East Asian Arch Psychiatry 2010;20:123-32

Review Article

Internet Addiction: Consensus, Controversies,

and the Way Ahead

K Chakraborty, D Basu, KG Vijaya Kumar

Abstract
Objectives: To review the fast-growing literature on Internet addiction.
Methods: Descriptive review, using electronic databases as well as hand-search of relevant publications
or cross-references from 1970 to 2010.
Results: There are no universally accepted definitions for the captioned condition, but investigators
seem to agree that it involves problematic computer usage that is time-consuming and causes distress or
impairs functioning in important life domains. Several aetiological models have been proposed, from the
diverse perspectives of learning theory, cognitive behavioural theory, social learning, reward deficiency,
culture, genetics and neurobiology. Controversies abound, ranging from conceptual (whether behavioural
addictions are true addictions), technical (which component of Internet use is a person addicted to),
and practical (how should Internet addiction be diagnosed, if it exists at all). However, using various
instruments and populations, Internet addiction has been suggested as having a prevalence of 0.3 to 38%,
with a young male preponderance. Several screening, diagnostic, and severity assessment instruments are
now available, but few have been subjected to rigorous psychometric testing. Psychiatric co-morbidity
is common. Treatment modalities lack a firm evidence base, but antidepressants, mood stabilisers, and
cognitive behavioural therapy and other psychotherapies have been used.
Conclusions: Recently, the American Psychiatric Association recommended including Internet addiction
in its forthcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, but only as
an appendix and not in the main body of the addictive disorders. This appears to be a fairly balanced
and cautious approach, which can hopefully give rise to more meaningful research in this important but
controversial area.
Key words: Behavior, addictive; Internet; Psychotherapy

19702010

0.338%

Dr Kaustav Chakraborty, MD, Drug De-addiction and Treatment Centre,

Department of Psychiatry, Postgraduate Institute of Medical Education and
Research, Chandigarh, India.
Dr Debasish Basu, MD, DNB, MAMS, Drug De-addiction and Treatment
Centre, Department of Psychiatry, Postgraduate Institute of Medical Education
and Research, Chandigarh, India.
Dr KG Vijaya Kumar, MBBS, Drug De-addiction and Treatment Centre,
Department of Psychiatry, Postgraduate Institute of Medical Education and

2010 Hong Kong College of Psychiatrists

Research, Chandigarh, India.

Address for correspondence: Dr Debasish Basu, PGIMER, Chandigarh
160012, India.
Tel: (91-172) 2706 618; Fax: (91-172) 2744 401;
Email: db_sm2002@yahoo.com
Submitted: 25 February 2010; Accepted: 7 July 2010

123

K Chakraborty, D Basu, KG Vijaya Kumar

Introduction
The Internet is an integral part of modern life for many
people. The idea that almost any subjectively rewarding
activity (e.g. drug use, shopping, working, running,
gambling, using the computer, and using the Internet),
which can become the object of addiction, has become
increasingly popular.1-4 Although the earliest reports on the
phenomenon of excessive use of the Internet date back to
the 1970s, it was not until the early 1990s that reports began
to appear in the medical and psychological literature for
what Griffiths5 called a technological addiction, described
it as a non-chemical addiction involving human-machine
interaction.

Young6 was one of the first to describe excessive
and problematic Internet use as an addictive disorder.
Internet addiction is not a recognised diagnostic category
in the 10th edition of the International Classification of
Diseases (ICD-10) or the 4th edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV), and
thus considerable nosological ambiguity surrounds the
phenomenon.7 Although much literature is available from
abroad, India has been a silent spectator despite its large
population and increasing levels of computer and Internet
use. Hence, it was worth reviewing the fast-growing
literature in this important area wherever it stemmed from.

The data search strategies for this review included
electronic databases as well as hand-searches of relevant
publications or cross-references from 1970 to 2010. The
electronic search included PubMed and other search engines
(e.g. Google Scholar and PsychINFO). Cross-searches of
electronic and hand-searched key references often yielded
other relevant materials. The search terms used, in various
combinations, were: Internet, computer, addiction,
dependence, assessment, scales, prevalence,
treatment, co-morbidities, and correlates.

