technological agent serving as the addiction itself. The addictiveness of technologies may be contributed to by the reinforcing features such as the sound effects and features that may promote addictive tendencies. (Griffiths, 1999)
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Kraut, et al., (1998) identify that most empirical work has indicated that television watching reduces social involvement, physical activity, mental health, and promotes boredom, and unhappiness. They identify time displacement (time not spent socially engaged) as the major causal factor of negative effects. Lonely people they report, watch television more than others. Young, (1998) and Young and Rodgers, (1998b) point out the fad associated with the Citizen’s Band (CB) Radio as a similar technological fascination (and potentially addictive agent) as the Internet (in terms of such qualities as interactiveness and anonymity).
Capacity of the Internet to Express Maladaptive Behaviors
The rapidity and convenience of the Internet has opened up an entirely new set of doors for people looking for resources and fulfillment. As in so many other things, what man can create to do good things, he can use in equally negative fashions. Often, this negativity comes from not the phenomenon itself, but from an immoderate frequency and volume of its use. Such functions of the Internet that have the capacity to be misused in this way are listed in the following paragraphs.
“Pornography” is the most frequently searched for topic on the Internet...with the Internet pornography industry expected to reach $366 million to $1 billion in 2001. (Greenfield, 1999; Griffiths, 2001) Griffiths reports estimates that one in five excessive Internet users are engaged in some form of online sexual activity. Nearly 20 percent of the Internet users surveyed by Pratarelli, et al., (1999) used the Internet to become sexually aroused.
A variety of pornography related activities might be realized via the Internet. Persons may seek out sexually related material (e.g. pornography websites), buy or sell sexually related goods, order from virtual sex shops, (find) sex therapists, escorts, prostitutes, swingers, and other types of material for masturbatory purposes (such as the heads of famous people superimposed on someone else’s body). (Griffiths, 2000, 2001) “Cyber-pornography” is legal, readily available in one’s own home or office, inexpensive (unlike prostitutes or phone sex), safe from physical harm or venereal diseases, and is ideal for hiding an activity from a partner. (Griffiths, 2001)
Cyber-relationships or Cyber-affairs, involve individuals married or unmarried forming on-line love relationships which may or may not evolve into real-life affairs. (Young, 1997) The user may carry on as many of these affairs as desired in relative safety, and at the same time without leaving the house or office. According to Griffiths, (2001) innocent chat room affiliations can turn into a passionate cyber-affair, evolving into intense mutual erotic dialogue (cyber-sex) with text-based fantasies. Masturbation, he notes may often accompany the fantasies. Accelerated intimacy, (Greenfield, 1999) as explained later in terms of reinforcers unique to the Internet, refers to the unnatural rapidity with which persons seem to develop these relationships. For disenfranchised groups such as homosexuals, the Internet may be a tremendous advantage. (Griffiths, 2001) Three types of online relationships are conducted: those in which people never meet, those developing online but with a desire to meet in real life, and those where people meet in real life but maintain a relationship online. (Griffiths, 2001)
Cyber-stalking may be described in terms of such behaviors as online sexual harassment and pedophilic grooming. (Griffiths, 2000) According to Griffiths, the first may include such behaviors as sending someone unsolicited pornographic or hateful material (from individuals or groups), or giving someone‘s e-mail address out to others involved in (bizarre behavior) web-groups to be besieged with unwanted contacts. The second, refers to those manipulating others with deception about themselves, often with the ultimate purpose setting up real life meetings. Young, et al., (1999) point out that the act of pedophilia does not require physical molestation, but is present when intense reoccurring sexual fantasies about children are being entertained. Young, (1988) describes such grooming tactics used by pedophiles as pretending to be another child, or pretending to be a caring adult friend unlike the way they
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perceive their parents. An organization entitled the “CyberAngels,” a branch of the Guardian Angels organization, (an unofficial policing organization) was set up in 1995 to help protect victims of cyber-stalking. (Griffiths, 2000)
Gambling may be found on the Internet, chiefly in the form of online stock trading and auctions. According to Pratarelli, et al., (1999) 4 percent of the Internet users in their study reported using the Internet for gambling. Online stock trading and online auctions such as eBay, according to authors, Orzack and Young, are gambling behaviors providing the user with a sense of accomplishment, power, and excitement. (Networker@USC, 1999)
Multi-user dungeons, or multi-user domains, (MUDS) involve games where players take on roles...ranging on themes from space battles to medieval duels. (Young, 1997) MUDS, are places where a user under a character name, fights monsters, saves maidens, buys weapons...and can be social in the same fashion as a chat room, but typically always in character. (Young, 1997) MUDS, according to the consensus of writers on the subject, represent one of the two most problematic (addictive) uses of the Internet, for reasons of depersonalization into their fictional characters and fictional world.
