Richard N. Rosenthal, MD and Zebulon Taintor, MD
CHAPTER OUTLINE
■ HISTORICAL PERSPECTIVE
■ DIAGNOSTIC DILEMMAS
■ ASSESSMENT
■ INTERNET CHARACTERISTICS
■ TREATMENT MODEL
■ TREATMENT PLANNING
■ INDICATIONS FOR TREATMENT
■ PRETREATMENT ISSUES
■ RELEVANT TREATMENT RESEARCH
■ SUMMARY AND CONCLUSIONS
Microprocessors are all around us, serving as prosthetic brains, guides, knowledge sources, calculators, and the like, a technologic leap of the late 20th century that will have profound effects on human functioning in the 21st Century. Microprocessors help us manage many aspects of our lives, and we use them a lot. They can provide much stimulation, but they don’t manage our time, our motivations, and our involvements. Some of us use them too much, lose track of time while getting too involved, and become dependent on the stimulation they provide. Some of us have significant negative life consequences as a result of that dependence, not that different from addiction to substances, which in itself is a topic of debate. This chapter is about the use of microprocessors and the problems that can ensue.
The Internet has five major uses that affect clinicians and their patients: (a) source of information on disease, diagnosis, treatments, and therapists; (b) support and self-help groups (moderated or not); (c) provision of advice, diagnosis, and counseling whereby the person being helped has not met the helper except over the Internet; (d) obtaining addictive substances, both prescription and nonprescription; and (e) enhanced opportunities for people to do things that would tend to bring them to the attention of a clinician even if they didn’t happen to use the Internet (sex, gambling, etc.). Some of these last activities are regarded as addicting in their own right.
“Internet addiction” covers only part of the problems encountered by clinicians in patients who spend too much time using devices built around microprocessors. Consider the accident resulting from instant messaging (IM) while driving, the gunshots exchanged over Xbox use, too many hours on the Internet using a souped-up mobile phone, or a person who finds Second Life more real than his or her real life. The common denominator is the use of microprocessors in an increasingly wide variety of devices. Thus, the title of this chapter is expanded past “Internet Addiction” and a considerable broadening of situations to be considered. What is clear is that the human problems that are now becoming apparent in the context of microprocessor use are related to the interaction of the novel technology and the people using it, as compared to intrinsic mental disorders that have been around for millennia, such as depression and schizophrenia, or other disorders of compulsive/impulsive behavior such as eating disorders or pathologic gambling.
HISTORICAL PERSPECTIVE
The history that matters is the most recent, as the pace of change has been so fast. The Internet was established in 1969 at the University of Southern California as a way of linking computers for national defense uses. Even early on, computers offered opportunities to impair functioning, even in the absence of the Internet. Weinberg (1) described programmers so immersed in programming they failed to properly document their work. Later, Weizenbaum (2) described the development of compulsive programmers who had lost the broad view of problem solving and came to see problems simply as means to interact with the computer. The concept of the impaired computer user was described in 1992 by Kuiper (3), who called them “space cadets,” characterized as spending too much time in front of industrial or commercial computers and having too few other ambitions or interests. Once the Internet became functional in the business community, it didn’t take long for it to become an instrument of non–work-related use in the workplace, problematic if not necessarily pathologic. A recent survey of 224 US companies by Greenfield and Davis (4) demonstrated that 60% of companies had disciplined employees about inappropriate Internet use and 30% had terminated employees owing to Internet behavior. Forty-seven percent of a randomly selected group of workers from the 224 companies surfed non–work-related Web sites more than 3 hours per week and 19% 4 or more hours per week (4).
Specialized offers to certain customers via e-mail began in 1973, and the first online service among users started in 1979. Use of e-mail for therapy was documented in the 1980s, and simulated patients were developed (e.g., “Eliza” and “Parry”) to demonstrate typical psychopathology to those who signed on to interact with them. But widespread use of e-mail skyrocketed in the 1990s as e-mail programs became interoperable, and anyone was able to get and send from any of a variety of software programs. The first wave of articles about Internet addiction appeared in the mid-1990s, and the Center for Internet Addiction Recovery was one of dozens of sites set up to help the addicted. A book by its founder, Kimberly Young, PsyD, provides a picture of Internet addiction in the late 1990s (5). Text and instant messaging took off as the 21st century began with personal digital assistants (PDAs), BlackBerrys, and increasingly smart cellular telephones. As of August 2012, it is estimated that 94% of the American population has fixed broadband access to the Internet, including 80% of households with download speeds as high as 100 Mbps, although approximately 100 million Americans are not yet subscribers where broadband is available, citing perceived lack of usefulness, lack of digital literacy, and unaffordability (6). Modern cellular telephones typically include a wide variety of communication modes such as Internet, e-mail, and messaging capability. Year 2010 U.S. Census data have 74% of the American population having some sort of Internet access, including 145 million individuals 15 years and older (7). Most use e-mail, which can be used without the Internet or a computer. That handheld devices can be taken anywhere and are used in many places was evidenced by America Online’s Fourth Annual Survey of 4,000 e-mail users. It found an increase from 15% (in 2007) to 46% (in 2008) of those describing themselves as “e-mail addicts.” E-mail is checked while in bed (67%), the bathroom (59%), while driving (50%, up from 37% last year), and church (15%) (8). Yet, just a few years after this report, the data and interpretation seem quaint, given the integration into daily life of microprocessors in handheld phones and tablets used for communications.
