Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses.
We propose a screening tool called “MOUSE” and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:
- How does problematic Internet use present?
- Is it an addiction or an impulse control disorder?
- How can we help those afflicted with this problem?
When Internet use goes over the line
Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:
- an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function1
- and employment and relationships are jeopardized by the hours spent online2 (Box).
HARMFUL EFFECTS OF PROBLEMATIC INTERNET USE
Relationships—particularly marriages but also parent-child relationships, dating relationships, and close friendships—appear to suffer the greatest harm. At least one-half of “Internet addicts” (53%) report that their Internet use has caused serious relationship problems.
School. Academic problems are common; one study showed 58% of students blamed Internet use for a drop in grades, missed classes, declining study habits, or being placed on probation.
Workplace. Many executives—55% in one study—complain that time spent on the Internet for non-business purposes reduces their employees’ effectiveness.
Health. Some users spend 40 to 80 hours per week online, and single sessions can last up to 20 hours. Lack of sleep results in fatigue, decreased exercise, and decreased immunity. Sitting in front of the computer for hours also increases the risk of carpal tunnel syndrome, eye strain, and back pain.
Other addictions. The more time spent on the Internet, the greater the user’s risk of exposure to other addictive activities, such as online gambling and sexual solicitations. This risk is particularly concerning in children and adolescents.
Source: Young KS. Innovations in Clin Pract 1999;17:19-31.
Case: Computer gamer out of control
Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.
He is taking no medications. The only clinically significant family history is his father’s apparent OCD, undiagnosed and untreated.
Mr. A’s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.
Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week—nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:
- 35% in chat forums, communicating with gaming partners he has never met
- 25% in multi-player, video/strategy games
- 15% using e-mail
- and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).
He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.
Internet overuse: An ‘addiction’?
Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke.3 He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.4,5
Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder.5-8 Shapira et al studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.1