Internet addiction

DEFINITION: Internet addiction (IA) represents a controversial compulsive-impulsive spectrum disorder, characterized by excessive, time-consuming, and uncontrollable use of various internet applications. This abnormal use results in social, occupational, or financial difficulties. Although not considered a formal diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the disorder is formally recognized by the American Psychological Association.

ALSO KNOWN AS: Compulsive internet use; excessive internet use; internet addiction disorder; internet-enabled compulsive behavior; pathological internet use; virtual addiction; web addiction; internet use disorder; internet gaming disorder

Causes

Some researchers have suggested that problematic internet use stems from introversion, inability to communicate directly with others, and social isolation. Other experts have developed models to explain the etiology of this puzzling disorder.

One cognitive-behavioral model states that internet use provides a way to escape real or perceived problems, often for persons who tend to overgeneralize and hold catastrophic and negative views of reality. The anonymous character of the internet appeals to persons with low self-esteem and with negative thinking. The internet offers a nonjudgmental environment and induces an artificial feeling of self-worth and belonging.

The compensation theory, promoted by Chinese researchers, maintains that the internet serves a spiritual compensatory function and represents an avenue for forming social networks in an increasingly demanding and threatening society. Another explanation centers on the neurophysiology of internet use and the pleasurable, euphoric effect it induces. This effect leads to a host of phenomena, such as reinforcement (in mitigating loneliness or social awkwardness), repeated use, tolerance, and withdrawal, all of which are analogous to other addictions. Finally, some research indicates that situational factors, including the loss of a loved one, unemployment, and relocation, might prompt a person to seek solace on the internet, thereby precipitating the development of IA.

Risk Factors

Internet access occurs anywhere, anytime. Although fraught with issues of sampling and standardization, a large body of research confirms the existence of problematic internet use across cultures and age groups. IA, a newer disorder, is more prevalent in young and middle-aged people, especially males and college students. Homemakers also appear to be at risk for the disorder.

The status of the internet in modern culture ensures that all susceptible persons (that is, persons with a genetic predisposition to addiction or those with psychological disturbances) spend time on the internet and can develop IA. Persons undergoing life-changing events (such as bereavement, divorce, or job loss) are more vulnerable to developing problematic internet use. In some young persons, studies show, the pressure to succeed can lead to internet overuse as a means to relieve the stress.

Socially isolated persons and persons with attention deficit hyperactivity disorder (ADHD), depression, and other psychological disorders are at an increased risk for developing IA. Depression, ADHD, social phobia, and hostility predicted the occurrence of IA in follow-up studies. Hostility and ADHD were the most important predictors of IA in male and female adolescents, respectively. Persons with multiple addictions have a high risk of becoming addicted to the internet and to subsequently relapsing.

Symptoms

IA lacks formal diagnosis criteria. Many researchers still consider excessive internet use a compulsive, rather than addictive, behavior. In addition, some think of it as a coping mechanism, a symptom of underlying psychological abnormalities, or even a lifestyle change inherent to technological advances. Significant progress has been made, however, in diagnosing IA since it was first described in the mid-1990s. The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, included internet gaming disorder in Section III as a disorder that warrants more clinical research before it can be considered for inclusion as a formal diagnosis, signaling increased acceptance in the psychiatric community for the existence of internet addiction; however, the DSM's criteria for the condition are limited to internet gaming and do not include problematic use of the internet in general or of social media.

Overall, the fundamental components of the addictive process, in some ways similar to gambling addiction, are the following: preoccupation with internet use, greater usage than desired, numerous unsuccessful attempts to reduce usage, withdrawal (with anger and tension when not online), tolerance (including the need for more hours and better equipment), and lying about internet usage. The DSM criteria for internet gaming disorder include playing internet games compulsively, to the exclusion of other interests; causing clinically significant impairment or distress due to internet gaming; experiencing withdrawal; and incurring negative consequences at school or work.

Several subtypes of problematic online behavior exist, as the criteria for internet gaming disorder indicate. These subtypes include addictions to gaming, gambling, sexual activities such as viewing pornography, shopping, social media use, and email or text message exchange. Affected persons also may overuse digital devices such as smartphones and tablets. Some of these behaviors likely indicate underlying psychological disorders (such as gambling and compulsive shopping), while others represent internet-specific behaviors (such as gaming, texting, and browsing). The affected person might turn to the internet when feeling lonely and might establish online relationships.