It is important to recognize that some portion of what has been thought as problematic use of microprocessors may have to do more with social adaptation to new technology than with psychopathology. Forming new relationships with fellow online users may have once represented eccentric or problem behavior, but the advent of Internet social utilities such as social networks, commercial dating sites, special interest blogs, chats, and others has made this a mainstream activity (9). Similarly, checking one’s e-mail before something else that you need to do is a more mainstream behavior, now that Internet access is ubiquitously available on wireless as well as wired and cabled devices (9).
Identity and the Internet are emerging as a separate field of study with the mushrooming growth of programs like Second Life (www.secondlife.com), which has more than 18 million users, 1,404,640 of whom have logged in the last 60 days (10). Second Life describes itself as “a 3D virtual world” entirely created by its residents (who socialize, create, and chat using voice and text chat). Since opening to the public in 2003, it has grown explosively and today is inhabited by millions of residents from around the globe. Its world is filled with creations of the residents, often elaborately and colorfully costumed, often with special powers. Second Life creations can include cities, countries, and whatever. Real-world commercial interests, such as Sony, BMG Music Entertainment, Sun Microsystems, Nissan, Adidas/Reebok, Toyota, and Starwood Hotels have operated in Second Life. NYU has placed a virtual filmmaking school in Second Life; the Second Life marketplace uses Linden Dollars, which can be earned in Second Life or bought with, or exchanged for, world currency. Several other sites (Metaverse, Open Life) offer similar fare. All are developing additional features to make their offerings more attractive and enveloping. Participation in alternate realities offers rich material for considering identity choices and psychodynamics. Some people have reported having more success in Second Life than in their real lives (11), while other patients have entered therapy because of Second Life relationships gone awry. One creates an identity for oneself, which often is quite opposite from one’s regular self. Second Life uses Linden dollars, which are convertible to regular US dollars. In 2008, a bank in Second Life failed via a Ponzi scheme, and the crowd milling around in front seemed to consist of hookers, Mafia types, and many bizarrely dressed unidentifiable characters. They had lost real money; banking regulations were added in 2011. However, alternate existences abound in con games.
As any assessment of addiction involves considering risk-taking behavior, it is important for clinicians to understand the current risks that the use of microprocessors offers. One can easily become a victim when participating in e-mail and chat groups wherein others are using false identities, often for a specific purpose such as sexual predation. Technology change has outstripped the legal system’s ability to provide basic protections. Even where economic damages can be claimed, such as false information engendering stock price swings, prosecution has been scant. Meanwhile, there are almost daily reports of data security breaches involving thousands of people (see http://datalossdb.org/).
DIAGNOSTIC DILEMMAS
There has been an animated discussion of terms such as “Internet addiction,” “pathologic computer use,” “pathologic Internet use,” “e-mail addiction” (see above), and the like in the popular press, where the concept of addiction is used to describe a much less serious phenomenon than what clinicians usually mean by “addiction.” With increasing use of microprocessors, the terms have progressed from being jokes to being taken seriously. In considering whether the microprocessors are a bona fide substrate for addictive processes, it is important to present some caveats:
■ Using the computer, cell phone, or video game is not intrinsically illegal, although the media can be used for that purpose.
■ Using the computer, cell phone, or video game is generally normal, prosocial, encouraged behavior.
■ There is a learning curve to information acquisition, time management, and social behavior when people experience these new and powerful tools (think about pedestrians walking in city streets holding their cell phones that block their view of oncoming traffic or listening to iPods, which attenuate their ability to hear important auditory cues from without).
■ People can be very engaged in microprocessor use without its being pathologic.
■ Calling maladaptive microprocessor-related behavior pathologic rather than, say, a bad habit may medicalize what is in actuality a social problem.
Unanswered questions thus arise in the context of considering whether Internet addiction is a discrete disorder and whether it is an addiction or some other type of disorder:
■ Are most surveys that present high rates of pathological Internet use (PIU) suffering from selection bias?
■ Is the term Internet addiction overstated and overgeneralized (i.e., are there too many false positives determined by current screening instruments)?
■ Is it the technology or that which it enables that people may become addicted to?
■ Does the use of the Internet as a conduit for other disorders such as pathologic gambling or compulsive sexual behavior become in itself a substrate for addictive process?
■ Is Internet addiction a component of another disorder, or, if a discrete disorder, does it frequently cooccur with other mental disorders?
Martin and Petry debated whether non–substance-related addictions (i.e., behavioral addictions) were really addictions (12). In this debate, Martin pointed out that addiction as a process requires transformation of basic survival-oriented drives into misdirected or overly frequent actions that leave less time for more adaptive functioning.