Definitions and Proposed Diagnostic Criteria

Although no universally accepted definitions for the
condition, investigators seem to agree that it involves
problematic computer usage that is time-consuming and
causes distress or impairs functioning in important life
domains. The many names given to this phenomenon
are a testament to the various ways in which it has been
perceived. They include: compulsive Internet use,
pathological Internet use, problematic Internet use,
Internet dependency, Internet addiction and even
Internetomania.8 If viewed from an addictive disorders
perspective, Internet addiction has the following 4
components: (1) excessive use, which is often associated
with a loss of a sense of time or a neglect of basic drives;
(2) withdrawal, including feelings of anger, tension,
and / or depression, when the computer is inaccessible;
(3) tolerance, including the need for better computer
equipment, more software, or more hours of use; and
(4) negative repercussions, including arguments, lying,
124

poor achievement, social isolation, and fatigue.9 Internet

addiction is the most widely used term to describe this
maladaptive behaviour. In this article, this term will be used
to describe these collective phenomena to avoid further
confusion.

Young10 modified the DSM-IV diagnostic criteria for
pathological gambling to construct diagnostic criteria for
pathological Internet use, which she defined as 5 or more of 8
characteristic symptoms present in the preceding 6 months.
She further divided Internet addiction into 5 subtypes
depending on the particular component of use to which it
was directed addiction, namely: (1) cybersexual addiction;
(2) cyber-relational addiction; (3) net compulsions; (4)
information overload; and (5) computer addiction.11 Young10
also found that email, chat, and the web are examples of
applications used on the Internet, whose nature has addictive
properties. Moreover, interactive real-time services such
as Internet relay chat and multi-user domains proved to be
most addictive.

Shapira et al12 defined problematic Internet use as
uncontrollable, markedly distressing, time-consuming or
resulting in social, occupational, or financial difficulties,
and not solely present as a manifestation of hypomanic
and manic symptoms. Later, Shapira et al13 conceptualised
Internet addiction as an impulse control disorder (ICD) and
proposed the diagnostic criteria of problematic Internet use
to be based on the general style of ICDs in the Text Revision
of the DSM-IV. Aboujaoude et al14 developed 4 sets of
diagnostic criteria, which were created from diagnostic
criteria of other ICDs (obsessive-compulsive disorder and
substance abuse) and then suggested criteria for problematic
Internet use.

Very recently, Tao et al15 proposed formal diagnostic
criteria for Internet addiction disorder (IAD). These
were listed as follows. Criterion (a) or the symptom
criterion entailed 7 clinical symptoms of IAD, of which
2 (preoccupation with Internet use and withdrawal
phenomena) along with at least 1 of the remaining 5 had to
be satisfied [what the authors call the 2+1 rule]). Criterion
(b) referred to clinically significant impairment (functional
and psychosocial impairments). Criterion (c) dealt with
the disorders course (duration of addiction lasting at least
3 months, with at least 6 hours of non-essential Internet
usage per day). Criterion (d) dealt with exclusions (e.g.
dependency attributed to psychotic disorders). Using a
series of statistical analyses, they demonstrated excellent
inter-rater reliability, diagnostic accuracy, and specificity
for their diagnostic criteria.

Aetiological Models
Various aetiological models have been proposed to
understand Internet addiction. Learning theory emphasises
the positive reinforcing effects of Internet use, which can
induce feelings of well-being and euphoria in the user, and
works on the principle of operant conditioning.16 Further,
Internet use by a shy or anxious individual to avoid anxietyEast Asian Arch Psychiatry 2010, Vol 20, No.3

Internet Addiction

provoking situations such as a face-to-face interaction tend

to reinforce use by avoidance conditioning. Yet why so
few and not everybody using the Internet develop Internet
addiction remains unclear. In this context it may be worth
studying the temperament of predisposed individuals.

