Intervention for Internet Use: Current Understanding and Perspective

Do you feel preoccupied with the Internet (think about previous online activity or anticipation of next online session)?

Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction?

Have you repeatedly made unsuccessful efforts to control, cut back, or stop Internet use?

Do you feel restless, moody, depressed, or irritable when attempting to cut down or stop Internet use?

Do you stay online longer than originally intended?

Have you jeopardized or risked the loss of a significant relationship, job, educational or career opportunity because of the Internet?

Have you lied to family members, therapist, or others to conceal the extent of involvement with the Internet?

Do you use the Internet as a way of escaping from problems or of relieving a

dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)?

Young’s criteria have been criticized by Beard and Wolf (2001) on the grounds that they are weighted too heavily on self-report and the characteristic symptoms appear to be more consistent with an impulse-control disorder rather than a true addiction. At least one of the last three criteria is required for diagnosis, as these criteria impact the person’s ability to cope and function. Criteria for identifying Internet addiction (Beard and Wolf 2001) are as follows

Is preoccupied with the Internet (think about previous online activity or anticipate next online session).

Needs to use the Internet with increased amounts of time in order to achieve satisfaction.

Has made unsuccessful efforts to control, cut back, or stop Internet use.

Is restless, moody, depressed, or irritable when attempting to cut down or stop Internet use.

Has stayed online longer than originally intended.

17.2 Clinical Features

Internet addiction is not recognized as a formal mental health disorder. However, mental health professionals who have written about the subject note symptoms or behaviors that, when present in sufficient numbers, may indicate problematic use. These include the following:

Preoccupation with the Internet: User often thinks about the Internet while he or she is offline.

Loss of control: Addicted users feel unable or unwilling to get up from the computer and walk away. They sit down to check e-mail or look up a bit of information, and end up staying online for hours.

Inexplicable sadness or moodiness when not online: Like any other substance, there occur mood altering side effects when the addicted user is refrained from using the Internet.

Distraction (Using the Internet as an antidepressant): One common symptom of many Internet addicts is the compulsion to cheer oneself up by surfing the Web.

Dishonesty in regard to Internet use: Addicts may end up lying to employers or family members about the amount of time they spend online, or find other ways to conceal the depth of their involvement with the Internet.

Loss of boundaries or inhibitions: While this often pertains to romantic or sexual boundaries, such as sharing sexual fantasies online or participating in cyber sex, inhibitions can also be financial or social.

Creation of virtual intimate relationships with other Internet users: Web-based relationships often cause those involved to spend excessive amounts of time online, attempting to make connections, and dating via the Net.

Loss of a significant relationship due to Internet use: When users spend too much time on the Web, they often neglect their personal relationships. Over time, such relationships may fail as partners simply refuse to be treated badly and break off from relations with the addicted individual.

17.3 Types of Internet Addiction

Researchers have attempted to identify subtypes or sub-categories of Internet addiction, and various such proposals have been given till date, but they are yet to reach some common consensus. One of the first such attempts was made by Young (1999), who categorized it into five specific subtypes:

Cyber-sexual addiction: Compulsive use of Internet pornography, adult chat rooms, or adult fantasy role-play sites impacting negatively on real-life intimate relationships.

Cyber-relationship addiction: Addiction to social networking, chat rooms, and messaging to the point where virtual, online friends become more important than real-life relationships with family and friends.

Net compulsions: Net compulsions encompass a broad category of behaviors including obsessive online gambling, shopping, or stock-trading behaviors.

Information overload: Compulsive web surfing or database searching, leading to lower work productivity and less social interaction with family and friends.

Computer addiction: Obsessive playing of offline computer games, such as Solitaire or Minesweeper, or obsessive computer programming.

A brief description of the widely used and commonly observed types in the context of Internet addiction is as follows:

Cyber-sexual addiction: Internet sex addiction typically involves viewing, downloading, and trading online pornography.

17.4 Psychiatric Comorbidities with Internet Addiction

Liu and Potenza (2007) studied and suggested that Internet addiction is frequently associated with DSM-IV Axis I and Axis II disorders. Several cross-sectional studies show that comorbidities are norm rather than exception in case of Internet addiction. Block (2008) had noted that nearly 86 % of the individuals with Internet addiction have at least one comorbid psychiatric condition, in some cases with multiple comorbidities.