Internet addiction disorder (IAD) was codified by Young (13) as an eight-item polythetic diagnostic set modeled on pathologic gambling. Recent neuroimaging studies have demonstrated altered regional cerebral activity and structural changes associated with IAD in ways generally consistent with studies of drug and behavioral addiction (14). Positron emission tomography studies have demonstrated that compared with normal users, individuals with IAD have increased glucose metabolism in the right orbitofrontal cortex, the left caudate, and the right insula and decreased metabolism in the bilateral postcentral gyrus, the left precentral gyrus, and the bilateral occipital regions (15) and, in men, decreased dorsal striatal dopamine D2 receptor availability that is inversely correlated with IAD severity, consistent with the substrates of reward deficiency hypothesized in substance use disorder (SUD) (16). Dong et al. (17) examined neural correlates of response inhibition using event-related functional magnetic resonance imaging (fMRI) in 24 males without SUD performing the Stroop task; among the group (n = 12) who had Internet gaming–related IAD (score > 80 on the Internet addiction test (18)), there was greater activity in the anterior and posterior cingulate cortices, consistent with impaired inhibitory control and decreased cognitive efficiency of response inhibition processes (17). In addition, among Internet gamers with IAD, diffusion tensor imaging demonstrated abnormalities in the posterior cingulate cortex and thalamus with higher fractional anisotropy in the thalamus associated with greater severity of Internet addiction (19). Among adolescents (n = 18) with IAD, demonstrated that decreased gray matter volumes in the bilateral dorsolateral prefrontal cortex, the supplementary motor area, and the left ros-tral anterior cingulate cortex (rACC) as measured through voxel-based morphometry and increased white matter fractional anisotropy of the left posterior limb of the internal capsule as measured through diffusion tensor imaging, were significantly correlated with the duration of Internet addiction (20). These results suggest that long-term IAD may lead to structural brain changes and altered function, although a causal relationship has not yet been established. However, one might expect increased coherence in tracts carrying information about finger movement and motor imagery (posterior limb of the internal capsule) given the man hours Internet game addicts spend on game play with manipulation of keyboards, mice, and/or joysticks.
In considering whether Internet addiction is a real disorder, an approach different from the DSM-IV polythetic approach may be useful in creating a narrow construct within which to categorize Internet addiction. In a monothetic approach, all criteria must be endorsed in order to give a diagnosis, and it should have high sensitivity for diagnosing true positives. If a monothetic approach can be constructed that has good construct and predictive validity, then expanding out from that may allow a criterion set that has reasonable clinical utility in reducing false negatives. Griffiths (21), in considering the necessary components of addiction that would subtend diagnostically both chemical and behavioral addictions, identified six necessary domains based on the work of Brown (22,23) in modeling problem gambling 'margin-top:18.0pt;margin-right:0cm;margin-bottom: 3.6pt;margin-left:16.2pt;text-align:justify;text-indent:-16.2pt;line-height: normal'>■ Salience: The drug or behavior has gained primacy in a person’s life, which can be a cognitive change, dominating the person’s mental life or, behaviorally, dominating a person’s activity in a compulsive fashion.
■ Mood modification: The substance or behavior subjectively gives one a rewarding high or alleviates a negative mood state.
■ Tolerance: The person must increase the amount or intensity of the substance or behavior in order to achieve the desired effect.
■ Withdrawal symptoms: After stopping or reducing the substance or behavior, the person demonstrates either physical symptoms after or dysphoria characterized by irritability, mood lability, depressive symptoms, and so on.
■ Conflict: The person has conflicts regarding the use of the substance or the behavior that manifests as either interpersonal (e.g., marital strife) or intrapsychic (e.g., guilt).
■ Relapse: After a period of abstinence, the use or behavior is reinstated with the same intensity.
Proponents of a polythetic approach to Internet addiction modeled after DSM-IV substance dependence might point out that one of the hallmarks of the modern concept of addiction is the idea of loss of control despite negative consequences, which is embodied in several of the DSM-IV criteria and not included as one of the six necessary domains of the monothetic approach. However, compulsive behavior in the salience category accounts for the symptom of loss of control.