Davis17 proposed a cognitive behavioural theory of
problematic Internet use, which he viewed as arising from a
unique pattern of Internet-related cognitions and behaviours.
Examples of maladaptive cognitions include self-doubt,
self-focused rumination, low self-efficacy and negative selfappraisals. Although interesting at a theoretical level, this
hypothesis needs to be proven through systematic research.

Caplan18 has developed an explanatory theory
invoking deficient social skills. His first assumption
was that lonely and depressed individuals hold negative
views of their social competence. The second assumption
was that there are several features of computer-mediated
communications that are particularly attractive to persons
who see themselves as low in social competence. In this
context, computer-mediated communication interactions
give people greater flexibility in self-presentation than
face-to-face communication, which facilitates omission
or editing of information regarded as negative or harmful.
As Morahan-Martin and Schumacher19 put it, The
Internet can be socially liberating the Prozac of social
communication. Although this theory attempts to explain
Internet addiction in a subgroup of people, it cannot account
for the whole phenomenon.

The reward-deficiency hypothesis suggests that
those who achieve less satisfaction from natural rewards
(food, water, sex) turn to substances to seek enhanced
stimulation from reward pathways.20 Internet use provides
immediate reward with minimal delay, mimicking the
stimulation provided by alcohol or drugs. Impulsivity
is seen as a risk factor for the development of addiction.
Shaffer21 has suggested that Internet use is linked to
sensation-seeking behaviour, which is a sub-trait of
impulsivity. Neurobiological research aimed at finding the
neural substrates / pathways that can be useful to establish
the causal link.

Ongoing research into various aspects of Internet
addiction, coupled with the fields of genetics and
neurobiology have also contributed to this topic. Recently,
genetic polymorphisms of the serotonin transporter gene (SS5HTTLPR) have been found in excessive Internet users.22
However, in view of association of this polymorphism with a
number of other psychiatric conditions (e.g. mood disorders,
anxiety disorders, alcoholism, nicotine dependence), this
finding needs replication in a well-controlled population. A
voxel-based morphometry study by Zhou et al23 found that
adolescent Internet addicts had lower grey matter density
in the left anterior cingulate cortex, left posterior cingulate
cortex, left insula, and left lingual gyrus, compared with
healthy controls. They suggested that this may provide a
new insight into the pathogenesis of Internet addiction,
especially in light of deficits in decision-making function
and strategy learning lag.24 Functional neuroimaging studies
East Asian Arch Psychiatry 2010, Vol 20, No.3

with provocation techniques can be useful for this purpose.

From the above discussion, it is evident that none of the
theories is self-explanatory and a combination of them
may help us understand this complex phenomenon to some
extent.

Controversies regarding Internet Addiction

Under typical circumstances, the Internet should not be
considered the source of gambling or an object of addiction.25
Despite the above-mentioned aetiological models, it is still
not clear precisely what Internet addicts become addicted
to. The possibilities suggested are: the process of typing,
the Internet as a medium for communication, and the
Internet as a source of information. Particular applications
(e.g. email, gambling, video games, pornography and
multi-user domains / dungeons) can be enjoyed with the
anonymity of the Internet.26,27 Critics of Internet addiction
as a discrete disorder point out that the Internet is merely a
communications medium not a substance. Thus it merely
fills a pathological need to play a game or view pornography
and therefore merely represents a means to fulfilling an
underlying psychopathology that would be manifested in
some other way, were it not available.

