It must be March, because “Internet addiction disorder” is again making the news rounds, spurred on by a new editorial in the American Journal of Psychiatry. It published an editorial by Jerald J. Block, M.D. pushing for “Internet addiction disorder’s” inclusion in the upcoming DSM-V. Block is an Oregon psychoanalytic psychiatrist, not a researcher. So I couldn’t help but wonder what leads him to write such an editorial?
Dr. Block owns a patent on technology that can be used to restrict computer access. Dr. Freedman has reviewed this editorial and found no evidence of influence from this relationship.
So wait a minute… A patent is potentially worth money if turned into a product (or if the patent holder sues others who already have products that use their patent). A patent that describes a process that is used to restrict computer access appears to be something very useful to people suffering from “Internet addiction disorder,” no? To stop them from accessing the computer, therefore reducing their use and “addiction.” And the writer just happens to hold such a patent. If approved to the DSM-V, Block could make money from marketing his patent. How is that not a pretty direct and clear conflict of interest?
Worse, the author doesn’t even pretend to take an objective point of view in the editorial, and suggests the research clearly shows this thing exists. But the research in this area is all over the map: the self-selecting surveys done show exactly what we expect to find — people complaining of an issue that they said was an issue in the first place. It’s funny, but if you ask 100 Boston Red Sox whether they like the Red Sox or not, I bet you I could predict what their response will be. That’s the quality of much of the research into “Internet addiction disorder.”
There are zero studies that have been conducted to monitor whether these behaviors change over time and with increased or decreased usage (e.g., is it possibly a type of learning curve that most people successfully negotiate on their own, as with any new technology). Or whether such Internet use really is just a coping mechanism for a pre-existing but unscreened psychiatric condition (e.g., the psychiatric disorder — such as depression — is causing increased and excessive use of the Internet, not the other way around).
Have we done enough studies to untangle the different ways different age groups use and view the Internet? Teens and children today rely on the Internet as adults relied on the telephone when they were growing up. Are there any diagnostic criteria being proposed that understand and make these important distinctions?
Significantly, most of Block’s citations used in the editorial are from conference presentations or magazine articles, not peer reviewed journal articles or large scale clinical trials, the gold standard of psychiatric and psychological research. In one of the two peer reviewed studies actually published about Korea (but not one included in Block’s editorial), the researchers who studied 1,291 teens and children note:
By structured interview, we found that Internet-addicted subjects had various comorbid psychiatric disorders. The most closely related comorbidities differ with age. Though we can not conclude that Internet addiction is a cause or consequence of these disorders, clinicians must consider the possibility of age-specific comorbid psychiatric disorders in cases of Internet addiction.
As noted above, the occurrence of coexisting conditions causes most researchers to suspect people are turning to the Internet as a coping mechanism to deal with their mental health concern, like ADHD or depression. But since we already can diagnose ADHD and depression (and know very well how to treat them), it’s not clear why Block feels the need for yet another diagnostic category.
Imagine someone goes to college for their first time and feels depressed, misses home and their old friends. They start procrastinating and stop doing much of their schoolwork. Instead, they turn to music and greatly enjoy playing piano, first for the college jazz band, then at local nightclubs. What’s the problem here — too much piano playing? Or is it depression?
People spend a lot of time online for one of a couple of reasons, according to the research: sex, gaming or social relationships. Taken in any other context, these activities are all fun, enjoyable activities! Imagine researchers having this conversation if a wave of book-reading overtook America… And with the popularity of reading devices like Amazon.com’s Kindle reader, it’s within the realm of possibility to consider such a scenario.
That is the kind of absurdity Block is proposing for the DSM-V. If successful, look to reading, television watching, talking on the telephone, and yes, even piano playing to make it into the DSM-VI shortly thereafter.
References:
Block, J.J. (2008). Issues for DSM-V: Internet Addiction. Am J Psychiatry, 165, 306-307.
Ha, J.H. et al. (2006). Psychiatric Comorbidity Assessed in Korean Children and Adolescents Who Screen Positive for Internet Addiction. Journal of Clinical Psychiatry, Vol 67(5), 821-826.
23 comments
Wonderful, emotional blog. Very informative. Thanks.
I hope the committee for the DSM V will be more critical about their task and evidence for this diagnosis.
“…no evidence of influence…”??? What WOULD he identify as “influence” (aka conflict of interest)? Never mind that treating “internet addiction” is junk medicine. This is just incredible.
Love your take on this, Dr. Grohol. Thanks.
> But the research in this area is all over the map: the self-selecting surveys done show exactly what we expect to find — people complaining of an issue that they said was an issue in the first place. It’s funny, but if you ask 100 Boston Red Sox whether they like the Red Sox or not, I bet you I could predict what their response will be. That’s the quality of much of the research into “Internet addiction disorder.â€
The quality of a lot of research into disorders is like that… DID, depression, anxiety etc… If you believe that you have it then SURPRISE! You have it! Not so surprising at all, really. The use of self report as a measure tends to have that effect. People who ALREADY BELIEVE they have X will self-report in a way that is consistent with what they believe about what it takes to have X. The problem is that questions used in self-report are often very transparent in this way.