It may be argued that problem Internet use better fits criteria for DSM-IV disorder groups other than the substance-related disorders (i.e., Internet addiction). This is what was behind the differing nomenclature, such as Pathological Internet Use, which is modeled after pathologic gambling, a DSM-IV impulse control disorder (ICD) diagnosis, which has been moved as gambling disorder to the substance-related and addiction disorders in DSM-5 (24). For example, problem Internet use has been proposed as an obsessive– compulsive disorder (OCD) spectrum disorder. However, in compulsive disorders such as OCD, the intrusive thoughts or compulsive behaviors are typically ego-dystonic, whereas in PIU, the preoccupation is ego-syntonic and pleasurable. While most OCD patients are anxious and full of doubt and tend to avoid risk, others dispel their obsessions and resultant anxieties through compulsive Internet use (CIU). Patients with problem Internet use tend to underestimate risk. Shapira et al. (25), using the SCID, Internet use history, and a Yale-Brown Obsessive-Compulsive Scale modified for Internet use, examined 20 recruited volunteers or referred patients with problematic Internet use characterized as uncontrollable, markedly distressing, time- consuming, or resulting in social, occupational, or financial difficulties and not solely present during hypomanic or manic symptoms. In general, the subjects had, in contrast to patients with compulsive disorders, low levels of distress and resistance to excessive Internet use. Their problem Internet use symptoms were highly impulsive, with all subjects meeting DSM-IV criteria for an ICD not otherwise specified, whereas only 15% subjects met DSM-IV criteria for OCD based on their problem Internet use. However, this uncontrolled study had a small sample size and a clear selection bias, so generalizing from the results may be problematic. Nonetheless, like pathologic gambling, PIU could be conceived as an ICD, and several authors have proposed this (5,26–28). In fact, a cross-sectional association analysis of n = 81 subjects equally grouped into IAD, pathologic gambling, and normal controls revealed that those with IAD have increased trait impulsivity comparable to those with pathologic gambling and a positive correlation of trait impulsivity to IAD severity (29). Similarly, Meerkerk et al. (30) explored personality correlates predictive of CIU, an IAD proxy, and demonstrated in a survey among n = 304 respondents who met criteria (score > 28) on the Compulsive Internet Use Scale (CIUS) that dysfunctional impulsivity (i.e., rash spontaneous, including constructs of novelty seeking, sensation seeking, behavioral undercontrol and disinhibition) was the strongest predictor of CIU compared to reward or punishment sensitivity (30).
Hallmarks of ICD are repeated failure to resist impulses that are harmful to self or others and tension or arousal before and pleasure or relief during the act, followed by guilt or self-reproach. However, this may not necessarily be the case in patients with problematic Internet use and will need to be explored with larger epidemiologic studies and more refined research of potential diagnostic criteria. In addition to symptoms that overlap with impulse control disorders (e.g., intense preoccupation with Internet use, CIU, loss of control over online time), however, Internet addiction also shares symptoms with behavioral addictions, such as development of euphoria, craving, and tolerance (31). The DSM-5 workgroup had at one point been contemplating problematic Internet use as a compulsive– impulsive disorder in the group of ICDs (28). As such, it may be that the placement of what may be considered Internet addiction among the DSM-IV impulse disorders was an artifact of the failure to expand the category of substance-related disorders to broader diagnostic category that includes non–substance-related “behavioral addictions.” The monothetic approach to addiction described above supplies one potential model for building that category (21). The utility of a monothetic approach is that in requiring all symptoms to be present, if any subgroup of those with problem Internet use fits the criteria, then the high specificity should make it easier to validate as a disorder. In order to provide construct validity of the monothetic model, it remains to objectively demonstrate tolerance and perhaps physiologic or neuroimaging concomitants of withdrawal that are more than reported withdrawal-related dysphoria (although dysphoria may be sufficient for a polythetic approach, as it is in pathologic gambling) (32). Assuming high construct validity, if anyone has Internet addiction, it is someone who meets monothetic criteria. As is, in DSM-5, Internet Addiction has been reduced to Internet Gaming Disorder and placed in the appendix, and the placement of Gambling Disorder in the substance-related disorders raises the possibility of other behavioral addictions ultimately being validated as belonging to that group (24).
Another approach to developing stable and valid criteria for Internet addiction has been to build a bottom-up construct of most frequent symptoms from factor analysis of a group. Pratarelli and Browne (33) conducted a 94-item anonymous survey in college students (n = 524) and demonstrated the nonindependent factors: Internet addiction (preoccupation, external complaints, less sleep, food, exercise, and punctuality) (salience), sexual (downloading graphic sexual material), and an Internet use factor (excessive use for professional, educational, gaming, shopping activities, etc.). When the data were best fit to a structural equation model, the addiction factor was primary and causal to sex and use factors rather than vice versa. Charlton (34) performed a factor analysis on 47 variables derived from the six-factor mono-thetic model of addiction described above (21–23), with added items that evaluated engagement (computer apathy/ engagement and computer anxiety/comfort) from data collected from a survey of 404 college and graduate students. The addiction factor loaded upon all items of the monothetic model behavioral addiction criteria supporting the construct validity of this model of computer addiction. However, the engagement factor also loaded upon tolerance, euphoria, and cognitive salience, demonstrating that these factors are not unique to addiction. This suggests that high computer engagement is part of the structure of “computer (includes Internet) addiction” but is not necessarily pathologic in and of itself. One can be highly engaged in Internet use without negative consequences. Beard and Wolf (35) describe a woman who is preoccupied by thoughts; desires increased time spent in activity; is unsuccessful or unable to control or cut back interactions; is restless, anxious, or moody when not interacting; and interacts for longer periods than intended. Without a defined substrate, the symptoms seem ominous in the example above, but the high engagement of this woman for her baby is not pathologic, and the authors suggest that additional requirement of impairment in a person’s daily functioning (i.e., jeopardized loss of relationship or work/ educational opportunity, lied to significant others to conceal extent of Internet involvement, or used so as to escape problems or relieve dysphoria), over and above symptoms of high engagement, is necessary for a diagnosis of Internet addiction. This find is paralleled in the work of Ko et al. (36), who in establishing a criterion set for adolescent Internet addiction that had high diagnostic accuracy and specificity, as well as good sensitivity, determined three main criteria: characteristic symptoms of Internet addiction not dissimilar from DSM-IV substance-dependence symptoms, an exclusion criterion, and functional impairment due to Internet use.
