Twenty years of Internet addiction … Quo Vadis?

“A person who never made a mistake never tried anything new. ” -Albert Einstein THE BEGINNING In 1995, when the New York based psychiatrist Dr. Ivan Goldberg posted a sincere-looking but satirical note on the online psychiatric bulletin board PsyCom. net (no longer available now) taking a dig at the rigid diagnostic criteria of the newly released 4th edition of the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association (APA) by “creating” a fictitious disorder called Internet addiction disorder (IAD) and cooking up its “diagnostic criteria” as per DSM style for substance dependence, little did he know that he had opened the proverbial Pandora's box. 1 He and his bulletin board were flooded with people narrating their tales of woe of “remaining caught in the Net” and seeking help for their condition. This was one condition he did not intend to create (he himself did not believe that there could be a true “addiction” to Internet but rather excessive or pathological use), but there it was whatever name you gave it! In 1995, a clinical psychology student Ms Kimberly Young, then in Rochester, USA, got interested in the psychological factors behind computer use and independently conceived of “addictive use of the Internet” as a pathological condition. 2 It is interesting to hear of this story from the author herself 20 years later: “Internet addiction began as a pet project in a young researcher's one bedroom apartment in Rochester, New York. I was that young researcher. It was in 1995, and a friend of mine's husband was seemingly addicted to AOL Chat Rooms spending 40, 50, and 60 h online at a time when it was still 2. 95/h to dial into the Internet. Not only did they suffer financial burdens but also their marriage ended in divorce when he met women in online chat rooms. ”3 The rest, as they say, is history, with her first illustrative case report published in 1996 having been cited 755 times, and her first definitive research article titled, “Internet addiction: Emergence of a new clinical disorder, ” published in 1998, having been cited a phenomenal 3144 times as on December 15, 2015!4 In 1995, a clinical psychologist Mark Griffiths, working at Nottingham Trent University, Nottingham, UK, who had been interested in research on gambling, computer use, and use of various machines or technology by humans in general for a few years at that time, published an article named, “Technological addictions. ”5 The next year, in 1996, he published on Internet addiction, conceptualized by him as a subset of the broader term technology addiction. 6 This was the beginning, 20 years ago. As the freelance writer Michael OReilly, reporting in Canadian Medical Association Journal in 1996, (who, himself, interestingly, declared that “he may be at risk for developing IAD”) titled his article as “Internet addiction: A new disorder enters the medical lexicon, ” where he mentioned Young's still unpublished research on Internet addiction. 7 Truly, a PubMed search on “Internet addiction” pegs this short report as the very first article included in PubMed on the topic. THE ACCOLADES… Now, in 2015/6, as on December 15, 2015, there are 1561 articles cited in PubMed on “Internet addiction. ” What is more interesting is a look at the acceleration rate of publication. While there were only three articles in 1996, there were 32 in 2005, 275 in 2014, and 296 (and still counting) in 2015! Thus, while the growth rate of publications was not hugely impressive in the first decade of its life, Internet addiction is now a robust young adult in its postteen year with a sizeable growth spurt in its second decade. Not many “new” terms can boast of such growth in just 20 years in the PubMed! As an aside, it is to be noted that the term “Internet addiction” has many competing contenders; some of the important ones are pathological Internet use, problematic Internet use (PIU), compulsive Internet use, Internet use disorder (IUD), and pathological use of electronic media among others. Pathological Internet use or PIU is often a favored term these days, but we have stuck to the original term because it is still very popular certainly with the social media but also in medical/psychological scientific research, and especially because we wanted to place this editorial in a historical perspective. Hence, what kinds of articles are being published on Internet addiction over the past decade or so? This is no place (and space) for a comprehensive review on the topic. Suffice it to say that, in addition to individual research articles from America, Europe, Asia, and Oceania, there are now a number of published narrative and even a few systematic reviews on almost every aspect of Internet addiction, including its concept and historical perspective, 89 diagnostic criteria, 10 epidemiology, 11 psychosocial and neuropsychological aspects, 1213 neurobiological aspects, 1314151617 and management, both pharmacological and nonpharmacological. 