When the concept of Internet addiction was first
introduced in a pioneer study by Young,28 it sparked a
debate among both clinicians and academicians. Part of
the controversy revolved around the contention that only
physical substances ingested into the body could be termed
addictive. While many believed the term addiction
should be applied only to instances involving the ingestion
of a drug,29,30 defining addiction has moved beyond this to
include a number of behaviours not involving an intoxicant,
such as: compulsive gambling,31 video-game playing,32
overeating,33 exercise,34 love relationships,35 and televisionviewing.36

Internet addiction has been thought of as a compulsiveimpulsive spectrum disorder.37 However, Pies38 contends
that withdrawal and tolerance have not been established in
Internet addiction subjects using physiological measures
comparable to those used in patients dependent on various
substances. As per Pies,38 these terms have been used either
metaphorically or to describe coarse behavioural criteria,
such as the patients complaints of feeling irritable or
anxious. He also emphasised that there was no universal
agreement as to specific diagnostic criteria for Internet
addiction. Nor was it clear whether it is a discrete mental
disorder, or, indeed, whether it is a disorder at all.38 Similar
concerns have been raised by others.39 According to Pies, a
less emotionally loaded and more encompassing term than
Internet addiction is what he terms as pathological use
of electronic media (PUEM). He does not suggest PUEM
as a discrete diagnosis for the present; however, he does
suggest a detailed description of PUEM should be added to
the DSM-V appendix, as a condition for further study.38
He further hints that PUEM-like symptoms be classified as
impulse control disorder not otherwise specified (NOS)
under the current DSM-IV system, rather than as an
125

K Chakraborty, D Basu, KG Vijaya Kumar

addictive disorder. While appreciating Pies fairly balanced

critique, we feel that both his suggestions (of PUEM rather
than Internet addiction, and lumping it under ICD NOS
rather than addictions) are premature and that only future
studies can clarify the issues. We agree with him, however,
that the condition deserves further rigorous, systematic, and
unbiased study and that it cannot simply be wished away.

Furthermore, the issue of psychiatric co-morbidity
raises other diagnostic dilemmas. A high prevalence of
co-morbid depressive and anxiety disorders along with a
low prevalence of substance-related problems have raised
doubts as to whether Internet addiction may be a symptom
of Axis I or Axis II disorders, particularly in adolescents.40,41

A constellation of related signs and symptoms
essentially, a syndrome may ultimately be understood as
a specific disease entity when at least one of the following
criteria are met: (i) a pattern of genetic transmission is
discovered, sometimes leading to the identification of
a specific genetic locus; (ii) the syndromes aetiology,

pathophysiology and / or pathologic anatomy become

reasonably well understood; and (iii) the syndromes course,
prognosis, stability, and response to treatment are seen to be
relatively predictable and consistent across many different
populations.42,43 Notwithstanding the huge amount of
research emerging mainly from Asia and the United States,
there is a worry that creating a separate category for Internet
addiction will open the door to all kinds of new disease
categories, as new technologies develop (e.g. iPhone
addiction, mobile addiction, virtual reality addiction).
Expanding an already mushrooming catalogue of supposed
disorders requires caution, lest it undermines the publics
trust in psychiatric diagnosis.38,39 Table 1 summarises the
various pros and cons of the proposed definitions, symptoms
and subtypes, diagnoses, and aetiologies.

Epidemiology
There have been various community and online surveys

Table 1. Pros and cons of the proposed definitions, symptoms, diagnoses, and aetiologies of Internet addiction.
Definition

Symptoms
and
subtypes

Diagnosis

Aetiology

126

Pros

Cons

Cybersexual addiction, cyber-relational addiction,

net compulsions, information overload, and computer
addiction.11
Uncontrollable, markedly distressing, time-consuming or
resulting in social, occupational, or financial difficulties, and
not solely present during hypomanic and manic symptoms.12

No universal agreement on what

constitutes the symptoms of Internet
addiction, although most agree that for
some individuals, excessive Internet use
assumes a compulsive, addictive quality
that is harmful and dysfunctional. More
work is needed on the symptoms
of Internet addiction to make them
universally acceptable.

