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Is Internet addiction a useful concept?

Vladan Starcevic Aust N Z J Psychiatry 2013 47: 16 DOI: 10.1177/0004867412461693 The online version of this article can be found at: http://anp.sagepub.com/content/47/1/16

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461693
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ANP47110.1177/0004867412461693ANZJP PerspectivesStarcevic

Viewpoint

Is Internet addiction a useful concept?

Vladan Starcevic

Australian & New Zealand Journal of Psychiatry 47(1) 1619 DOI: 10.1177/0004867412461693 The Royal Australian and New Zealand College of Psychiatrists 2012 Reprints and permission: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com

The Internet is utilised by hundreds of millions of people worldwide, with its numerous benefits only leading to an increase in the number of users. But there is a dark side to the Internet, and one of the negative consequences of the vast potentials of the Internet has been its excessive and uncontrollable use, often referred to as Internet addiction. Hardly a day passes without this phenomenon of the modern age being mentioned in the media. Over the past decade, Internet addiction and related behaviours have been attracting the attention of mental health researchers and clinicians, although this field is still in its infancy. In some Asian countries, such as South Korea, Internet addiction and similar problems are considered issues of public health significance. However, in such countries, competitive online video gaming is heavily promoted, blurring the boundary between normal excessive and pathologically excessive use of the Internet and online video games. The very term Internet addiction is controversial and the concept remains elusive. This article aims to examine some of the most important issues surrounding Internet addiction and to propose an alternative conceptualisation.

What is addiction?
Addiction does not appear as a diagnosis in the diagnostic and classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV. The diagnostic concept most closely related to addiction has been dependence, which has been linked with psychotropic substance use. In recent years, however, there has been a trend to replace dependence with addiction and to include among addictions not just those conditions caused by substances, but also behaviours performed with little or no control and having detrimental consequences. The latter became known as behavioural addictions, the prime example of which is pathological gambling. It was pathological gambling as a behavioural addiction that served as the model for the concept of Internet addiction. However, this was inappropriate because of the differences between the two that were either neglected or overlooked. Furthermore, behavioural addiction itself is a problematic construct, as it implies that any behaviour that is rewarding can be addictive. In other words, any pleasurable activity performed in excess and having some negative consequences would constitute an addiction. Thus, people could be addicted to eating, having sex, exercising, shopping, working or even indulging in hobbies such as model railroading (Mihordin, 2012). Such an understanding of addiction is in agreement with the more recent, broad definitions of addiction. For example, it has been suggested that addiction is an overwhelming involvement with any pursuit whatsoever that is harmful to the addicted person and his or

her society (Alexander, 2008: 48). Likewise, the American Society of Addiction Medicine (2011) has defined addiction as impairment in behavioural control, craving and diminished recognition of significant problems with ones behaviour and interpersonal relationships. If these definitions were to serve as the basis for a diagnosis of behavioural addiction, the diagnostic threshold would be set very low, leading to an epidemic of behavioural addictions. However, behavioural addiction is not only about excessive behaviour and the harm associated with it (Blaszczynski, 2008; Wood, 2008). If the concept of behavioural addiction is to be meaningful and useful, the activity in question would need to be associated with several characteristics. These have been integrated and summarised from the literature (Blaszczynski, 2008; Block, 2008; Charlton and Danforth, 2007; Hussain and Griffiths, 2009; Kuss and Griffiths, 2012; Sim et al., 2012), as follows: 1. Salience of the activity, which refers to preoccupation with it because of its pleasurable or mood-altering effects so that the person craves for it, experiences it as central to their lives and neglects other important everyday activities.

Terminological conundrums
As a concept, Internet addiction faces two types of challenges. The first one is about it being an addiction. The second refers to the Internet as a medium to which a person is presumably addicted.

Discipline of Psychiatry, Sydney Medical School Nepean, University of Sydney, Sydney, Australia Corresponding author: Vladan Starcevic, Department of Psychiatry, Nepean Hospital, PO Box 63, Penrith, NSW 2751, Australia. Email: starcev@wahs.nsw.gov.au