Since the Internet is here to stay, future work will probably need to differentiate the substrates of behavioral addiction from an overall diagnosis of IAD, much as SUDs are classified according to substance used, for example, alcohol, stimulants, and sedative–hypnotics. The most likely domains are sexual content, video gaming, and gambling/day trading and eventually perhaps social networking/ live interfacing (including chat, texting, video), shopping/ auctions, netsurfing, and music/video downloading/torrenting. At present, only Internet gaming disorder is included as a proposed diagnostic category in Section 3 of DSM-5. Much as social networking is a recently invented phenomenon, there may be future Internet applications that end up as new substrates for Internet addiction. Inquisitive folks are at risk for falling down the Wiki rabbit hole because the hypertext content links can bring one to interesting new content pages in an infinite regress, but evidence of this at a disorder level has not yet been reported.
Recent evaluations of social network sites demonstrate that they are used for social purposes, mostly related to maintenance of already established offline networks, and there has been scant documentation of pathologic use (37). Kuss and Griffiths (37) identified interesting correlates of social networking related to increased use, such as social enhancement in extraverts with high self-esteem and social compensation in introverts with low self-esteem, as well as high narcissism and low conscientiousness. In addition, they found correlates that might signal addiction vulnerability, such as decreases in academic achievement, non-Inter-net community participation, and relationship problems.
Chemical addictions occur at high rates with other mental disorders in the population, so it would not be surprising to see a related pattern in those with behavioral addictions (38). Carli et al. (39) conducted a systematic review of 20 studies of the correlation of PIU, as assessed by the Internet addiction test (IAT) and other scales, with other psychopathology and found among the mostly Asian cross-sectional studies, consistent and strong correlation of PIU with attention deficit hyperactivity disorder (ADHD) and depression. Among online gamers (n = 722) who filled out a survey questionnaire, weekly online gaming time was averaged 28.2 ± 19.7 hours and was significantly and linearly associated with severity of depression, social phobia, as well as Internet addiction scores (40).
ASSESSMENT
Talking to patients, one can discuss the intensity and impact of their use of microprocessor-containing devices and assign general risk categories based upon the information provided. A simple screening cutoff can begin to establish whether use is “normal” or problematic. From there, it becomes more difficult to establish what one is dealing with, owing to the lack of scientific consensus as to whether certain types of maladaptive microprocessor use rise to the level of disorders, what type of disorders they may be, and what the criteria are for those disorders. As discussed above, functional impairment is a good marker for a clinically relevant misuse of microprocessors (41).
Use: A reasonable time spent accomplishing specific goals using microprocessors, such as a Google search on “pathologic computer use” (243,000 results) or getting back your dog that strayed because the staff at the pound found the chip under his skin with your name and telephone number. Remember that high engagement does not necessarily mean pathology.
Problem use: One can conceptualize this as use with trouble in that the use is causing clinically significant impairment. The issue here is the repeated taking on of undue risk, getting oneself into legal problems, the interference with fulfilling major role obligations, or continuing the microprocessor use in spite of recurring social or interpersonal problems. These parallel the abuse category for the DSM-IVsubstance-related disorders. IM while driving is risk taking and increasingly illegal, yet emerging as more accident related in some jurisdictions than a handheld cell phone. A mother showed author ZT her initial failure to limit her daughter’s IMs to 500/d—one printout showed more than 3,000—“She’s here but she’s not here.”
Dependence: The patient experiences that he or she can’t get along without it. Here, the problem is the level of functioning. Can we get by without the facts so easily pulled off the Internet? Can you calculate as well or as fast as your spreadsheet? Can you avoid e-mail for a day a week, as is increasingly recommended in the popular press? As with most dependencies, there may be a false sense of being in control and “able to stop any time” when one cannot.
Though some describe addiction as a severe form of dependence, many reserve this term for physiologic dependence, as evidenced by withdrawal symptoms. Symptoms such as nervousness, aggression, agitation, insomnia, anorexia, tremulousness, and depression have been noted after microprocessor deprivation. While one can argue that use of an exogenous substance is necessary to produce the physiologic changes of true addiction, it is increasingly evident that the body and brain change in response to the environment. Whereas the brain is composed of chemicals, its final pathway of action is electrical, and input from computers increasingly taps into cerebral rhythms. Virtual reality, use of smell, more sophisticated visual and auditory inputs, and probably other paths into the brain will increase influence on the brain. However, at least one study (42) found surprisingly that the interactive functions of the Internet are not as addictive as other functions such as salience, lack of control, or anticipation. Substance addiction can result from buying addictive substances through the Internet, where enforcement has been unsuccessful against thousands of sites offering prescription drugs and a handful of sites openly offering cocaine, heroin, synthetic cannabinoids, and other illegal substances (43).
INTERNET CHARACTERISTICS
The Internet offers many advantages over other agents with high liability for abuse and dependence (44), including the following:
■ Always available: 24/7, lending itself to impulsive access and marathon sessions
■ Convenient: No need to leave home or work (those caught downloading pornography or playing games at work are the tip of the iceberg)
■ Inexpensive: Now just the cost of the hookup. Internet addiction was a problem when users were paying $800 per month access fees (5). There are no dealers to pay.