1819 It appears that the issue is, at least partly, resolved, and that we have sufficient power in our knowledge base to conceptualize, detect, diagnose, characterize, treat, and prognosticate something called Internet addiction. Twenty years … and we are quite there. Well, not quite, yet. …AND THE BRICKBATS The first jolt came from APA in their widely publicized 5th edition of the DSM (DSM-5) published in May 2013. 20 Although the much-awaited and much-hyped category of “behavioral addictions” was indeed kept in its re-formulated category, “Substance-related and addictive disorders, ” the sole diagnostic category kept in its final version under behavioral addictions was gambling disorder, which was a slightly tweaked version of the earlier pathological gambling, shifting its parental home from impulse control disorders of DSM-IV (there is no broad category of impulse control disorders any more in DSM-5) to addictive disorders in DSM-5. Despite early speculations and expectations, Internet addiction did not find a home under behavioral addictions. Instead, and almost as a consolation prize, one particular subtype of Internet addiction, called Internet Gaming Disorder, has been entertained in the DSM-5, but only as a tentative “Condition for Further Study” that “requires further research before they might be considered formal disorders, ” in its Section III called Emerging Measures and Models. The second jolt, and the one more important from an international perspective including India, comes from the forthcoming 11th revision of the International Classification of Diseases (ICD-11) by the World Health Organization (WHO). A recent article from the WHO Working Group on Classification of Obsessive-Compulsive and Related Disorders, while deliberating on this area as a “key controversy, ” concluded that, “based on the limited, current data, it would therefore seem premature to include it in the ICD-11. ”21 Consequent to this stand, the very recently released Beta Draft of the entire ICD-11 (where Mental and Behavioral Disorders is coded as 07) sticks to its previous model of separate groups for “disorders due to substance use” (which has, by definition, no mention of any behavioral addictions but only substance use related disorders), and “impulse control disorders, ” which continues to house pathological gambling but has also added “compulsive sexual behavior disorder, ” a contender for the behavioral addictions, under impulse control disorders. Internet addiction, in any of its avatars, is nowhere in sight. 22 This is certainly a big disappointment for the advocates and champions of behavioral addictions, technological addictions, including Internet addictions. Let alone classifying it as an addictive disorder, ICD-11 Beta Draft refuses to recognize Internet addiction as a disorder in the first place! Why is it so? And, what can be done? To our mind, there is a hierarchical series of questions that need to be answered to get a grasp on the issue. Each successive question builds on its predecessor, assuming that the question hierarchically one step above is answered in the affirmative. THE FOUR CARDINAL QUESTIONS The first and foremost question: Is Internet addiction better conceptualized as a “disorder” or as a continuum of normal behavior (after all, Internet use is an essential part of everyday life of a vast proportion of people worldwide, and steadily increasing – we all are Internet “dependent” in much the same way we are dependent on so many basic things in life)? Although heavily debated already, the simple answer to this question can be borrowed from ICD-11 Working Group: “Where there is a continuum between normal and pathological behavior, associated impairment may become a key determinant of whether or not behavior is disordered. An additional important consideration, from a public health perspective, is whether efficacious treatments are available. ”21 As abundantly documented in the literature over the past 20 years, excessive, uncontrolled, and inflexible Internet use behavior can indeed lead to severe functional impairment in some persons. Further, consider the definition of a mental and behavioral disorder as espoused in the Beta Draft of ICD-11: “Mental and behavioral disorders are recognizable and clinically significant behavioral or psychological syndromes that are associated with distress or interference with personal functions. ”22 Many (but not all) cases of Internet addiction would satisfy this definition. As in many other psychiatric disorders, there would be a large “gray area, ” but that only proves that there is indeed a “white” (“normal”) and a “black” (pathological or disordered) area as well. From a public health perspective, this is an important question because of its policy implications. There is also some evidence that at least nonpharmacological interventions (especially cognitive behavioral therapy for Internet addiction) can be useful though much more research is needed. And that would only be feasible, once we initially and tentatively agree that indeed there can be a disorder for which we are seeking a treatment! The second important question we ask is, assuming that some cases of these excessive, uncontrolled, and inflexible Internet use behavior indeed is a mental and behavioral disorder: Is this pattern of behavior an addictive disorder? There are actually three sublevels of