1. Excessive use of the Internet, often associated with a

loss of sense of time or a neglect of basic drives.9
2. Withdrawal, including feelings of anger, tension, and /
or depression when the computer is inaccessible.9
3. Tolerance, including the need for better computer
equipment, more software, or more hours of use.9
4. Negative repercussions, including arguments, lying,
poor achievement, social isolation, and fatigue.9

Five schools of thought:

1. It is a compulsive-impulsive spectrum diagnosis.37
2. It is an impulse control disorder.13,38
3. It is an addictive disorder.11,15,28
4. Combination of all above14
5. It is not a disorder at all but rather a sociological
phenomenon that should not be medicalised at all.18,19
1.
2.
3.
4.
5.

Learning theory16
Cognitive behaviour theory17
Social skills theory18,19
Reward deficiency theory20
Neurobiological theory22-24

It is not known if these proposed

characteristics actually define a discrete
entity called Internet addiction that
can be viewed as a psychiatric disorder.
More data are required to validate
this, or any other, definition of Internet
addiction.

The very fact that there are so

many divergent opinions about the
phenomenon suggests that either there
is something fundamentally wrong
about how we presently conceptualise
disorders and diagnosis, or that more
work is clearly needed in this area.

Often these are mere speculations,

or isolated findings, rather than solid
evidence-based theories; thus at the
most these are hypotheses that need
to be confirmed or rejected by welldesigned studies. Further, these are often
derived from the respective authors
own theoretical orientation rather than
objectively verifiable facts.
East Asian Arch Psychiatry 2010, Vol 20, No.3

Internet Addiction

to estimate the prevalence of Internet addiction, with little

uniformity of the definitions employed or assessment
methods.44 The studies have predominantly focused on
younger populations rather than the wider adult population.
This perhaps reflects the view that this is primarily a disorder
of younger persons. In studies that focus on younger
people, prevalence estimates range from 0.9 to 38%.45,46
Interestingly, the 4 online surveys produced prevalence
estimates ranging from 3.5 to 18%.47-50 The reasons for
such huge variability could be: difficulty in conceptualising
Internet addiction, lack of availability of standard diagnostic

criteria, heterogeneity of the populations studied, and failure

to consider psychiatric co-morbidity in some of the studies
(Table 2).14,19,45-57

Based on data from the community, online surveys, as
well as clinical samples, Internet addiction appears to have
a male preponderance.19,45,48,53-55 Regarding age of onset,
studies have found that the disorder manifests itself in the
late 20s or early 30s.11,58 Black et al58 reported that their
subjects were introduced to computers at a mean age of 17
years; there was a lag time of 11 years from initial computer
use to problematic computer use, and it led to a deficit in

Table 2. Epidemiologic data on the prevalence of Internet addiction.

Authors

Location

Sample (No.)

Criteria used

Egger and
Switzerland People (450)
Rauterberg (1996)50

Online

Morahan-Martin
and Schumacher
(2000)19

US

Whang et al
(2003)47

Korea

Yoo et al (2004)45

Korea

Leung (2004)46

China

Johansson and
Gotestam (2004)55

Norway

Kim et al (2006)56

Korea

Students (1573)

Pallanti et al
(2006)57

Italy

Students (275)

Korea

Students (912)

Greenfield (1999)49 US

Chou and Hsiao

(2000)53

Taiwan

Kaltiala-Heino et al Finland
(2004)54

Niemz et al
(2005)48

UK

Aboujaoude et al
(2006)14

US

Jang et al (2008)51

Ghassemzadeh et al Iran
(2008)52

Abbreviations: M = male; F = female.

East Asian Arch Psychiatry 2010, Vol 20, No.3

Prevalence Gender
(%)
preponderance
10.6

Not addressed

People aged 8-85

years (17,251)

Online, 36-item
questionnaire

5.7

M=F

13-Item questionnaire

8.1

M>F

University students
(910)

Self-made questionnaire

5.9

M>F

Respondents
(13,588)

3.5

M=F

Youths (7229)

Online Modified Youngs

Internet Addiction Scale

1.7 (Boys)
1.4 (Girls)

M>F

Chemistry students
(535)

