Running head: MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER!

An Investigation of Internet Addiction Disorder: Etiology, Enabling Factors, Psychosocial Impacts, and Interventions Faraz Hussain Illinois Institute of Technology

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

Abstract This paper examines the rise of Internet Addiction Disorder (IAD) in the context of recent technological and social developments, with particular attention devoted to the underlying causes and factors predisposing an individual to IAD, different diagnostic models and comorbid conditions. The effect of the neurotransmitter dopamine, which is responsible for both the initial euphoric associations related with maladaptive internet use and the subsequent decrease in physiological rewards, is elucidated. The impact on aficted individuals personal, family and social lives is described, as well as the physical and psychological effects of their behavior. Treatment modalities for IAD have met with varying degrees of success due to a dearth of research and diagnostic validity; the APA is indicted for a failure to pay due consideration to this incipient epidemic in the DSM-5.

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

The rate at which technological advances are accelerating is dictated by Moore's law, an informal axiom which holds that 'overall processing power for computers will double every two years.' This inexorable pace of development allows ever more sophisticated data processing, communication, and entertainment devices to become more widely and cheaply available, with capabilities that often prove irresistibly enticing to consumers by virtue of their design, functionality, and ease of use. Whereas technological advances as revolutionary as electricity and telephony took several decades to penetrate even 10% of the market, mobile phones were able to accomplish that in just a decade, and computers and the Internet in even less time. The most recent innovation in consumer technology, tablets, have achieved that milestone in a matter of less than two years and are currently owned by a quarter of the United States adult population. The Internet has become simultaneously vast and all-pervading, as well as compact and mobile enough to t in the palm of ones hand and the pockets of ones clothing. Ever since its broad adoption in the 1990s, the Internet has paved the way for faster and more reliable communications, widely disseminated and accessible information resources, engaging media and online gaming, e-commerce and online services, and social networking. It is an important tool in education, from preschool to postdoctoral levels. Collaborative software enables the sharing of ideas, skills and knowledge across a variety of platforms and around the globe. Email, instant messaging and Internet relay chat allow for instantaneous communication. However, these capabilities and conveniences come with inherent disadvantages. There have been concerns about the detrimental effects of the Internet ever since its

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

usage rst became extensive. Evidence is now mounting that despite its potential to increase prociency and interconnectedness, maladaptive consumption of the Internet leads users not only prone to becoming more isolated and unproductive, but also susceptible to developing or exacerbating comorbid conditions like attention decithyperactivity disorder and obsessive-compulsive disorder (Weinstein and Lejoyeux, 2010). As early as 1998, when widespread use of the Internet was still in its infancy, Young and her colleagues had identied a subset of online users whose addiction to the Internet was reminiscent of drug or alcohol addiction. In fact, the same neurological pathways are responsible for reinforcing compulsive attitudes towards technology as are responsible for leading to dependence on substances. Our responses to both kinds of behavior are also similar, including a reduction in heart rate, dilatation of blood vessels in the brain, and the diversion of blood away from major muscle groups. These actions facilitate the focusing of the brain on mental and visual stimuli up to an extent, until eventually fatigue leads to a sudden but persistent decline in concentration and cognitive abilities. The euphoric rush or high resulting from engaging in pleasurable online behavior is linked to both chemical and structural changes in the brain. Dopamine, the neurotransmitter that regulates activities involving reward, punishment and mood, triggers the euphoria which addicts obsessed with experiencing. Conditioned to repeatedly seek out the elevated mood associated with being online, addicts are redirected away from their day-to-day activities and return to the comfort of their devices due to the reinforcing effects of this neurotransmitter. Oblivious of distractions such as noise, discomfort, and even their own personal hygiene, the addict continues unabated

