Internet Addiction: An Overview

Educational Objectives

The goal of this program is to improve the management of internet addiction. After hearing and assimilating this program, the clinician will be better able to:

1. Appreciate the factors that make the internet potentially addictive.
2. Counsel patients on appropriate internet use and how to limit it.
3. Screen patients for internet use disorder and other comorbid illnesses that may exacerbate it.
4. Utilize motivational interviewing to help patients acknowledge problematic internet use.
5. Recommend the appropriate treatment modalities and resources to manage internet addiction.

Summary

Internet addiction: the internet became available in the 1990s; in Western countries, 2% to 15% of people meet criteria for internet addiction, while in China and South Korea, prevalence is as high as 27%; accessibility and availability make the internet addictive; the context is also intoxicating and the stimulation and information it provides can be exciting and novel; there is synergistic amplification of addictive processes, eg, gambling, shopping, and sex; there is no end to the internet, and it is possible to fall into rabbit-holes of hyperlinking, leading to time distortion or dissociation; the internet is an important means of connection, but the connection is one step removed and lacks spontaneity, resulting in the formation of parasocial relationships, where people feel as though they know others based on what they choose to post online; the perceived anonymity is important in some subtypes of internet addiction and allows people to cross lines they normally would not; however the anonymity is not real, and it is important to teach younger children about this; instant gratification makes the internet addictive since access to content is very quick; it is relatively inexpensive and interactive, and like gambling, has a variable ratio reinforcement schedule; most people carry smartphones and have easy access to the internet; the anticipation is often stronger than the actual reward the device offers; achieving mastery in online platforms can be important, especially for those who have difficulty with social interaction or are unsuccessful in the real world

Subtypes: 6 forms of excessive internet use are being explored as subtypes; real-world gambling tends to be more episodic while internet gambling progresses more quickly due to constant access and ease of placing bets; people engage in cybersex and pornography addictions for purposes of dissociating, unlike with real world sexual dysfunctions; in most cases, violence in gaming and illegal pornography do not correlate to real-world illegal or aggressive behaviors; texting and emailing are not proposed as diagnostic criteria

“Generation D”: refers to generation Z children who were born with access to screens and are considered digital natives; toddlers engage in parallel play using screens at an age when engaging with each other and learning social skills is important; Dr. Sherry Turkle has explored this topic and conceptualized the Goldilocks Effect, ie, connection that is neither too close nor too far away but lacks development of interpersonal skills that require practice and experience; there has also been a reversal of the generational hierarchy of power and knowledge, and this imbalance in families makes treatment challenging; children can now outsmart their parents or teachers when screen limits are set, but since their brains are not fully developed, they need someone to contain them

Identity development: studies have explored the effect of the internet on identity development in children; it is important to understand the motivation and rewards of internet use; adolescents who are trying to find their identities need to explore different roles, find a self-concept, have it validated, and commit to an identity that resonates with them; the internet can speed up this process greatly by connecting people with similar interests and minimizing the amount of research needed; adolescents are exposed to all kinds of ideas and lifestyles quickly and receive feedback on what they express; feedback can be positive or negative, and cyberbullying can be an issue; they have a tendency to compare themselves to other people; studies have investigated healthy vs problematic engagement with the internet; as with all addictions, people are more prone to addiction later in life if they start engaging during adolescence and young adulthood; during this time their nucleus accumbens and dopamine reward systems are active, creating strong desires and need for novel experiences and excitement; the neural systems to buffer these take another 10 or 15 yr to develop fully; testosterone increases the potential for risk-taking and pleasurable behaviors; depression is associated with estrogen fluctuations, and girls undergoing puberty may seek mood-altering technology behaviors; genetic predisposition, trauma, and attachment issues may also play a role

Other considerations: tetrahydrocannabinol aside, drug use is at an all-time low; stimulation, reward, and excitement that teenagers get from their smartphones may be replacing drugs; the internet is easier for teenagers to engage with and the barriers to meeting these needs is much lower; people of all age groups use the internet; there are implications not only for modeling but attachment as well; parents may not be able to engage with children if they are distracted by smartphones, and the children will be less resilient and have a more negative perspective of themselves; the children feel more sad, lonely, angry with their parents, and that they are competing for attention with the smartphones; parents may not be aware of how little attention they are giving children; children have less ability to recover emotionally from things when parents are more distracted; for adolescents, there are differences in their association with and reliance on rewards; among children and adolescents, internet addiction is correlated with self-destructive or suicidal behavior, depression, attention-deficit/hyperactivity disorder (ADHD), anxiety, obsessive-compulsive disorder (OCD), social phobias, and aggressive behavior; decrease in empathy and social skills have also been observed; development of tolerance, need for larger quantities, and affective withdrawal occurs with the internet as well; to treat the negative affect, they try to change their mood by returning to the addiction, creating a cycle