Chat Rooms (and various types of news sharing groups) are identified by writers and researchers as the other of the two most addictive of activities on the Internet. (Griffiths, 2000; Young, 1998) A chat room is a place where anyone online can access, to carry on conversations with others in “the room.” Chat rooms are available 24 hours a day, 7 days a week. A savvy chat room user can be carrying on multiple conversations at once, and may develop relationships of any variety and depth.
Shopping for virtually any types of products may be accomplished through the Internet. Convenience is of course the most attractive aspect of on-line buying. As differentiated from auctions or stock trading, (gambling for cost on items) there has been little concern by authors and researchers as to addiction to Internet shopping, except in cases where persons already have an addiction to shopping. (Griffiths, 2000; Pratarelli, et al., 2002)
Information Surfing is a relatively benign activity, where the user is looking for resources, or finding out things of interest. This may include researching a topic as not only condoned but also encouraged by educational institutions. (Griffiths, 2000; Kandell, 1998; Young, 1998) Information surfing is generally accepted by all writers on the subject of the Internet to be not only mildly or non-addictive, but healthy.
Symptoms to Suggest Addiction Potential of the Internet
The Degree to Which the Internet Meets Core Components of an Addiction
Authors such as Walters, (1996, as cited by Young, 1996b) Young, (1996b, 1998) and Griffiths, (2000) have made a case for the criteria associated with all pathological addictions as the measure by which the behavior should or shouldn’t qualify as addictive. Griffiths, (2000) identified a required presence of: preoccupation with the addictive agent (salience), mood modification, tolerance, withdrawal, conflict, and relapse. Additional criteria of progression, denial, and continued use despite consequences were added by Young. These and other authors, through research and relation to social/addiction theory have made attempts to qualify use of the Internet as meeting these required criteria.
Salience occurs when an agent becomes perhaps the most important activity in the person’s life, causing a preoccupation with the activity. Restructuring time and other activities, are common salient traits cited by authors such as Young, (1998) and Griffiths, (2000). Fabian, et al., (2001) found 92 percent of their respondents who met Internet addiction criteria felt the world was a dull, empty place without the Internet, and 77 percent reported daytime fantasies about the Internet. Greenfield, (1999) found 83 percent of Internet users experiencing salience.
Mood Modification refers to the previously mentioned euphoria or excitement induced when dopamine is released in the nucleus accumbens (pleasure center) of the brain. Persons
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may include such reasons for accessing the Internet as a “buzz,” “high,”, “tranquilizing,” “escaping,” or “numbing” effect. (Griffiths, 2000)
Tolerance is the process by which increasing amounts are required to achieve the former mood altering effects. (Griffiths, 2000) Young, (1996a) found that those meeting criteria as Internet addicted, (modified from that of pathological gambling) used the Internet nearly 8 times more than non-addicts, and 10 times more than average use before familiarity with the online skills. Brenner, (1997) found 55 percent of Internet users to have been told they spend too much time on the Internet. This phenomenon may be likened to tolerance levels which develop among alcoholics who gradually increase their consumption of alcohol in order to achieve the desired effect. (Young, 1996a) Tolerance levels in Internet use, according to Young, may be also seen by fear of missing out on something, driving users to marathon-length Internet sessions. Tolerance was found in 58 percent of Greenfield’s, (1999) survey respondents.