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

in these pleasure-seeking behaviors even after become aware of their negative consequences on other aspects of their life. Structural abnormalities introduced within the brain as a result of prolonged maladaptive Internet use cause depletion of both gray matter, which is responsible for muscle control and sensory perception, and white matter, which is responsible for message conduction, by up to 20% each (Lin at al, 2012). This leads to diminished inhibition, short-term memory impairments, compromised decision-making abilities, and the lack of goal-oriented behavior. These changes begin to occur within the rst few occasions of exposure to online stimuli, and continue with each subsequent interaction. To facilitate diagnosis of Internet Addiction Disorder (IAD), Young and colleagues initially modied a seven-item instrument originally designed for diagnosing pathological gambling (DSM-IV TR 312.31) and adapted it so that it would be applicable to individuals with Internet addiction instead. This approach was criticized as being too rigid, and more sophisticated diagnostic criteria were proposedpreoccupation, tolerance, inability to cut back, restlessness or moodiness when attempting to reduce use, and spending more time online than intendedwhich when accompanied by one of the following three were sufcient for a diagnosis of IAD: adverse consequences, lying to conceal Internet use and use of the Internet to escape from problems (Beard & Wolf, 2001). A more reliable instrument to assess pathological online activity patterns is the Internet Addiction Test (IAT), which measures an individuals online involvement on a 100-point scale and classies it into one of three gradations based on severity (Young, 2011). In order to be diagnosed with Internet addiction, an individual also has to meet Grifths diagnostic criteria, namely, salience: Internet use plays a dominant role in the

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

individuals life, feelings, and behavior; mood modication: the individual experiences marked changes in mood when online; tolerance: Internet use accelerates to accommodate desensitization; withdrawal symptoms: halting use produces unpleasant symptoms; conict: defensiveness and a tendency to lie when confronted about Internet use; and relapse: the individual is prone to reverting to the maladaptive behavior, despite periods of abstinence and control. Excessive use of the Internet contributes to sedentary lifestyles, obesity and a general deterioration in physical tness. The physical effects of IAD also include dry eyes and other vision problems, migraines and other headaches, neck aches, backaches, and carpal tunnel syndrome, a painful condition stemming from compression of the nerves in the wrist when typing. Individuals often put off going to bed, wake up later, or sometimes refrain from getting any sleep altogether when within the throes of Internet addiction. Staring at the screen, whether a computer monitor, tablet or phone display, allows the light incident upon the eyes to affect circadian rhythms and potentially induce insomnia. All of these factors combine to create less restful sleep and an overall decrease in sleep quality. Not unrelated are changes in mood and behavior. Individuals that indulge in Internet overuse tend to frequent websites devoted to gaming, pornography, social networking, and chatrooms in disproportionately greater numbers than the rest of the population. This is correlated with an increase in depressive episodes, but scientic consensus has yet to be established as to whether these changes in mood and affect spring from, are a cause of, or are simply comorbid with IAD. A similar debate exists for attention decithyperactivity disorder and obsessive-compulsive disorder, the conditions mentioned

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

earlier. However, a signicant correlation between depressive episodes in individuals with bipolar disorder and problematic Internet use (Shapira et al., 2000) lends weight to the evidence that there is a two-way relationship between mood and Internet abuse. Risk factors for developing IAD include pre-existing anxiety, depression, a lack of social support, an unhappy adolescence, reduced mobility or opportunities to socialize, and addiction to other substances or behaviors such as drugs, alcohol or compulsive gambling. Regardless of etiology, the psychological effects of IAD are clear. Individuals struggle with a constant preoccupation with being online, suffer from a loss of control, and cope with increasingly more debilitating distractibility. They have difculty maintaining healthy boundaries and inhibitions, and often resort to defensiveness and dishonesty when questioned about their Internet use. Their dependency leads them to incur inexplicable bouts of sadness or moodiness when they are not online. The impact on the individuals family and social life is no less pronounced (Turel et al., 2011). Their quality of social life suffers when others complain about their behavior, and the addicted individual snaps back in response, resulting in a vicious cycle of shame and recriminations. Addicts may neglect various important duties when they are compelled to remain online instead, and suffer from withdrawal symptoms when they are forced to spend time away from the Internet. Whenever the pressures of their lives become too great to withstand, addicted individuals retreat to the 'mental safe haven' that the Internet provides them. Excitatory usage is especially indicative of addiction, leading individuals to prefer their interactions online over those with families and friends. It becomes progressively easier for them to lose track of time spent online, missing out