The most common psychiatric comorbidities that are found are mood disorders, anxiety disorders, attention deficit/hyperactivity disorder, impulse-control disorders, and substance dependence.

Shapira et al. (2000) reported DSM-IV Axis I diagnosis in all 20 problematic Internet users they assessed. In all, 70 % met the criteria for a current bipolar disorder and the figure jumped to 80 % when a lifetime diagnosis was considered. It was also noted that 35 % met the criteria for an impulse-control disorder, including intermittent explosive disorder (10 %), kleptomania (5 %), pathological gambling (5 %), and compulsive buying (20 %).

Bernardi and Pallanti (2009) found ADHD (14 %), hypomania (7 %), generalized anxiety disorder (15 %), social anxiety disorder (15 %), dysthymia (7 %), obsessive-compulsive personality disorder (7 %), borderline personality disorder (14 %), and avoidant personality disorder (7 %) to be associated with comorbidities. The same study also found that Internet addicts had higher mean score on the Dissociative Experience Scale, suggesting that dissociative symptoms were related to the severity and impact of Internet addiction.

Yen et al. (2009) noted an association between Internet addiction and harmful alcohol use. Comorbidity with other psychiatric conditions is also common among addictive disorders clouding the actual awareness that a client may suffer from a computer-related problem. While self-referrals for Internet addiction are becoming more common, often the client does not present with complaints of computer addiction. The client initially may present with signs of clinical depression, bipolar disorder, anxiety, or obsessive-compulsive tendencies, only for treating professional to later discover signs of Internet abuse upon further examination. Even when confronted by the therapist, a client may actively minimize the addictive behavior justifying his or her need to be online.

17.5 Tools Used for Assessment

Multiple assessment instruments have been developed by researchers from the west and the east. They are derived from different theoretical underpinnings and do not agree on the underlying dimensions that constitute problematic Internet use (Beard 2005). The most widely used instruments are the Diagnostic Questionnaire (DQ) (Young 1996) and the Internet Addiction Test (IAT) (Young 1998). Caplan (2002) has described the Generalized Problematic Internet Use Scale (GPIUS), which was reliable and valid in a preliminary study. Davis et al. (2002) described the Online Cognition Scale (OCS), a 36-item questionnaire they recommended for clinical assessment and pre-employment screening. Other instruments include Brenner’s Internet-Related Addictive Behaviour Inventory (IRABI) (Brenner 1997) and the Pathological Internet Use Scale (PIUS) (Morahan-Martin and Schumacher 2000).

17.5.1 Psychotherapy

When it comes to psychotherapeutic interventions for Internet addiction, no particular form of psychological intervention can be suggested as being the gold standard for its treatment. Treatment includes a variety of inventions and a mix of psychotherapy theories to not only treat the behavior but to address underlying psychosocial issues that often coexistent with this addiction (e.g., social phobia, mood disorders, sleep disorders, marital dissatisfaction, job burnout). However, the most frequently investigated approaches had been cognitive behavioral therapy (CBT) and motivational interview (Wieland 2005; Young 1999).

The psychotherapeutic intervention can also be done under two contexts—total abstinence and controlled use. Given the Internet’s numerous advantages and positive uses in day-to-day life, it is impractical to try the total abstinence model (as in treatment of substance addictions), even in those who are addicted to the Internet. The guiding principle should primarily be “moderate and controlled use.” In the abstinence model, the individual abstains from a particular Internet application (e.g., using chat rooms or playing games) and uses other applications in moderation. This model of abstinence is recommended for those who have tried and failed to limit their use of a particular application (Murali and George 2007). The intervention starts with collecting information about the initiating factor as well as the maintaining factors:

17.5.2 Case Vignette

Ms 16-year-old female, educated up to 11th std presented with the complaints of increase use of social networking sites for the last four years. Temperamentally, easy-going child and extrovert. Personal history revealed normal developmental milestones, average in studies and attained puberty at the age of 12 and absence of high-risk behaviors presented with the complaints of increase use of social networking sites for the last four years. She spent on an average 6–7 h per day on social networking sites and started neglecting other works and academic works. Initially, it was used at home, subsequently on objections of family members, she started surfing at cyber café. Stealing and lying in form of excuse present to support her habit. The content shared on the social networking sites was to have chat with friend. She had currently 350 online friends. She attributed the usages to feeling of enjoyment, free time and boredom. She met some of these online friends. She disliked sexual comments/gesture during offline meeting/cheating happen due to fake status.

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