doi:10.1111/j.1440-1754.2010.01879.

VIEWPOINT

Getting plugged in: An overview of Internet addiction jpc_1879 557..559

Caroline Flisher
Waltham Forest Child and Family Consultation Service, Waltham Forest, London, UK

Abstract: Internet addiction is not formally recognised as a clinical disorder by the WHO despite increasing evidence that excessive internet
use can interfere with daily life and work. There is increasing pressure from Psychologists for Internet addiction to be recognised. This article
explores the prevalence, symptoms and management of Internet addiction and the consequences of ignoring the ever growing concerns from
public figures and institutions.

Key words: compulsive disorder; ICD-10; internet addiction; online video games.

The internet is so big, powerful and pointless that for some it Definitions of IA
is a complete substitute for life.
Andrew Brown, Journalist and Author Young defined IA as ‘use of the internet for more than 38 hours per
week’, but it has also been defined as ‘a maladaptive pattern of
One of the earliest modern computers was built at Pennsylvania internet use leading to clinically significant impairment or distress’.5
University during the Second World War. It was called Elec- DSM IV and the International Statistical Classification of Dis-
tronic Numerator Integrator Analyzer Computer; it took up an eases (ICD-10) define addiction in terms of substance depen-
entire room and was hailed by the press as ‘the Giant Brain’. dence or pathological gambling. In order for IA to be classed as
Following the birth of the Internet in 1969, and the advent of dependence, it must meet at least three of the following criteria:
the personal computer in the early 70s, computer technology
has continued to evolve at a staggering rate. Fast-forward to • Tolerance
2009 and the global number of Internet users has now sur- • Salience
passed 1.5 billion.1 China holds the record for the highest • Withdrawal symptoms
number of Internet users with 19% of the population going • Difficulty controlling use
online regularly.2 The Internet has become an integral part of • Continued use despite negative consequences
daily life for many people, and it is now as common for a child • Neglecting other activities
in the developed world to use a computer as it is for them to • Desire to cut down
play with their favourite toys.3
Young has developed eight criteria to diagnose IA based on
the DSM IV criteria for pathological gambling.6 These include:
The Concept of Internet Addiction
• Preoccupation with use of the computer, think about pre-
The term Internet addiction (IA) was first used in 1995 by vious online activity/anticipation of next online session
psychiatrist Dr Ivan Goldberg, who coined the term ‘Internet • Craving more and more time at the computer
Addiction Disorder’ along with a list of symptoms. In the same • Making efforts to cut back on computer use or stop, and
year, Dr Kimberly Young conducted a study of 500 heavy users of failing repeatedly
the Internet or ‘internet addicts’, and compared their behaviour • Feelings of emptiness, depression and irritation when not
to the Diagnostic and Statistical Manual of Mental Disorders at the computer or when attempting to cut down
(DSM IV) criteria for pathological gambling.4 Subjects reported • Staying online longer than originally intended
significant impacts on ‘academic achievement, social life, rela- • Jeopardising or risks losing significant relationships, job,
tionships, occupation and finances’. Young likened these to the career or education because of the Internet
effects of pathological gambling and alcoholism. Although her • Hiding the extent of computer/Internet use to family and
study raised the profile of IA among health-care professionals, it friends
was later criticised for its method of recruiting subjects. • Use of the Internet as a way of escaping from problems or
of relieving a dysphoric mood (e.g. feelings of helplessness,
Correspondence: Dr Caroline Flisher, Specialist Registrar in Child and guilt, anxiety, depression)
Adolescent Psychiatry, Waltham Forest Child and Family Consultation
Service, Waltham Forest, London E17 3EA, UK. Fax: 02085663434; IA is an umbrella term encompassing various subtypes including:
email: docfl[email protected]
• Net compulsions (online shopping and online gambling
Accepted for publication 9 August 2010. addiction)

Journal of Paediatrics and Child Health 46 (2010) 557–559 557

© 2010 The Author
Journal of Paediatrics and Child Health © 2010 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
 14401754, 2010, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2010.01879.x by Cochrane Croatia, Wiley Online Library on [29/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Getting plugged in C Flisher