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

on formerly meaningful events and opportunities, and making it even more difcult to cut down on Internet use once they have come to rely on it to cope with the consequences of these actions. Besides biological factors predisposing individuals to addictive behaviors in general and Internet addiction in particular (Montag et al., 2012), there are various environmental factors also at play that make it extraordinarily easy to become addicted to the Internet without even realizing it. The proliferation of high speed Internet connections at work, home and school in conjunction with the wide availability of inexpensive web-enabled devices in a variety of form factors co-conspire to create an atmosphere that is very conducive to spending large amounts of time online without attracting undue attention and avoiding immediate consequences. Individuals working in an ofce setting are often required to be plugged in and in front of a screen for up to 8 hours a day at work, making it difcult to distinguish time spent productively online from that wasted on less fruitful endeavors. A growing number amongst the workforce are taking to bringing their work home even after the working day has concluded, exacerbating this issue still further. The ubiquity of social networking and the fact that the vast majority of ones acquaintances maintain and continually update accounts on one or more of the various services available online creates an environment that fosters competition for likes, retweets and +1s and caters especially effectively to the addictive proclivities of individuals with IAD. In a few cases, problematic Internet use corrects itself within a year of onset of the troubling behavior as individuals learns to wean themselves off or develop more adaptive strategies of managing their time online. Treatment of IAD has been historically

MEDICAL & PSYCHOSOCIAL ASPECTS OF INTERNET ADDICTION DISORDER !

predisposed towards attending to comorbid psychiatric disorders, if present. Behavioral strategies employed that have been used with some success to treat Internet addiction include introducing neutral activities such as spending time outdoors to break the cycle of spending all one's time online, using external stoppers such as alarms to remind one when the time to disconnect approaches, setting clear daily and weekly goals allowing only specic periods of time to be spent online, using reminder cards to encourage the individual to be mindful of the negative consequences of their Internet abuse, and taking personal inventory of the number of life activities they have neglected in the wake of their disorder (Murali & George, 2007). Selective abstinence entails refraining from particular activities such as gaming or social networking; total abstinence is impracticable because of the requirements of most peoples jobs and daily lives. Content control software and invisible monitoring of Internet usage are also signicantly less effective than human oversight and accountability (Yellowlees & Marks, 2007). The importance of the human factor, in fact, cannot be overstated in successful treatment paradigms for IAD. Often, people with inadequate social support resort to the Internet in an attempt to establish new relationships. Our neurotransmitter receptors, however, are not wired to respond as strongly to virtual engagements as they do to real human interactions, leaving such individuals pursuing increasingly more repetitive activities online for ever more elusive rewards. Integrating them into supportive social networks such as those modeled after twelve-step recovery programs, like the ones treating substance or alcohol dependence, can allow these individuals to share their experiences with one another and address their feelings of inadequacy. Since Internet addiction also takes a toll on interpersonal relationships within an individual's family,

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family systems therapy can also serve as an effectual tool in recovery. Family interventions can educate different members about their loved one's addiction, eliminating blame and accusations by promoting open and honest communications. The most effective mode of counseling for the addicted individual has proved to be cognitive therapy, which identies negative cognitions and false assumptions, and reframes them in such a way that the person can develop healthy, adaptive cognitive patterns (Murali & George, 2007). Current models of therapy, however, leave a lot to be desired and are often wholly incapable of keeping pace with the rate of technological development and the increasing number of outlets for individuals to indulge their addictive tendencies online. A 2008 survey of marriage and family therapists by Goldberg et al. revealed that they had not been adequately trained to deal with Internet pornography addiction. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due to be published in 2013, has not only chosen to relegate both Internet Use Disorder and Hypersexual Disorder to appendices in the back of the manual, but connes the latter of these, Internet Use Disorder, to a narrow denition related only to pathological online gaming. According to its editors, conditions such as IAD merit further study before they can be considered disorders (Urbina, 2012). While such deliberation and conservatism would have been laudable had the editors employed it to refrain from including homosexuality or Asperger's syndrome in earlier editions of the manual, their overabundance of caution at this juncture only serves to suppress diagnosis, education and treatment of this insidious disorder even as more and more individuals unknowing succumb to its deleterious effects.

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References

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