Criteria was tailored

analogously to the criteria
of pathological gambling

Youngs Internet Addiction

Test

0.9

M>F

Youngs Internet Addiction

Test

38

F>M

Youngs Internet Addiction

Test

M>F

Online Problematic Internet

Use Scale

18

M>F

1.6

F>M

Internet Addiction Scale

5.4

M=F

Internet Related Addiction

Scale

4.3

M>F

3.8

Not addressed

Undergraduate
students (277)

People aged 16-24

years (699)

Youths aged 12-18

years (3237)
Students (371)

Adults (2513)

Internet Addiction Scale

Survey questions were

extrapolated from established
diagnosis on impulse
control disorder, obsessive
compulsive disorder, and
substance abuse

Internet users (977) Youngs Internet Addiction

Test

0.3-0.7

Not addressed

127

K Chakraborty, D Basu, KG Vijaya Kumar

general mental health (as reflected by testing with the Short

Form-36 health survey).59

Assessment of Internet Addiction

Symptoms of Internet addiction may not always be revealed
in an initial clinical interview; it is therefore important that
clinicians routinely assess for its presence. Four specific cues
need to be explored, viz: applications; emotions; cognitions;
and life events which often trigger Internet use or Net
binges.60 Several screening and assessment instruments
have been developed to assess Internet addiction, although
none has emerged as the gold standard.9,10,27,50,61-68

The above-mentioned screening and diagnostic
instruments have severe limitations in terms of applicability.
First, they are based on different theoretical frameworks, so
there is limited agreement about their crucial components,
or dimensions. Second, most are self-reported instruments
and hence dependent on the respondent answering questions
honestly, yet none incorporate a lie scale to correct for this.
Third, none of them identify specific Internet applications
(e.g. chat rooms, email, pornography) to which the user
might be addicted.69 Hence, it is advisable to rely heavily on
the clinical interview and use diagnostic tools only within a
comprehensive framework.

Clinical Manifestations
Studies have attempted to delineate the behaviour of
problematic Internet users. Shotton70 found that, compared
with 2 normative groups, addicts spent significantly more
time using their computers at home and at work, and found it
difficult to stop computing and in the process lost all sense
of time. Egger and Rauterberg50 also found that Internet
addicts developed urges to use the Internet when offline,
and even felt guilty or depressed when spending too much
time online and recognised its negative consequences.

Black et al58 systematically assessed the experiences
of 21 compulsive computer users. Most admitted that their
computer usage had caused problems with family or friends,
or with work or school. Nearly one-third had tried to cut
back, but observed that doing so made them more anxious.

In a study of 596 subjects that 396 of whom were
considered computer-dependent, Young6 observed that
dependents predominately used the 2-way communication
functions on the Internet, such as chat rooms, multi-user
dungeons, newsgroups or emails, while non-dependents
tended to use information-seeking aspects of the Internet and
email. Computer dependents reported that their excessive
Internet use resulted in personal, family and occupational
difficulties, with more than 50% rating these problems as
severe.

A recently conducted study from Chandigarh, India
found that about 59% of respondents would get upset
when the Internet was not available, 54% felt the need to
use Internet every day, 45% lost track of time after starting
to surf, and 43% stayed online longer than originally
128

intended.71 Another Indian study has found that compared

with non-dependent subjects, those who were dependent on
the Internet would delay their work to spend time online,
lose sleep due to late-night log-ons, feel lonelier and feel
life would be boring without the Internet.72 Although the
above-mentioned studies attempted to tap the different
dimensions of Internet use, whether such reactions should
be labelled as pathological remains controversial. All
these studies were limited by lack of standardised criteria
for Internet addiction, not taking any account about the
subjects Internet use from relatives, and failure to apply
stringent disability criteria.