■ Rewarding: Content-rich, with Web sites consistently present and calculated to please; increasing, mostly benign interactivity; a continuous flow of new sites that offer novelty, more videos everyone is talking about, all developed and distributed at an ever-increasing pace.
■ Controllable: The user can go wherever desired and leave at will. Of course, addicts usually feel they can stop at any time. Users can better control others’ access to them but still interact.
■ Escapist: Sites of interest to the potentially addicted offer a welcoming reality in which all sex partners are attractive and interested and bets are likely to be won. Some women are attracted to the Internet because they can act like men (45), whereas introverts can act like extroverts (46).
■ Validating: One can find that which caters to one’s interests and tastes, thus verifying that these are legitimate because others feel the same way. The Internet is always at least nonjudgmental, unless one chooses a role-playing mode wherein negative feedback is part of the social context but positive judgments can be found readily.
The Internet may differentially support addictive process as Internet communication is anonymous, isolated from normative feedback, and provides easy access to reinforcing stimuli. Powerful search engines aggregate special interest groups and provide virtual and real communities where fringe behav-iors and beliefs are consensually validated (47). Given that some of the vulnerability to problem use of the Internet is due to the social learning curve regarding these novel technologies and applications, some of the risks of Internet addiction might be ameliorated through education and training (48).
TREATMENT MODEL
Theory of Change
Motivation is key. If rewards are the issue, others must be found. If obsessive–compulsive concerns are more important, efforts and medication are directed at developing different habits and thought patterns. Recovery is about learning to avoid triggers for impulsive Internet use, making use of social support for healthy reinforcers found in everyday life, and relearning how to use microprocessors in nonpathologic ways.
TREATMENT PLANNING
Evaluation–Diagnosis
Parents are often limited by technologic naïveté from understanding what their children may be experiencing and doing, adding a dimension of complication to the evaluation they may present.
Is there a need for a new diagnostic category? Possibly, as incidence estimates for Internet addiction range from 1% to 3% of the American population (49). It is not in the Diagnostic and Statistical Manual(DSM) of the American Psychiatric Association, currently being revised. However, the addiction field is used to epidemics of powerfully rewarding substances that die down and become endemic. There seemed to be no end to the crack cocaine epidemic of the 1970s and 1980s—much was made of rats pressing levers to inject cocaine into their brains until they died (50)—but it did end. We have had more than a decade of concern about pathologic computer use, and use and abuse are increasing.
The diagnostic divides are among addiction, impulse control (non–substance-based reward), and compulsive disorders. The addiction field is familiar with reward mechanisms, dopamine medication, conditioned cues, and the like. Rewards usually are related to content or specific activities, such as pornography, gambling, and so on. Diagnoses related to these specific areas are well established and should be used, although, for example, pathologic gambling had been classified by DSM-IV as an ICD rather than as an addiction under the substance-related disorders category, where it has now been placed in the DSM-5 as Gambling Disorder. There remains a population that compulsively uses devices without seeming to get much gratification. They don’t feel good, but not doing it leads to feeling bad. Addiction clinicians will recognize this state of compulsive use that is frequently seen in crack addicts using in spite of the lack of “liking” or heroin addicts shooting up in order to “get straight.” Compulsive device users rearrange files, check e-mail too often, get on mailing lists that shower them with trivia, and so on. Frequently, they meet criteria for a compulsive disorder.
Rating scales serve as diagnostic aids and, in offering objective data for feedback in motivational approaches, can help patients to realize the extent of their problems. Several are available, but that from the Center for Recovery from Internet Addiction, the IAT (http://netaddiction.com/resources/internet_addiction_test.htm) is best established, having been filled out by thousands of visitors to its Web site (5). Its 20 questions are answered on a five-point scale (with a sixth alternative: does not apply). A score of 100 is possible, with ranges of 20 to 49 indicating average online use and 50 to 79 indicating occasional or frequent problems using the Internet and the “need to assess their full impact on your life.” The questions get at staying on longer than intended, neglecting household chores, preferring the excitement of the Internet to intimacy with one’s partner, forming new relationships on the Web, others complaining about the amount of time one spends online, decreased productivity (grades, school work, job), checking e-mail before something else one needs to do, defensiveness or secretiveness when asked about online activities, blocking out disturbing thoughts about one’s life with soothing thoughts about the Internet, anticipating going online, thinking life would be empty and joyless without the Internet, irritability if bothered while online, losing sleep because of late-night use, preoccupation or fantasies while offline, rationalizing extra time online, attempts to reduce online time, hiding how long online, choosing online versus socializing, and depression and moodiness when offline remedied when online. Many of these items correspond to similar items in the DSM-IV-TR diagnostic categories of substance abuse and substance dependence (51). The scale can be used by significant others, who usually insist on treatment for reasons common to other addictions: a sense of losing the loved one whose life has been taken over by the addiction, significant impairment in activities, and relationships, all usually minimized by the patient. Widyanto and McMurran (2004) recruited 86 participants through the Internet who completed a Web version of the IAT with some added items, factor analysis of the IAT revealed six factors, which showed good internal consistency and concurrent validity: salience, excessive use, neglecting work, anticipation, lack of control, and neglecting social life (42).