Ultimately, the computer or other digital device becomes the person’s primary relationship. The affected person undergoes a cycle that rationalizes online behavior and that progresses through regret, abstinence, and relapse. These behaviors can damage relationships with family members and friends, further deepening social isolation. In addition, affected persons may experience difficulty setting and achieving goals, and may display poor attention skills, an inability to delay gratification, and poor school or job performance. One study suggested that young people who are initially free of mental health problems, but who use the internet pathologically, could develop depression as a consequence. Some people who present with depression, anxiety, or obsessive-compulsive manifestations later show signs of IA upon further examination.

In addition to mental problems, excessive internet use can lead to physical conditions. Using a computer for extended periods of time leads to weight gain, sleep deprivation, back pain, carpal tunnel syndrome, and vision impairment.

In 2024, researchers published a study that found a link between internet addiction in teenagers and impaired working memory. Using imaging devices, researchers gathered nearly ten years’ worth of evidence that indicated internet addiction impacted the brain’s ability to communicate between regions vital to executive function. That same year, Dr. Vivek Murthy, the US surgeon general, called for the addition of warning labels to social media platforms that declare the potential negative impact that social media can have on adolescents’ mental health.

Screening and Diagnosis

Unlike illegal drugs or gambling, for example, the internet has widespread legitimate uses in fields such as education, research, business, industry, and communications. In this context, IA can be easily masked. Therapists may not detect the disorder unless they look for it. To this end, they obtain a history of symptoms and previous treatment attempts, and information about other potential addictions.

Screening tests used include internet addiction expert Kimberly Young’s Internet Addiction Test (IAT) and multiple clinical interactions. Even so, diagnosing IA can prove difficult because of the lack of rigorous diagnostic criteria. Experts agree, however, that internet activities become problematic when the person loses his or her ability to control the use and when time spent online impairs daily functions and jeopardizes relationships, employment, education, and personal health. Studies generally indicate significant distress if internet usage exceeds twenty to twenty-five hours per week.

The first validated instrument to assess the disorder is the IAT. This questionnaire addresses the duration and frequency of online activities, job productivity, ability to form new offline and online relationships, fear of life offline, attempts to reduce internet use, and many other behaviors. The person answers each IAT question using a scale of 0 to 5. The higher the final score, the greater the level of addiction. In addition to the severity of the addiction, the therapist identifies the applications (such as gaming, pornography, and chat rooms) that are most problematic for a particular person. The assessment is completed by obtaining a history of earlier treatment attempts, identifying the most detrimental types of usage, analyzing the family environment, and conducting a motivational interview.

Treatment and Therapy

While China was one of the first countries to label IA as a clinical disorder, hospitals and clinics all over the world have established treatment centers and “detox” facilities for internet addiction. The programs aim to reconnect internet-dependent youth and adults to the offline world by temporarily eliminating all avenues for electronic communication or by gradually reducing online time. In the United States, Young founded and opened the country's first inpatient treatment program for IA in a hospital in 2013 at Bradford Regional Medical Center in Pennsylvania. A ten-day program, the treatment included evaluation, therapy sessions, and seminars. Since 2013, several other addiction treatment facilities have created their own IA programs. Although clinical research on internet addiction disorder is still rare as of the early 2020s, some studies have suggested that antidepressant medications and group therapy may offer some help.

Given society’s increasingly online nature, many therapists argue that traditional abstinence treatment models may not yield good outcomes, at least for some types of IA. Reorganization of the time periods usually spent online, using timers and reminder cards, and setting goals may help to limit the extent of online activities. Cognitive-behavioral therapy is often recommended as a first therapeutic approach, in addition to couples therapy (especially for networking and “internet infidelity” addictions), cultivating hobbies, home maintenance skill-building, and socializing opportunities.

The majority of individuals with internet addiction have an additional psychiatric diagnosis. In these persons, IA remains highly resistant to treatment and, in turn, can render the coexisting psychiatric disorder more difficult to treat. Consequently, any therapeutic attempt should consider the addict’s comorbid conditions and address them promptly.

Prevention

Despite providing undeniable benefits, the internet can be detrimental when used inappropriately or obsessively. An expanding body of research aims to clarify the causes, evaluation methods, and treatment outcomes for this phenomenon, which threatens to reach epidemic proportions. Meanwhile, persons at risk of IA, especially youth, can benefit from safeguards that ensure appropriate internet usage in schools and colleges. Setting limits for usage time is necessary for children and adolescents at home. Guardians and teachers should monitor and limit online time, especially among at-risk children with preexisting psychosocial difficulties.

South Korea has seen at least ten cardiopulmonary-related deaths in internet cafés and one murder related to online gaming. Also, because hundreds of thousands of South Korean youths age six to nineteen years are affected by and require treatment for IA, that country has identified IA as a prominent public health issue and started training counselors to address the problem. Competent, aware, technology-savvy professionals now help to identify populations at risk and provide correct diagnoses and therapeutic strategies.

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