Neurobiology: internet addiction taps into survival pathways; engaging with rewarding things is necessary for procreation, food, and shelter, but unlike the internet, these rewards are real; people use the internet because they want connection, and it offers the impression of connecting people with exciting things, but this does not really help; in reward deficiency syndrome, patients are in a genetic hypodopaminergic state and can fall victim to substance use to try and increase their dopamine levels; this can also occur with compulsive internet use or internet use disorder, where constant dopamine signaling causes downregulation of the receptors and lowered hedonic state, leading to withdrawal; a hallmark of internet addiction is that impulsivity and executive function are most affected; the self-awareness part of the brain and default mode network also seem to be affected; neuroimaging shows that people may identify more with their online avatars than with themselves; this may be due to engagement with the internet or lack of engagement with the real world; time spent online often does not leave much time for real-world engagement; however, professional gamers do not seem to have the same changes as people who have internet game addictions; since neural connectivity is plastic, they may be building connections on these platforms instead of the real world; long-term changes in gray and white matter volume associated with memory, attention, impulse control, emotional regulation, and motor function have been seen

Physiologic effects: oxytocin plays a large part in secure attachment; in a study, college students who had a hard experience were allowed to text a parent, not interact with a supportive person, or have a telephone or video call with a parent; oxytocin was raised and cortisol lowered in those who had in-person interactions, while those who did not interact or only texted had similarly elevated cortisol and no increase in oxytocin; this suggests that chatting and text-based interactions do not have the same benefits as hearing supportive people; more studies are needed to understand genetic and ethnic contributions; some benefits of internet use include improved hand-eye coordination and improved ability for conflict resolution within images; however, fundamental cognitive function is negatively affected; for pornography and cybersex addiction, differences are seen in putaminal activity that suggest tolerance and desensitization, leading to the need for more novel sources of stimulation; this can lead to illegal activities; certain parts of the prefrontal cortex are not active when engaging in sexual activity; logic and thinking about consequences are not prioritized, and the barrier to accessing illegal content on the internet is low

Definition: the International Classification of Diseases 11th Revision lists internet addiction as a diagnosis; Asian countries pushed for the diagnosis as the prevalence is higher there; internet cafes in Asia allow people to play video games for days on end; the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, lists it as an entity that needs further investigation; the proposed diagnostic criteria were largely based on gambling disorder; preoccupation with internet games, affective withdrawal symptoms, need to spend more time on the internet, and difficulty controlling or cutting back are included; deception is important as people deceive their families or therapists about the amount of time spent online; they use the internet as a psychoactive method to change mood, lose interest in previous hobbies, and jeopardize relationships; addiction is defined by engagement with the substance despite negative consequences; denial occurs and is often unconscious; most patients do not seek treatment of their own accord; time distortion is a major symptom, and they often do not believe it when shown their screen time statistics; they also tend to rationalize their use; psychologically, anger is common, especially when the device is taken away; violence is not the norm, but there have been cases of children killing their parents for this reason; threats of hurting themselves are common; when setting limits, it is important to have a plan; conflict should not be escalated without a plan in place to ensure safety

Other symptoms: behavioral symptoms include shortened attention span, seeking instant gratification, discomfort with stillness, not being able to handle boredom, distraction issues, and decreased academic and work productivity; people may say they are multitasking by doing homework while using the internet, but this is not true; internet addiction leads to a sedentary lifestyle and overall social withdrawal; social skills need to be developed; they may have difficulty making telephone calls and should be encouraged to do so; physical symptoms of pornography addiction include sexual desensitization and erectile dysfunction; online sexual stimulation is supernormal, fast-paced, and idealized for the user; social anxiety may play a role in performance anxiety; obesity and other issues related to sedentary lifestyles (eg, deep venous thrombosis) can cause issues; people who frequent internet cafes may not sleep or eat well for days and may soil themselves; repetitive motion injuries are common; circadian rhythm dysfunction is common; many adolescents do not get enough sleep because they stay up late using their smartphones; the Internet Addiction Test can be given to clients to help them realize that they have a problem; this is part of motivational interviewing; other tests have also been validated

Comorbid disorders: include anxiety, especially OCD and social anxiety; certain psychological traits can predict internet use disorder; people who have a fear of missing out are more likely to have social media addiction; extroversion is associated with it since people get feedback from the internet; preexisting lower scores in empathic concern and perspective-taking are also associated; depressive disorders are common and may be caused or worsened by, or be premorbid to internet addiction; learning and autism spectrum disorders are highly indexed, likely due to difficulty with real-world social interaction and the internet being a seemingly controlled space where they can interact; ADHD and impulse control disorders are also common; most children with gaming addictions also have ADHD, likely because it affects dopamine reward systems and provides stimulation that helps calm them down