INDICATIONS FOR TREATMENT
Patients and families understand and feel impairment, so responses to the scale above and issues of morbidity and mortality can help all concerned understand indications for treatment.
Mortality
Murder and suicide have been reported after microprocessor deprivation, usually an adolescent killing the depriving parent or demonstrating through suicide that life without the microprocessor is not possible. Many of these cases have occurred in South Korea where Internet and microprocessor use is among the highest in the world. One study found that among 452 South Korean adolescents, Internet addiction identified by the IAT was significantly associated with depressive symptoms (52).
Morbidity
Morbidity occurs at several levels. The amount of time spent with microprocessors results in necessary tasks going undone. Real-life social relationships get less time, and what may be thought to be more satisfying relationships are developed on the Internet. Impairment can be difficult to tease out but, as described above, becomes a crucial component of a diagnosis over and above high engagement. The patient is not necessarily a recluse but can document that those hours spent in his room involve communicating with “friends” around the world to play “World of Warcraft.” Objective observers may rate these relationships less favor-ably, often reminiscent of an alcoholic’s drinking buddies. Managing multiple identities can be taxing, and identity fragmentation occurs if one’s Internet persona is markedly different from one’s real-life persona. Clinicians have to assess cyber relationships in detail. Some patients present as having lost touch with what is the “true” reality. Impairment may also result from physical activity of prolonged sitting in front of screens, with increased obesity and less exercise. Decreasing use of national parks, 4 million fewer golfers, and a decline in outdoor activities may be related to increasing use of microprocessors. However, inactivity is preferable to accidents that occur while multitasking. The American College of Emergency Physicians (2008, http://www.emergencycareforyou.org/YourHealth/InjuryPrevention/Default.aspx?id=1240) responded to increasing reports of injuries related to being hit or falling while texting by issuing an alert against “text walking.” It may seem to be common sense that people should watch where they are walking, but the number of vehicle hits, falls, and running into trees, lamp posts, and other people has become noticeable in emergency rooms across the country.
PRETREATMENT ISSUES
Motivation—Rationale for Choice of Treatment
As with most addictions, motivation prior to engagement in treatment may be scant or absent. Problems are mini-malized, rationalized, or denied. A nonconfrontational discussion of impairment often helps the patient to gain perspective. This can be done using the principles of motivational interviewing, where the facts about the impact of microprocessor overuse are carefully elicited and then fed back to the patient in a nonjudgmental manner (53). This helps the patient to use his or her native analytic capacity and values in determining that the overuse is actually problematic or impairing and helps to tip the decisional balance toward seeking help to reduce the problem.
An important way station between Internet addiction and returning to the real world is more therapeutic use of the Internet and microprocessors. This is somewhat of a departure from the abstinence-oriented approach of classic addiction treatment. A mother was successful in restricting her daughter’s IM from 3,000 per day to 500 and then 200. Online support groups are thought to help, but a review of 38 controlled studies of illness (not just Internet addiction) support groups found no robust evidence of effects, in part because most were measuring complex interventions (54).
Selection and Preparation of Patients/Suitability
Unlike the subpopulations that comprise the sufferers of many chemical addictions, microprocessor abusers are technically competent, often innovative, and well educated (55), which makes them more suitable as a group for clinical interventions. However, the subpopulation has been demonstrated to have high rates of current and lifetime co-occurring mental disorders, which tend to have a negative impact upon recovery (25). Retreat into cyberspace may mask co-occurring social phobia and/or other anxiety disorders.
Therapist Characteristics
Familiarity with the Internet and uses of microprocessors and technology are important both for understanding patients, expressing empathy, and earning respect and credibility with patients, all of which are associated with better treatment outcomes (56).
Treatment and Technique
Choice and Timing of Interventions
When parents or significant others are in control, taking away or restricting access to the microprocessor may increase motivation or result in destructive anger, so clinicians must expect to hear about and perhaps participate in whatever decision is made. However, similar to binge eating and other disorders of compulsive food intake, complete abstinence is usually not a feasible long-term treatment goal, as use of microprocessors is unavoidable in today’s world, and nonuse is associated with significant vocational and social disadvantage.
General and Stage-Specific Interventions
The general plan is reintroduction into the real world, which must be done in stages to ease transitions. It is a desen-sitization process, with small steps to be taken that will bring about a sense of success and increased self-esteem. Where identity issues predominate, the successful elements of the Internet identity should be characterized, and there should be an open discussion of integrating these into the real-world persona. Therapy should be seen as a rewarding process that helps the patient get in real life what has been available only on the Internet. This is consistent with community reinforcement principles in replacing the rewards of the abused substance with more natural and socially appropriate reinforcers (57). With compulsive patients, the therapist can take responsibility for the compulsive behavior and relieve the patient’s anxiety. Medication treatment for co-occurring OCD and/or anxiety can be helpful. Clearly, treating co-occurring mood, anxiety, psychotic, and SUDs is likely to be helpful in supporting recovery from involvement of significant others and is key to supporting recovery and reintegration into the real world. Social skills training may also be helpful.