• Online game playing addiction months of problematic Internet use and eventually engulfing all
• Online research addiction aspects of the individual’s life. Teenagers with IA have report-
• Cybersexual addictions edly become physically aggressive when parents try to remove
• Cyber-relational addiction (chat rooms, social networking, them from the computer. Adults with IA have described marital
personal messaging and email addiction). problems and even marital breakdown. Late night use of the
Several self-report questionnaires have been developed to Internet can cause sleep deprivation and fatigue, which can
help diagnose IA.7 These diagnostic tools have not been vali- adversely affect work performance and can result in reversed
dated, and there is no official consensus on what length of time sleep pattern and job loss. IA is also commonly associated with
spent at the computer constitutes pathological use. depression, anger problems and anxiety disorders.
In the long term, IA can cause serious health problems.
IA: A Clinical Disorder? Repetitive strain injury and back ache are common complaints.
There have been at least 10 reports from Korea and China of
There has been much debate in recent years about whether IA users collapsing and dying following several days of uninter-
exists as a clinical disorder. It is recognised by the American rupted online video game playing.15 A sedentary life-style can
Psychological Association, but psychiatrists have remained scep- increase risk of deep vein thrombosis and pulmonary embolus,
tical. A recent article by American psychiatrist Jerald Block eventually leading to obesity and its associated complications.
discussed the increasing incidence of IA and highlighted the high
rate of co-morbidity with other psychiatric conditions.8 He pro-
Treatment of IA
posed its inclusion in DSM V as a ‘compulsive-impulsive spec-
trum disorder’. David Greenfield’s book, Virtual Addiction: Help for In 1995, Dr Kimberly Young founded the first private IA clinic.
Netheads, Cyberfreaks and Those Who Love Them, proposes that IA Based in the USA, ‘The Centre for Online Addiction Recovery’
should be classified as an addiction because sufferers can show offered a psychological treatment programme and telephone
symptoms of tolerance and withdrawal, which are also present in counselling services.16 In 1996, psychologist Dr Maressa Orzack
substance dependency.9 However, some psychologists argue that founded the Computer Addiction Service at the McLean Psychi-
IA is a symptom of depression rather than a clinical disorder in atric Hospital in Massachusetts offering cognitive behavioural
itself. Lenihan, a forensic psychiatrist in Edinburgh, questions treatment (CBT) as the mainstay of treatment. Since then, more
whether the Internet acts as a medium for the underlying con- clinics have been established in the USA, Amsterdam, China
dition and if we should be treating ‘online gamblers primarily as and Korea. Internet treatment clinics in China have since gained
gamblers rather than classifying them as internet addicts’.10 notoriety for their ‘boot-camp style’ treatment approach.
Block also highlighted that the South Korean government has There is currently no standardised treatment for IA. Clinics in
declared IA a ‘serious public health problem’.11 In November China implement regimented timetables, strict discipline, medi-
2008, psychologists in China called for IA to be officially recog- cation, addiction counselling and electric shock treatment. Treat-
nised as a clinical disorder and for it to be registered with the ment clinics in the USA use the 12-step programme along with
World Health Organization.11 Despite mounting evidence, psy- CBT, family therapy, group therapy, social skills training and
chiatrists have argued that we need further valid research into addiction counselling. During treatment programmes, patients
IA before including it in DSM V. abstain from using computers; however, because they are so
There are currently no published epidemiological studies of IA, readily accessible, relapse rates are thought to be high. Clinics in
and therefore, no official statistics exists on global prevalence. the USA also provide educational resources. These include: edu-
Assessing the true extent of the problem is difficult because most cational outreach programmes for schools, hospitals and univer-
people access the Internet at home. Over the last decade, with the sities; on-site workshops; accredited online home study courses;
release of massively multiplayer online games, such as Everquest and an e-booklet guide to assessment and treatment of IA.
and World of Warcraft (WoW), online video game (OVG) addiction Because IA is not recognised by the DSM IV or ICD-10, there is no
has continued to gain media prominence. An estimated 11.5 million formal training for psychiatrists in its assessment and treatment.
people subscribe to WoW.12 In 2008, Deborah Tate, of the Federal Murali, a consultant in addictions psychiatry, suggests a thorough
Communications Commission, cited WoW as one of the ‘top psychiatric assessment and mental state examination, and collateral
reasons for college drop outs in the US’.13 Following the global histories from relatives.16 Support groups, CBT and family therapy,
popularity of Facebook, the New York Times has reported that as well as Young’s behavioural strategies should be included in the
FarmVille, a Facebook application, has become the most popular treatment plan.17 Young’s behavioural strategies include:
online game in the world with sixty-one million users enlisted.13b
China has the largest number of OVG players in the world and is the
• Practising the opposite – identifying the patients pattern of
current leader in video game addiction research.
Internet use and doing neutral activities during that time
• External stoppers – use of external prompts, for example,
Consequences of IA an alarm clock to remind them when it is time to log off
• Setting clear goals
Teenagers tend to use the Internet as a medium for socialising,
• Reminder cards – negative consequence of Internet use are
but pathological Internet use can result in individuals spending
written down on a reminder card and carried at all times
ever-increasing amounts of time in online activities, leading to
• Personal inventory – make a list of hobbies
social withdrawal, self-neglect, poor diet and family problems.14
• Abstinence
The consequences of IA are insidious, becoming apparent after