Co-morbidities of Internet Addiction

Studies suggest that Internet addiction is frequently
associated with DSM-IV Axis I and Axis II disorders. Black
et al58 found that nearly 30% of the subjects in their study
met the criteria for a current disorder; the most common
being disorders of mood (24%), anxiety (19%), substance
use (14%), and psychoses (10%). Nearly half of the
subjects met the criteria for a lifetime psychiatric disorders,
including for substance use (38%), mood (33%), anxiety
(19%) and psychotic symptoms (14%). Various ICDs were
also conspicuous by their presence; 38% of the subjects had
at least 1 ICD (compulsive buying, 19%). Besides, 52%
of Internet addicts met criteria for at least 1 personality
disorder, the most frequent being borderline, antisocial, and
narcissistic disorders.

Shapira et al12 reported DSM-IV Axis I diagnosis in
addition to their problematic Internet use in all 20 of the
subjects 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. They also noted that
35% of their subjects met the criteria for an ICD, including
intermittent explosive disorder (10%), kleptomania (5%),
pathological gambling (5%), and compulsive buying (20%).

Increased use of the Internet was associated with
higher ratings on measures of depression, loneliness and
social isolation.73,74 In other studies, a high mean score
on the Beck Depression Inventory was also found among
Internet addicts.75,76 A recent study77 found attention-deficit /
hyperactivity disorder (14%), hypomania (7%), generalised
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 co-morbidities.
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. Another recent
study78 noted an association between Internet addiction and
harmful alcohol use.

Based on the above findings, it is still unclear whether
Internet addiction should be considered a discrete disorder.
Critics of Internet addiction argue that excessive use of the
Internet is a secondary manifestation of underlying Axis
East Asian Arch Psychiatry 2010, Vol 20, No.3

Internet Addiction

I or Axis II disorders and may represent adaptive selfsoothing or a form of avoidance of interpersonal discomfort
associated with these underlying conditions.

Consequences and Correlates of Internet

Addiction
Despite its positive uses, excessive Internet use to the point
of addiction can have wide-ranging adverse consequences
that affect many domains of an individuals life, including:
interpersonal, social, occupational, psychological, and
physical.7,79

The scope of relationship problems caused by Internet
addiction has been undermined by its current popularity and
advanced utility. Young28 found that serious relationship
problems were reported by 53% of Internet addicts surveyed.
Marriages appear to be the most affected as Internet use
interferes with responsibilities and obligations at home,
and it is typically the spouse who takes on these neglected
chores and often feels like a cyberwidow.80 Matrimonial
lawyers have reported seeing a rise in divorce cases due to
cyberaffairs.81

Employers have found that employees with access to
the Internet at their desks spend a considerable amount of
the working day engaged in nonwork-related Internet use.82
Internet addiction can lead to poor academic performance
in school and college and impaired functioning at work.83,84
There is even a case report of cardiac arrest leading to death
in an Internet addict after an Internet gaming binge, during
which the subject neither ate nor slept.85

Various studies have attempted to predict Internet
addiction by finding its correlates. Much attention has been
paid to the predictive value of personality characteristics
for Internet addiction. Evidently, high novelty seeking, high
harm avoidance, and low reward dependence behaviour
predict a high proportion of adolescents with Internet
addiction.86 A recent study87 carried out among Turkish
university students reported that loneliness, depression,
and computer self-efficacy were significant predictors of
Table 3. Proposed treatment modalities for Internet
addiction.
1. Pharmacological
Antidepressants (selective serotonin reuptake
inhibitors, venlafaxine, bupropion)
Mood stabilisers (lithium, gabapentin,
divalproex)
Combined antidepressant and mood stabiliser
Anxiolytics
Naltrexone
2. Non-pharmacological
Cognitive behaviour therapy
Family therapy
Marital therapy
Support groups
Halfway home
East Asian Arch Psychiatry 2010, Vol 20, No.3

problematic Internet use. A Finnish study88 found that the

severity of Internet addiction (as measured by an Internet
Addiction Test) yielded a significant negative correlation
with social support and a significant positive correlation with
the CAGE score. A study among adolescents by Lam et al89
identified male gender, drinking, family dissatisfaction,
and experience of recent stressful events as potential risk
factors. A prospective study90 among adolescents found that
depression, attention-deficit / hyperactivity disorder, social
phobia, and hostility predicted the occurrence of Internet
addiction in the 2-year follow-up. Among these, hostility
and attention-deficit / hyperactivity disorder were the most
significant predictors of Internet addiction in male and
female adolescents, respectively. A survey of university
freshman in Taiwan91 found a positive relationship between
Internet addiction and male gender, neuroticism scores and
the Chinese Health Questionnaire12 score.

