DSM5 in Distress

The DSM's impact on mental health practice and research

Internet Addiction - The Next New Fad Diagnosis

Let's stop it before it starts

'Internet Addiction' may soon spread like wildfire. All the elements favoring fad generation are in place- the profusion of alarming books; the breathless articles in magazines and newspapers; extensive TV exposure; ubiquitous blogs; the springing up of unproven treatment programs; the availability of millions of potential patients; and an exuberant trumpeting by newly minted 'thought leading' researchers and clinicians.

 

So far, DSM 5 has provided the only restraint. Exercising uncharacteristically wise decision making, it has chosen to rain on this parade by relegating Internet Addiction to an obscure appendix, rather than legitimizing it as an official psychiatric diagnosis. But Internet Addiction seems to be picking up steam even without DSM 5 endorsement.

 

There is no doubt that most of us have become hooked on our electronic devices and that some people are gravely harmed by what develops into an unhealthy and uncontrollable attachment to them. The question is how best to understand, define, and deal with this. What does the term 'addiction' mean and when is it a useful way of describing our passions and needs. We don't consider ourselves addicted to our cars, TV's, refrigerators, or air conditioners. Is attachment to the Internet fundamentally different? If so, how and what do we do about it?

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The definition of Internet addiction is closely related to the definition of drug addiction- so this is the best place to start if we are to gain understanding and avoid confusion. Three features define drug addiction: 1) tolerance- needing more to get the same kick; 2) withdrawal- feeling terrible when you try to stop; and 3) a pattern of compulsive use- continuing the substance even if the pleasure is largely gone and the cost is extremely high (eg terrible health, work, interpersonal, financial, and/or legal consequences).

 

Drug addiction means being enslaved: not being able to stop using despite the lousy cost/benefit ratio of no longer getting much pleasure from the drug while suffering much harm from it. This has to be clearly distinguished from the much more common pattern of recreational use- ie taking drugs because they are fun and accepting the harms because (at least in the short run) they seem worth it. Recreational use may lead to really stupid choices and dreadful outcomes- but it is not to be considered a mental disorder.

 

DSM 5 proposes to introduce a category of 'Behavioral Addictions' with gambling as the first member and Internet addiction standing next in line to become a possible second. Behavioral Addictions could eventually easily expand to include passionate attachments to many other common activities. If we can be addicted to gambling and the Internet, why not also include addictions to shopping, exercise, sex, work, golf, sunbathing, model railroading, and (you name it). All passionate interests are at risk for redefinition as mental disorders.

 

The whole concept of behavioral addictions is highly controversial and has never heretofore been given any official status. There is a good reason for this. It is extremely difficult to distinguish the relatively few people who are really enslaved by shopping, sex, work, golf (or the Internet) from the huge army of those who are attached to these as pleasurable recreation. It should not be counted as a mental disorder and be called an 'addiction' just because you really love an activity, get a lot of pleasure from it, and spend a lot of time doing it. To be considered 'addicted,' you should be compulsively stuck doing something that is no longer fun, feels out of control, serves no useful purpose, and is certainly not worth the pain, costs, and harms. The unfavorable cost/benefit ratio should be pretty lopsided before mental disorder is considered.

 

We all do dumb things that offer short term pleasures but cause bad long term consequences. It is not 'addiction' whenever someone gets into trouble because of over-spending, golfing too much, or having repeated sexual indiscretions. That's our human nature- derived from many millions of year's of evolutionary experience where life was short, opportunities for pleasure rare, and the long term didn't count for nearly as much as it does now. There is a risky slippery slope if we medicalize our pleasure seeking, irresponsible selves. 'Addiction' could easily become an Oprah- ready excuse for impulsive and irresponsible pleasure-seeking ("I am really sorry I did it, but it is not my fault- my addiction made me do it").

 

Which brings us to 'internet addiction'.

Granted that lots of us are furtively checking emails in movie theaters and in the middle of the night, feel lost when temporarily separated from our electronic friends, and spend every spare minute surfing, texting or playing games. But does this really qualify us as addicts?

 

No, not usually. Not unless our attachment is compulsive and without reward or utility; interferes with participation and success in real life; and causes significant distress or impairment. For most people, the tie to the internet, however powerful and consuming, brings much more pleasure or productivity than pain and impairment. This is more love affair and/or tool using than enslavement- and is not best considered the stuff of mental disorder. It would be silly to define as psychiatric illness behavior that has now become so much a necessary part of everyone's daily life and work.

 

The best analogy is caffeine. Many millions of people can't get through the day without their treasured cups of coffee. Starbucks built its franchise and skillfully sited its drug distribution centers on the proven premise that coffee is addicting. In preparing DSM IV, we didn't include caffeine as an addictive substance only because it doesn't cause that much trouble for most of the people hooked on it. It seemed crazy to diagnose mental illness in all those people patiently waiting in line for their next hit. Most Internet users deserve equally benign neglect from psychiatric diagnosis. Ditto passionate shoppers, workaholics, sexual athletes, golfing fiends, and dedicated sun worshipers. If the activity works for them, it is not to be labeled addiction and is not a mental disorder.

 

But what about the small minority of Internet users who really are stuck in a pattern of joyless, compulsive, worthless, and self destructive use- the 24/7 gamers, the shut-ins, the people trapped in virtual lives. The concept of addiction may indeed apply to many of them and diagnosis and treatment may someday be proven to be useful. But not yet- it is still far too early to tell. We don't know how to define Internet addiction in a way that will not also mislabel the many who are doing just fine being chained to their electronics. We also don't know what proportion of excessive users are stuck on the Internet because they have a primary psychiatric problem that needs to be addressed first and may be missed if Internet addiction becomes an explain-all masking their underlying problems.

 

So far, the research on 'Internet Addiction' is remarkably thin and not very informative. Don't get too excited by pretty pictures showing the same parts of the brain lighting up during Internet and drug use- they light up non-specifically for any highly valued activity and are not indicative of pathology. The history of psychiatry is filled with fad diagnoses that far overshoot their target, get wildly misapplied, and spawn new 'treatments' that are often no more than expensive quackery. 'Internet Addiction' needs to be less a media darling, more a target of sober research.

 

South Korea is the most wired country in the world and has the biggest problem with excessive Internet use. The government is attempting to tackle this head on with education, research, and intelligent public policy- none of which has required declaring 'Internet Addiction' a mental disorder. This is an excellent model for the rest of the world to follow. Deal with the problem of excessive Internet use as it exists in those who have it, without prematurely jumping to a label that may be misleading and is likely to unleash a set of harmful unintended consequences.

 

Despite all the media hype, it is way premature to conclude that the Internet is controlling our lives, ruining our brains, and driving us crazy. We are not all of us Internet addicts. Let's stop this fad before it starts.

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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