558 Journal of Paediatrics and Child Health 46 (2010) 557–559

© 2010 The Author
Journal of Paediatrics and Child Health © 2010 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
 14401754, 2010, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2010.01879.x by Cochrane Croatia, Wiley Online Library on [29/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
C Flisher Getting plugged in

Murali also highlights the importance of enquiring about the from 2007–2015, June 11th 2007. Available from: http://www.forrester.
patient’s motivation to address their addiction. At present, there com/ER/Press/Release/0,1769,1151,00.html [accessed 3 April 2009].
is a need for research into the effectiveness of these treatment 4 Young KS. Internet addiction, a case that breaks the stereotype.
programmes and the long-term results of treating IA. Psychol. Rep. 1996; 79: 899–902.
5 Goldberg I. 2009. Available from: http://www.psycom.net/
iadcriteria.html [accessed 6 April 2009].
Conclusion 6 Young K. Online Gambling, 2009. Available from: http://
www.netaddiction.com/index.php?option=com_content&
Because IA is a relatively new concept in psychiatry, there are view=article&id=60&Itemid=83 [accessed 7 April 2009].
few studies into its prevalence and treatment. Epidemiological 7 Clark DJ, Frith KH, Demi AS. The physical, behavioural, and
surveys and clinical studies are urgently needed to establish the psychosocial consequences of Internet use in college students.
efficacy and effectiveness of different interventions. Psychiatric Comput. Inform Nurs. 2004; 22: 153–61.
associations are coming under increasing pressure to recognise it 8 Block JJ. Issues for DSM V: Internet addiction. Am. J. Psychol. 2008;
165: 306–7.
as a treatable clinical disorder and include it in the DSM V.
9 Greenfield D. Virtual Addiction: Help for Netheads, Cyberfreaks and
The health department of the South Korean government has
Those Who Love Them. Oakland, CA: New Harbinger Publications,
now recognised IA as a serious public health problem. Arguably, it is 1999.
time for the World Health Organization and health departments 10 Lenihan F. Computer addiction – a sceptical view. Advances in
around the world to develop effective health policies to increase Psychiatric Treatment 2007; 13: 31–3.
public awareness of IA and produce standardised treatment proto- 11 Macartney J. Beijing 2008. Available from: http://www.timesonline.
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Until these steps are taken, child psychiatrists will continue to 12 Available from: http://eu.blizzard.com/en/press/081223.html
receive referrals for children and adolescents with IA, and [accessed 6 April 2009].
13 Tate D. Speech made at Practising Law Institute on Telecom Policy
remain powerless to implement effective interventions. If we
ad Regulation, December 2008. Available from: http://
fail to acknowledge IA as both a clinical disorder and a public
hraunfoss.fcc.gov/edocs_public/attachmatch/DOC-287221A1.pdf
health issue, then it will continue its silent, endemic spread, [accessed 7 April 2009].
affecting millions of children and adults, and eventually affect- 13b Available from: http://www.nytimes.com/2010/08/14/opinion/
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© 2010 The Author
Journal of Paediatrics and Child Health © 2010 Paediatrics and Child Health Division (Royal Australasian College of Physicians)