Withdrawal involves unpleasant feeling states, and/or physical effects that occur when the mood-modifying agent is discontinued or suddenly reduced. (Griffiths, 2000) Studies by Seeman, et al., (cited in Mitchell, 2000) and Bai, et al., (2000) found subjects who met criteria for Internet addiction exhibited typical withdrawal symptoms of nervousness, agitation, and aggression when not online. Fabian, et al., (2001) found 82 percent of their subjects who met criteria for Internet addiction, to report a great urge to be online if disconnected, and 81 percent to become very nervous if the Internet connection was slow. Withdrawal was also noticed by Brenner, (1997) who found 28 percent of his Internet users to find it hard to stop thinking of the Internet if they weren’t logged on.
Conflict is a common factor associated with addictions, whereby others, or the user himself is under increased stress from use of the agent (family, job, social life, interests, etc.). (Griffiths, 2000) Fabian, et al., (2001) found 43 percent of their subjects to feel depressive mood and guilty after a long use of the web. 71 percent of those subjects reported aggressive behavior if interrupted by others while on the web. Young, (1996a) found that those determined Internet addicted, had moderate/severe scores in areas of conflict, to include: academic 40%/58%, relationships 45%/53%, financial 38%/52%, occupational 34%/51%, and physical 10%/0%.
Relapse, as defined by Griffiths, (2000) involves reversions to earlier patterns after a period of abstinence. An explanation provided by Hirschman, (1992) defines relapse as one or more failed attempts to stop consumption, (of an addictive agent) often failing because the underlying emotional problems helping to perpetuate the addiction have not been remedied. Young, (1996a) found that 46 percent of the persons considered Internet addicted, had made unsuccessful attempts to cut down the time they spent online to avoid negative consequences. Brenner, (1997) found 22 percent of his respondents had tried to cut down their Internet use but were unable. Greenfield, (1999) reports 68 percent of respondents reporting relapse, with 79 percent feeling restless when trying to cut back.
Progression, serves as a criterion of addiction, whereas the person may begin use with “softer” agents, and find he or she is later taking more risky, dangerous, addictive agents (e. g. a drug user begins with milder drugs like tobacco and continually progresses to more highly addictive drugs like heroin). Young’s study, (1996a) produced interesting results which may be likened to a progressive nature in the Internet. She found that Internet addicts used the more benign functions of information protocols, like www-websites and email less, as Internet use increased, while the more personal and interactive functions (news groups, MUDS, and chat rooms) became much more highly used by those addicted. Results for non-addicted users were exactly opposite.
Denial of a problem, represents a subconscious feeling of stability and self-control, despite external, observable cues that a problem exists. Young, (1998, 1999) describes
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Internet denial as including such beliefs as “no one can be addicted to a machine,” or “this is part of my job.” Further, she says, the user may be convinced that “this is just a hobby, and besides, everyone is using it today.” Young, (1999) points out that professional therapists may exacerbate denial by not taking seriously a person’s problem with excessive Internet use.
Consequences, and Continued Use Despite Consequences, represent a final addiction criterion. Kimberly S. Young’s, (1996a, 1998) original survey respondents, had reported that they were staying online for up to10, or more hours at a time, day after day despite the problems the habit was causing in their families, their relationships, their work life, and their school work. They were found to crave their next date with the Internet, and unable to stop or even control their online usage despite divorces ( 53 percent reporting serious relationship problems [Young, et al., 1999b]) lost jobs, or poor grades. Kraut, et al., (1998) found the ties developed in Internet associations to be “weak,” organized around specific topics, and not like one would develop around families and friends.
Young, et al., (1999) pointed out tendencies of hiding and lying behavior about Internet use to delay consequences. Using her criteria for Internet addiction, Young, (1998) found that those meeting criteria for Internet addiction spent an average of 37 hours on the Internet each week, despite such effects as: serious and continuous fatigue resulting from staying up on the Internet until early morning hours, having to take caffeine pills to facilitate longer Internet sessions. Other problems in life areas included, physical effects such as carpal tunnel syndrome, back strain, and eyestrain. (Young, 1997, 1999). Brenner, (1997) found Internet users averaging 19 hours per week on the Internet and experiencing 10 signs of interference in role functioning to include: failure to manage time, cutting short on sleep, missing meals, job problems, and social isolation.