criticism or question in this: How can there be an addiction to something which is not as tangible a thing as drugs? Why is it not better explained by simply as a manifestation of other underlying disorders such as depression, anxiety, or social phobia? Why is it not better conceived as, say, an impulse control disorder (as done for pathological gambling or the new category of compulsive sexual behavior disorder), or an obsessive-compulsive spectrum disorder? As to the response to the first sublevel of this question/critique, our take is: Epistemologically, “addiction” to psychoactive substances was a later development in history. The Latin root of the word “addiction” – addicere – simply meant “to adjudge, sentence, doom, assign, confiscate, or – importantly – enslave. ”23 Thus, “addicted” would simply mean “being sentenced, doomed, or enslaved. ” The object of this transitive verb could be theoretically anything, from drugs to playing poker. On a neurobiological note, it is the brain learning or memory of a rewarding experience that is the basis of dopaminergic-based positive reinforcement which defines the early stages of addiction, rather than which specific stimulus (whether cocaine or social networking online) triggered that experience. 24 Once continued for a while, this early mechanism paves the way for a delayed-onset recruitment of nondopaminergic anti-reward mechanisms that provides negative reinforcement for a particular behavior which perpetuates that behavior in a compulsive manner. 24 Finally, at a behavioral level, addiction (as opposed to pharmacological dependence on a substance) is always with regard to a core behavior. Even in case of substances, what characterizes substance dependence is the pathological pattern of “use” of the substance (please note: Use refers to a particular behavior). For example, take the definition of alcohol dependence as in the ICD-11 Beta Draft: “Alcohol dependence is a disorder of the regulation of alcohol use, arising from repeated or continuous use of alcohol. Characteristic features are a strong drive to use alcohol, impaired ability to control its use, and giving increasing priority to alcohol use over other activities. Often individuals develop tolerance and experience withdrawal symptoms when cutting down or stopping, or use alcohol to prevent or alleviate withdrawal symptoms. Use of alcohol increasingly becomes a central focus of the person's life and relegates other interests, activities, and responsibilities to the periphery. Continuation of alcohol use despite adverse consequences is a common feature. ”22 Now, let us do a little fun experiment. Try substituting the word “alcohol” with “Internet” in this definition and see what comes out of it! The second level of this second question/criticism is partly true. There is a documented large comorbidity between the putative behavioral addictions (including Internet addiction) and other psychiatric disorders, particularly depressive and anxiety and bipolar disorders. 25 However, that is true for many psychiatric disorders and certainly true for substance use disorders in general. The fact that alcohol dependence is heavily comorbid with depression does not make the former identical with the latter! If at all, such a pattern lends credence to the similarity of these behavioral disorders with addictive disorders. 26 Of course, Internet addiction should not be diagnosed if such behavior is exclusively contained within the boundaries of a bipolar, depressive, or anxiety episode and spontaneously resolves after the resolution of such conditions. Coming to the third level, the very nature of these behavioral disorders, we land in a debate that goes to the very heart of concept and nosology of psychiatric disorders. Substance use disorders too, from time to time, have been conceptualized as impulse control disorders, obsessive spectrum disorders, compulsive spectrum disorders, or combinations of these. 27 Impulsivity in decision making and behavior, obsession-like repeated preoccupation, and a compulsion-like quality in repeated use of substances, all are important components of the process of addiction, but addiction as a gestalt has characteristics beyond each of these individual phenomena; otherwise, all substance use disorders would have been consumed under any of these too. Thus, we take on this matter at the moment (admittedly incomplete and one that will require a lot more research to settle) is that pathological or PIU, after a certain threshold of severity and functional impairment, can be conceptualized as an addictive disorder. However, we suggest that the name of the condition be changed to “Internet Use Disorder (IUD). ” This term retains the three cardinal characteristics: First, it is a disorder; second, it is concerned with a particular core behavior of using the Internet as a medium (for whatever purpose) ; and third, Internet) the target “object” (in a metaphorical sense, not as a substance but as a vehicle or medium) of use. The third question, assuming that the two above have been answered, is: If PIU is indeed best conceptualized as an addictive disorder (i. e. 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