RELEVANT TREATMENT RESEARCH
There is little relevant treatment research because funding agencies have not yet recognized the problem as deserving much attention (i.e., significant clinical impact, public outcry, or political will). The development and use of the Internet are seen as an enormous technologic advance. More and more material is being made available on the Internet, and its legitimate use is increasing exponentially. There is strong commercial support for Internet use, as the Internet generates huge advertising revenues and is used to sell many products. Complaints about Internet addiction can be seen as spoiling the party. The American Medical Association called in 2007 on the National institutes of Health and the Centers for Disease Control to start research programs in Internet addiction, but no grant programs have as yet been announced. As such, much of the available epi-demiologic and treatment outcome research devoted to Internet addiction has been based upon case studies and survey data, of which Internet-based surveys can be driven by the motivation of the responders and thus subject to selection bias.
Efficacy
Winkler and colleagues conducted a meta-analysis of the extant treatment research for IAD, including studies with various Internet-related problems, and found evidence in pre–post analyses for effective treatment of IAD, time spent online, depression, and anxiety (58). Yellowlees and Marks (59) suggest that given that cognitive process maintains IAD, appropriate psychotherapeutic strategies would include cognitive restructuring focused on the Internet applications of choice, behavioral exercises, and graded exposure therapy with increasing duration of offline activity. An uncontrolled trial of cognitive– behavior therapy (CBT) specifically focused upon Internet addiction demonstrated efficacy in reducing pathologic Internet usage and improving online time management among 114 patients who were screened with the IAT (55). Regarding pharmacotherapy for IAD, one study reported therapeutic success with escitalopram, a selective serotonin reuptake inhibitor antidepressant (60); however, the active treatment phase was open label. Han and colleagues treated male Internet video gaming addicts (n = 11) with sustained release bupropion titrated to 300 mg/d over a 6-week period and compared them to healthy controls who had the same video game preference as the experimental group, but not pathologically. Not only were the total amount of time spent playing, related maladaptive behaviors, and video game craving reduced at 6 weeks and significantly correlated with the drop in time spent playing, but video cue-induced brain activity in the dorsolateral prefrontal cortex, as assessed by fMRI, was also reduced from baseline (61). An 8-week trial of methylphenidate for ADHD (mean dose 30.5 mg/d) in Korean children (n = 62) examined the impact on measures of Internet addiction and Internet usage as well as ADHD symptoms and visual continuous performance test function and demonstrated reduced inattention and impulsivity–hyperactivity scores, as expected, as well as significantly reduced scores on hours of Internet use and the Internet Addiction Scale, which was significantly correlated with the decrease in ADHD symptoms (62). Additionally, a single case study reported, after failure of multiple antidepressant trials as well as psychosocial and self-help approaches, successful treatment of Internet-based sex addiction with up to 150 mg/d of oral naltrexone when added to a baseline of sertraline 100 mg/d, which supported normalized social, occupational, and personal function (63). Interestingly, in the prospective case series of recruited and treatment-seeking pathologic Internet users described above (25), there were high rates of current comorbid bipolar depression that responded to anticonvulsant treatment (with or without adjunctive antipsychotic or antidepressant agents) with both normalization of mood and moderate to marked remittance of pathologic Internet use. However, it is important to note that if IAD follows suit with chemical addictions, then effective treatment of co-occurring other mental disorders will generally have effect sizes insufficient to treat the IAD (64).
Effectiveness—External Validity
The usual addiction treatments (AA-type groups and other treatments described in this book) have been reported to be effective in case studies or vignettes, but there are no controlled studies of psychosocial treatments other than CBT. Likely validity for these approaches is derived from recognition of the applicability of the impulse control/OC model of addictions to microprocessor abuse but will require controlled trials of standardized interventions in target populations using established and validated diagnostic criteria and outcomes measures.
SUMMARY AND CONCLUSIONS
Use of microprocessors continues to increase rapidly as these are placed in a wide variety of communication and amusement devices. These devices are always available, cost little to use, and provide many rewards. About 1% of the US population uses them to the point of abuse, dependency, and addiction. These problems are likely to increase as microprocessor use and power continue to increase. While sharing many commonalities with other addictions, microprocessor abuse differs in that no exogenous substance is involved and patients are technologically savvy and computer literate and are able to manipulate their identities in cyberspace.
Even without resorting to a pathology model, current societal adaptation to the use of microprocessors can, at its most extreme, be likened to the London gin epidemic, where citizens previously comfortable with a culture that drank beer and ale, frequently to intoxication, had to adapt poorly to a new more potent alcoholic liquid, with disastrous results in a population that was already ripe for social unrest (65). Eventually, the culture moderated its use more globally, leaving the bulk of maladaptive and damaging alcohol-related trajectories to those with alcohol use disorders. It may be that our culture is on a similar path, and in the wake of our corporate learning curve will be those for whom microprocessor is a substance fulfilling its role as a substrate for a pathologic use disorder (2,25,49,63,66–68).
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