As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.8
Diagnostic criteria. Although Mr. A’s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),9 which we define as:
- uncontrollable
- markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
- and not solely present during mania or hypomania.
Teasing out comorbid disorders
As in Mr. A’s case, Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.10-12
Although some researchers feel that the many comorbid and complicating factors cannot be teased out,13 most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.
A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.
Shapira et al1,14 found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black11 found:
- 33% had a mood disorder
- 38% had a substance use disorder
- 19% had an anxiety disorder
- 52% met criteria for at least one personality disorder.
On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.1,11
Table 1
PROPOSED DIAGNOSTIC CRITERIA FOR PROBLEMATIC INTERNET USE
| Maladaptive preoccupation with Internet use, as indicated by at least one of the following: |
|
|
| Source: Reprinted with permission from an article by Shapira et al9 that has been accepted for publication in Depression and Anxiety. © Copyright 2003 John Wiley & Sons. |
Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al15 hypothesized that the Internet use caused the depression. Pratarelli et al16 noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.
In a survey of college students, individuals with “Internet addiction” were found to:
- have obsessive characteristics
- prefer online interactions to real-life interactions
- use the Internet “to feel better,” alleviate depression, and become sexually aroused.16
Personality traits. In another study, Orzack12 found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of “Internet addiction disorder:”
- boredom
- private self-consciousness
- loneliness
- social anxiety
- shyness
- and low self-esteem.
Table 2
5 SCREENING QUESTIONS FOR PROBLEMATIC INTERNET USE
| More than intended time spent online? |
| Other responsibilities or activities neglected? |
| Unsuccessful attempts to cut down? |
| Significant relationship discord due to use? |
| Excessive thoughts or anxiety when not online? |
Diagnosing Internet overuse
Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions—easily recalled by the mnemonic MOUSE—can help you screen for problematic Internet use (Table 2).
History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.17 Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.
To determine how the Internet may alter the patient’s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the patient sort through his or her emotions.17
Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.17 They tend to take pride in their computer skills2 and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use (“I’m using it for work, academics, travel, research, etc.”).