Treatment: motivational interviewing is the start; helping patients see the discrepancy between their values, the life they are living, and their goals is important; this process readies them for treatment; once they are ready, cognitive behavioral therapy can be effective if depression and anxiety are present; exercise-based interventions can be helpful; acceptance and commitment therapy is particularly effective for pornography addiction, with an 85% reduction in use shown in one study after 8 sessions and maintained over 3 mo; medication plays a smaller role; a good history is important, being curious and nonjudgmental; patients should be encouraged to talk about their internet use; underlying psychiatric disorders should be identified; the guilt and shame cycle is common in addiction; helping patients identify and notice discrepancies and stop hiding and engaging with the behavior is important; negative social, educational, and interpersonal consequences should be addressed; trust should be rebuilt; financial issues may be a concern; the broad strokes about addiction and neurobiology can be explained to reduce the shame associated with the addiction; the need to put active effort into not engaging with the internet should be emphasized; plans should be put in place in case of relapses; eye movement desensitization and reprocessing may be useful; community support and engagement with pleasurable and sustainable real-life, real-time activities are important; they should be told that these may not feel good initially and encouraged to persist until they start having fun

Medications: there is little evidence on mood stabilizers; selective serotonin reuptake inhibitors can be used for OCD or severe anxiety; psychostimulants can be used in ADHD, but caution is needed as many patients use them to play video games for longer; blocking modalities to limit access or create abstinence is important; an information technology specialist may be needed to block them effectively; 1 to 3 mo of abstinence can be tried and moderate use then allowed if the patient has the self-awareness to know if they lose control; while internet abstinence as a whole is not possible, content relevant to the addiction should be blocked; switching from smartphones to telephones without internet capabilities can be useful; buprenorphine may be used for internet gaming addiction; naltrexone has been used for gambling addiction and has been studied for pornography and other process addictions; topiramate may be helpful for compulsive sexual behavior and shopping addiction; N-acetyl cysteine can help OCD-adjacent behaviors and is low-risk; the Center for Internet and Technology Addiction website has several resources and scales that patients can be referred to; the Center for Humane Technology was created to help people with such issues; Circle and Qustodio are applications that help with parental controls; residential treatment centers and peer support groups are also available; “The Social Dilemma”, “Dopamine Nation”, “Overcoming Internet Addiction for Dummies”, and “Social Studies” are books and documentaries that may be useful

Readings

González-Bueso V, Santamaría JJ, Fernández D, et al. Association between Internet Gaming Disorder or Pathological Video-Game Use and Comorbid Psychopathology: A Comprehensive Review. Int J Environ Res Public Health. 2018;15(4):668. Published 2018 Apr 3. doi:10.3390/ijerph15040668; Granic I, Morita H, Scholten H. Beyond Screen Time: Identity Development in the Digital Age. Psychological Inquiry. 2020;31(3):195-223. doi:https://doi.org/10.1080/1047840x.2020.1820214; James RJE, O'Malley C, Tunney RJ. Understanding the psychology of mobile gambling: A behavioural synthesis. Br J Psychol. 2017;108(3):608-625. doi:10.1111/bjop.12226; Jeon HJ, Kim S, Chon WH, et al. Is Internet overuse associated with impaired empathic ability in Korean college students?. Medicine (Baltimore). 2018;97(39):e12493. doi:10.1097/MD.0000000000012493; Kuss DJ. Internet gaming addiction: current perspectives. Psychol Res Behav Manag. 2013;6:125-137. Published 2013 Nov 14. doi:10.2147/PRBM.S39476; Kuss DJ, Griffiths MD. Internet and gaming addiction: a systematic literature review of neuroimaging studies. Brain Sci. 2012;2(3):347-374. Published 2012 Sep 5. doi:10.3390/brainsci2030347; Oliver G, Dean O, Camfield D, et al. N-acetyl cysteine in the treatment of obsessive compulsive and related disorders: a systematic review. Clin Psychopharmacol Neurosci. 2015;13(1):12-24. doi:10.9758/cpn.2015.13.1.12; Satish Kumar CR, Sharma MK, Amudhan S, et al. Digital gaming, musculoskeletal, and related health hazards among adolescents and young adults. Indian J Psychiatry. 2023;65(6):698-700. doi:10.4103/indianjpsychiatry.indianjpsychiatry_818_22; Turkle S. (2017). Alone together: Why we expect more from technology and less from each other. Hachette, UK.; Van Rooij AJ, Prause N. A critical review of “Internet addiction” criteria with suggestions for the future. J Behav Addict. 2014;3(4):203-213. doi:10.1556/JBA.3.2014.4.1; Vasiliu O. Therapeutic management of buying/shopping disorder: A systematic literature review and evidence-based recommendations. Front Psychiatry. 2022;13:1047280. Published 2022 Nov 3. doi:10.3389/fpsyt.2022.1047280; Zhang J, Wang E, Zhang L, et al. Internet addiction and depressive symptoms in adolescents: joint trajectories and predictors. Front Public Health. 2024;12:1374762. Published 2024 Jun 4. doi:10.3389/fpubh.2024.1374762.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Miller’s lecture contains information related to the off-label or investigational use of a product, therapy, or device.

Acknowledgements

Dr. Miller was recorded at the Regional Integrated Mental Health Conference, held in West Baden Springs, IN, on October 4-6, 2024, and presented by the Indiana Psychiatric Society. For information about upcoming CME activities from this presenter, please visit indianapsychiatricsociety.org. Audio Digest thanks Dr. Miller and the Indiana Psychiatric Society for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.75 CE contact hours.

Lecture ID:

PS540801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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