As Dr. John Grohol has cogently argued, there are many reasons to be skeptical of “Internet Addiction” as a discrete and specific “disorder” or diagnosis. Yet I am impressed, and a bit dismayed, by all the attention this issue seems to garner in the popular media. I don’t intend any disrespect to the reporters and journalists who are trying to cover the topic, several of whom have graciously interviewed me. Some reporters are as skeptical as many of us in the mental health field, and a number have asked pertinent questions as to how real so-called Internet addiction is. I simply wish that devastating illnesses like schizophrenia, major depression, and bipolar disorder created such a buzz in the media and in the awareness of the general public. Over the last 30 years as a psychiatrist, I’m guessing I have been contacted by the media perhaps four or five times, to discuss these serious disorders. I have had nearly that number of requests to discuss “Internet addiction” in the past three months.
Some of the interest probably stems from a professional article I did on the subject, but I suspect other factors are driving the media frenzy. For example, the pervasive influence of the Internet in our society; the hot button issues of online pornography, gambling, and gaming; and perhaps the perverse pleasure of skewering the psychiatric profession for even considering Internet addiction as a new diagnosis in the upcoming DSM-V. There also is a great deal of confusion around terms such as “addiction” (which is not even used in the DSM-IV), “disorder,” “disease,” and related terms of art. And so, after several interviews with inquiring reporters, here is my take on where the controversy stands.
In theory, we can distinguish harmful or self-defeating behaviors and bad habits from “disease.” But if the behavior goes on long enough and dramatically alters the individual’s brain chemistry, the central nervous system may be changed in enduring ways. There is not always a bright line between self-defeating habits–which, at first, may be relatively conscious, controlled, and deliberate–and pathological changes in the brain’s structure and function. These brain changes may lead to behaviors that become harder and harder for the individual to control. Over time, what started as a mere “bad habit” may become a self-sustaining impulse control disorder.
Nicotine dependence is a good example. A person may, at first, simply choose to smoke for pleasure or relaxation. Eventually, however, nicotine alters the reward centers of the brain in ways that may be hard to reverse. For example, nicotine is known to activate brain circuits using the chemical dopamine, and perhaps also circuits involving the body’s own natural opioid compounds, called endorphins. Over time, these circuits become more and more entrained — ready to reverberate at the first whiff of secondhand smoke, and impel the person to “light up.” I believe a similar continuum — from “bad habit” to disease — may also apply to excessive Internet use. Over long periods of time, the brain may become rewired in enduring ways by excessive Internet-mediated stimulation.
In an already susceptible individual — let’s say, someone with underlying chronic depression or an aversion to social contact — the person may eventually wind up in a state of such suffering and incapacity that the term “disease” (dis-ease) actually applies. A vicious circle is soon set up: the more the “Internet-addicted” person withdraws from the outside world, the less competent he or she becomes in carrying out the social and vocational functions the world requires. This in turn leads to more avoidance and isolation, which worsens the person’s depression, intensifies the Internet use, and round and round we go.
But does this unfortunate individual have a specific disease, one that is discrete and biologically identifiable (e.g., H1N1 flu or Parkinson’s disease)? Or should we consider it one of a family of related diseases or disorders which may have similar genetic origins, brain chemistry, course, outcome and response to treatment?
Let’s take obesity as an analogy. It would seem odd and a little silly if we started creating specific diseases called Twinkie-induced obesity, nachos-induced obesity, French fries-induced obesity, etc. We presume that these are not discrete diseases, like swine flu, but different pathways to a common disorder (obesity). Similarly, it may not make sense to elevate Internet addiction to the status of a discrete disorder if the same brain chemistry is involved in pathological gambling, nicotine and cocaine dependence. As mental health professionals, we surely want to avoid adding dozens of new disease entities as new electronic media are invented.
If we picture aberrant reward system disorders (ARSDs) as a large, multi-room house, it may be that there are many different doorways into that structure. It seems counterproductive to give each door a name and a status as a unique disorder, just as it would to speak of Twinkie-induced obesity in contrast to nachos-induced obesity. On the other hand — and this is a matter of empirical investigation — if it should turn out that pathological Internet use is very different from, say, nicotine dependence or pathological gambling in certain key respects, then perhaps separate disease status will need to be accorded each of these doorways.
For example, suppose we studied thousands of subjects with various ARSDs. If Internet addiction were shown to have a unique pattern of abnormal brain chemistry, associated genetic factors, co-occurring psychiatric disorders, course of illness, and response to treatment, we might then have to grant it status as a discrete disorder. But in my view, the data are simply not there to justify such a conclusion. We sorely need large-scale, comparative studies of these conditions to know how they relate to one another.
Yes, there are some individuals who are both suffering and incapacitated by their pathological
Internet use, and they deserve our compassionate care and attention. But let’s keep their problem in perspective, and hope that the media begin to focus on the many serious psychiatric disorders and diseases that afflict our friends, family, and loved ones.