Management
Although there are no evidence-based treatments for
Internet addiction, both psychotropic medication and
psychotherapy have been recommended (Table 3). There is
general agreement that one should be cautious in diagnosing
Internet addiction, but those who are diagnosed should
receive the benefit of whatever therapy is available.

There are small, open-label studies92 and case reports93
claiming benefits by escitalopram, other antidepressants, or
mood stabilisers. Recently, Bostwick and Bucci94 reported
a case of Internet sex addiction that did not respond to
prescribed antidepressants, psychotherapy (individual
and group), or participation in sexual addicts anonymous.
Significant improvement only ensued when the opiate
antagonist, naltrexone, was added to ongoing sertraline
therapy. In a shocking development, CCTV-12, a central
government channel, ran a series of glowing reports on
a clinic in Shandong Province in eastern China that used
electric shocks on Internet addicts, as part of what the
clinics director has called a holy crusade to cure Internet
addiction.95 Given the Internets numerous advantages and
positive uses in day-to-day life, it is impractical to advocate
total abstinence (as might be done for substance abuse). The
guiding principle should be moderate and controlled use.7

Cognitive behavioural therapy has been modified to
treat Internet addiction. Hall and Parsons96 observed that
these techniques are familiar to many mental health treatment
providers and can apply to treating not only substance
misuse but also nonchemical addictions, including Internet
addiction. Young97 has recently developed a guide, which
employs cognitive behavioural techniques, for therapists
working with Internet addicts. This suggests the following
exercises to achieve abstinence from problematic Internet
use: (i) practising the opposite behaviour; (ii) using external
stoppers (e.g. a timer signalling when the session should
end); (iii) setting time limits; (iv) setting task priorities to
aid in Internet goals during each Internet session; (v) using
reminder cards (posted on the computer) with a list of the
129

K Chakraborty, D Basu, KG Vijaya Kumar

5 major problems caused by the Internet addiction, and a

parallel list of the 5 major benefits of cutting down Internet
use; and (vi) taking a personal inventory, whereby the
therapist helps the client cultivate alternative activities that
take him / her away from the computer. A study98 evaluating
the efficacy of cognitive behaviour therapy for Internet
addicts indicates that the majority of subjects were able to
manage their presenting complaints by the eighth session
and symptom management was sustained at the 6-month
follow-up. Self-help books and tapes are available online and
may be helpful to some Internet addicts.6 Internet addiction
is likely to disrupt family relationships. If it does, family
intervention should be part of that individuals treatment.7
Marriage (or couple) counselling may be helpful when one
member of the dyad has disrupted the relationship. In China
there is even a halfway house for adolescents with Internet
addiction; the length of stay is from 10 to 14 days and
available treatments include: group therapy, medication,
acupuncture, and sports.99

In the past decade, much interest has been generated
regarding Internet addiction. Studies have started pouring in
from different parts of the world, generating important data
making it impossible to ignore the problem anymore. Yet
the concept of Internet addiction as a distinct psychiatric
disorder is still in its infancy. Lack of conceptual clarity has
hindered the development of proper assessment tools and
epidemiological research on the topic.

Thus, as of today, the American Psychiatric
Association recommendation to include Internet addiction
in its forthcoming DSM-V (but only as an appendix and
not in the main body of recognised addictive disorders)
appears a fairly balanced and cautious approach. Hopefully,
this could give rise to more meaningful research on this
important but controversial area.100,101 Understandably, this
has made news, and very recently has been cited by Science
in its News of the Week section.102

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