I have no problem at all with saying that there are different kinds of addiction and then listing them:
Alchohol
Nicotine
Caffine
Pornography
Internet
Whether the subgroupings matter or not will be determined by whether the treatments for the different kinds of addictions need to be substantially different or not.
Whether prior mental health issues are partly responsible for the development of internet addiction or whether internet addiction is partly responsible for the development of psychiatric disorders is up for grabs.
I guess I just don’t see the significance of the ‘it exists!’ ‘no it doesn’t!’ debate…
Because it matters what we say is a disorder and what isn’t. Is reading a disorder? Where do we draw the line between pro-social or pro-learning activities being demonized just because people, perhaps temporarily, have trouble integrating them into their lives? Why not just diagnose all aberrant behavior and be done with it?
Furthermore, if clinicians start treating people for this “disorder” when the person really has clinical depression or ADHD — which goes undiagnosed and untreated — how many people will suffer unnecessarily because some clinicians are focusing on coping mechanisms instead of the underlying concerns that kick those coping mechanisms into place?
Diagnostic systems of classification quickly become meaningless if we too far down this road…
Yeah, it matters. It matters for third party funded treatment (e.g., by governments or by health insurance providers). If we go too far in the ‘pathologizing of normality’ then treatment parity always will be an unrealized dream.
Do you really think that ‘internet addiction’ is about pathologizing ‘pro-social’ or ‘pro-learning’ activities? I thought that the idea was that while SOME people use the internet in such a way that their use is pro-social and pro-learning other people use the internet in a way that is harmful to them in their social and occupational (etc) functioning. It was just the latter people who were thought to have a disorder.
There is some kind of priority list of DSM disorders at the moment. Some disorders are considered more ‘serious’ than others. There can be exclusion criteria, too, such that one diagnosis takes priority over another diagnosis in the case that dx criteria for both are met.
I don’t think anybody is advocating that internet addiction be considered a treatment priority in the way that schizophrenia or bi-polar are prioritized. I don’t think that anyone is suggesting that when schizophrenia (for example) and internet addiction are comorbid that we forget about treating the schizophrenia and treat the internet addiction instead.
I’m very sceptical about some of the fundamental assumptions of the present system of classification. In particular, I favour dimensional systems (where symptoms are present to a greater or lesser extent so they are seen as on a continuum with normality) and where symptoms are the focus rather than symptom clusters (where there don’t really seem to be clusters at all). But I guess that is a seperate rant 😉
You didn’t really answer my question, though… Where do we draw the line when we start pathologizing pro-social and pro-learning behaviors? Why should we stop at Internet use if we go down this road?
Sorry, I thought I kind of did in the second paragraph. I guess it is like how food is (generally speaking) a good thing – but not too much of it. And alcohol is (generally speaking) a good thing – but not too much of it. And sex is (generally speaking) a good thing – but not too much of it. And similarly for… Ones internet usage.
So I don’t think that they are attempting to pathologize pro-social and pro-learning behaviors. I think that (they think) they are attempting to pathologize pathological variations on behaviors that are pro-social and pro-learning. Like how it is healthy and adaptive to feel anxiety and sadness sometimes, but it is unhealthy and maladaptive (that is the thought anyway) to feel anxiety and sadness most of every day for most days.
The addiction stuff reminds me of the phobia stuff (I think I’ve drawn this analogy before). There are some lists of phobias that are a couple hundred phobias long. The DSM makes do with three (I think – don’t quote me on that) subtypes. Is it useful to distinguish between the subtypes that the DSM distinguishes between? I’m not sure… Some of them might be less resistent to change (we might have a hardwired and readily learned phobia to blood / injury, spiders, heights etc). It was controversial whether little albert ever did successfully acquire a phobia to furry white things…
How does the DSM decide where to draw the line on how many kinds of phobia to include?
Similarly… How does the DSM decide where to draw the line on how many kinds of addiction to include?
I heard a story once about how inclusion and exclusion of dx’s in the the DSM can be a matter of individuals in a task force going ‘I’ll trade you xxx (vote for its inclusion) if you give me yyy’.
Lol.
Good points… but food and sex addiction are not listed or considered “addictions” in the DSM. And alcohol and drugs are substances that directly affect our brain and central nervous system’s chemistry, so the concept of addiction there is well-accepted and understood. Not so much for simple, usually positive behaviors.
The DSM’s conceptualizes phobias into gross categories — agoraphobia (fear of leaving one’s home), social phobia (fear of social situations), and everything else (simple phobias, because the phobia is about a specific but usually minor stimulus, like a spider).
Some have conceptualized “Internet addiction” as either a coping mechanism for another disorder (most commonly depression and ADHD are mentioned), an impulse control disorder (for which there already exists a DSM diagnosis), or a compulsive behavior (for which there already exists a DSM diagnosis).
So in following your suggestion, perhaps “Internet addiction” could be viewed as a specific subtype for one of these kinds of disorders. But since researchers aren’t really agreed on which one it is, it again seems a bit premature to be talking about including it in the DSM in the first place.
My stance is we need more robust research in this area to get actual agreement amongst the leading researchers in this area before we go asking for its inclusion in the DSM. I’m not saying it shouldn’t ever be considered for inclusion, just that the research base doesn’t even begin to compare with that of more serious (and I would argue, legitimate) mental health concerns.
Sure. I think I feel your pain. Everything said in your third paragraph could not only apply to internet addiction, it could similarly apply to drug addiction (and sex addiction) and so on and so forth.
I’m not terribly sure that the concept of addiction (in the case of substances) is particularly well understood… But maybe the thought is that while one can get addicted to substances that ones neurology can become tolerant to and where a person can suffer withdrawal from them one simply can’t get addicted to other sorts of things.
But then the line gets blurry. Sex releases neurochemicals… Chocolate does too… There is a great deal of controversy already over whether addictions should be considered mental disorders or whether they should be considered social / criminal problems best dealt with in the courts. Controversy over whether addiction is a disease or not.
I guess I think that since there is so much controversy already it really won’t do to add another to the list. I can certainly hear the health insurers and those who consider pay parity going ‘one in four already: internet addiction, where will it all stop. no way!’
Do you really think that DSM inclusion would cause clinicians to ignore the comorbid and perhaps primary disorder? (I’m just going to use depression as the example of a comorbid disorder for the rest of this.)
I’ve been researching this topic for a while, and everyone that I’ve spoken to seems aware of the strong need to treat the depression, not just the Internet Addiction.
Block doesn’t seem to be making the claim that the depression should go untreated. His argument for the DSM consideration seems to rest on the closing statement: “[Internet Addiction] makes comorbid disorders less responsive to therapy.”
From the people that I’ve spoken to, I’m not convinced that the comorbid disorder would be disregarded.
The other note that I wanted to toss out here is in regard to the boundary between a passion and an obsession, which is a fuzzy one, I agree. The trick in keeping Internet Addiction from being a technophobic mess ..as I understand it… is the diagnostic trick of qualifying it according to negative repercussions.
For example, Alice has a low stress job, no kids, a cat, a nice apartment and is happy with her life. Alice plays MMORPGs for hours every day, pretty much all her time before work and after work. Her guildmates are her best friends and she likes it that way. She doesn’t have an addiction to the Internet, because it’s not causing problems for her.
But what about Bob, who has a high stress job and serious responsibilities that he’s failing to meet. He’s depressed and he plays MMORPGs all day every day to forget about that. He doesn’t even really like playing that much anymore, but it’s the only thing that he feels good at. That’s the type of person who comes close to having an Internet Addiction.
To answer someone else’s question, I think that’s the place where the distinction becomes clear: negative repercussions.
Whether or not those negative repercussions need to be self identified as such is another question, and maybe worth more thought. Maybe I’m missing something here though. Is that too simple of a suggestion, or flawed in other ways?
Hi Rachel, good points.
To Block’s point (“[Internet Addiction] makes comorbid disorders less responsive to therapy”), I’d ask, “According to what research?” Because I couldn’t find any large-scale studies done that actually show that. While that may indeed be his opinion, using one’s opinion as the basis for a new mental disorder isn’t really going to sway many.
I’d ask, What about Fred, who has a high stress job and serious responsibilities that he’s failing to meet. He’s depressed and he spends nearly all of his free time (and much time he doesn’t have) simply watching television, usually whatever sports happens to be on. He doesn’t really enjoy what he’s watching, but it’s the only thing that seems to hold his attention for any amount of time. That’s the type of person who comes close to have television Internet.
I’d also ask what about Jane. Jane also has a high stress job and serious responsibilities that she’s failing to meet. She’s depressed and she ends up spending all of her time either talking to her friends on her cell phone, or chatting with them in the local coffeeshop. She ignores work that’s piling up, and knows she should get to, because talking with her friends feels so good. When she can’t reach one friend, she’ll just go through her entire list until she can find one who’ll talk to her. She loves the feedback and reinforcement she gets from talking with her friends — it’s like a natural high! It’s not uncommon for her to talk to her friends for 6 or 7 hours a day. That’s the type of person who comes close to have social addiction disorder.
The list could go on…… The point is that we all do — and we all have done since the beginning of time — activities that, when taken to an extreme, could be bad.
At what point do we stop focusing on the medium or technology or whatever, and just call depression, “depression” (or whatever the disorder underlying the behavior may be)?
Excellent blog i thought the same conflict of interest existed and i’m so glad to have found your blog and i hope more people will.
In conclusion i agree lets call depression what it is and while we’re at it (based on no subjective research naturally) why not also make the point that technologies that restrict access to the internet aren’t going to be the cure for this new disorder either! 😉