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Starcevic 2. Loss of control over the activity, such that the person finds it difficult to stop it despite an awareness that it is or that it might be detrimental and despite their willingness to cease the activity. 3. Tolerance, which is a need to spend more time performing the activity to achieve the same pleasurable or mood-altering effect as when the activity was performed initially. 4. Withdrawal manifestations, which refers to the occurrence of adverse mood states and behaviours (e.g. irritability and agitation) and perhaps physical symptoms, when it is not possible to continue with the activity. 5. Negative consequences, such that activity engagement leads to interference with occupational, academic, interpersonal and/or social functioning or that it has other detrimental effects (e.g. financial difficulties, sleep disturbance, significant weight change or various physical problems). If all of these criteria are required, only pathological gambling could so far be conceived of as a behavioural addiction. It is uncertain whether other candidates for behavioural addiction, including Internet addiction (or addiction to Internet-related activities), meet all the requirements for behavioural addiction. addiction, which would denote addictive gambling in casinos. If it is assumed that addictive use of the Internet does exist, the addiction would actually pertain to the corresponding activities and not to the Internet itself. These activities are quite diverse and include gaming, gambling, viewing pornography and related sexual behaviours, shopping, chatting, sending messages, etc. In other words, people presumably addicted to the Internet use it as a medium to fuel other addictions (Griffiths, 2000). Although one can develop some of these other addictions only on the Internet (e.g. addiction to online video game playing), that does not justify the term Internet addiction; it would be more accurate and appropriate to refer to the specific activity presumed to be addictive (e.g. online video game addiction). Internet addiction should therefore be replaced by addictions to specific online activities, although for each such activity it would need to be ascertained whether they follow the behavioural addiction pattern. As already noted, the concept of behavioural addiction is not without problems and should be used with extreme care. In light of these considerations, the focus will now shift to problem video game use and online video game addiction, as these are usually referred to when using the term Internet addiction.

17 2010). As PVGU is not characterised by tolerance, it does not meet all the criteria for behavioural addiction. The criteria for PVGU have been preliminarily validated (Porter et al., 2010) and in an online, anonymous international survey, 8% of video game players had PVGU (Porter et al., 2010). Interestingly, other studies using somewhat different criteria and terminology (e.g. excessive computer game playing and pathological video game use) reported similar rates, between 8.5% and 11.9% (Gentile, 2009; Grsser et al., 2007; Tejeiro Salguero and Morn, 2002), suggesting that a minority of online video game players develop a pattern of use that may resemble addiction. But what about online video game addiction itself? Does it exist? This issue has been debated, but it is still unclear whether the presumed online video game addiction meets the criteria for a behavioural addiction the way pathological gambling does. A number of important differences between the proposed online video game addiction and pathological gambling have been reported (e.g. Blaszczynski, 2008; Wood, 2008), suggesting that the former is not a true behavioural addiction. Opinion is divided and evidence is equivocal as to whether tolerance is associated with online video game playing (e.g. Hussain and Griffiths, 2009; Tejeiro Salguero and Morn, 2002; Wood, 2008); this is important because in addition to PVGU-like characteristics, tolerance would qualify such online video game use as a true addiction. Some authors have emphasised similarities between addictive use of video games and substance-related addiction (Chappell et al., 2006). Certain structural characteristics of online video games, such as their ability to reinforce playing, have been implicated in making these games potentially addictive (Kuss and Griffiths, 2012). Complicating matters further, there is some uncertainty about the criteria for addiction and distinction between the core and peripheral addiction criteria (e.g.

What are Internet addicts addicted to?

Although Internet addiction has become a widely used term, it is a misnomer and should be abandoned. This is because of the conceptual heterogeneity of the term (Starcevic, 2010) and because being addicted to the Internet implies addiction to a delivery mechanism (Sim et al., 2012) or, more precisely, addiction to a medium, a means to an end or a vehicle for achieving something. Therefore, Internet addiction is as meaningful a term as casino

Problem video game use and online video game addiction

Given the uncertainty about the putative online video game addiction as a true addiction, several concepts overlapping with it have been proposed. One of them has been problem video game use (PVGU), which was defined as a preoccupation with playing video games to the extent that there is a loss of control over this activity, with various negative psychosocial and physical consequences (Porter et al.,

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Australian & New Zealand Journal of Psychiatry, 47(1)

18 Charlton and Danforth, 2007). Only a consensus on the criteria for addiction and further research can resolve the question of whether online video game addiction is real or not. Notwithstanding the ambiguity about what is meant by dysphoric mood, people with PVGU or any form of pathological online gaming resort to this activity for a variety of reasons, including socialising, experimenting with various identities, escaping from a painful reality, attempting to cope with specific problems, obtaining gratification, etc (e.g. Kuss and Griffiths, 2012). Limiting these reasons to one or two motivations as a diagnostic criterion is clearly inappropriate. Despite pressure put by some clinicians and relatives of people afflicted with PVGU and similar problems to attach a formal diagnosis to these behaviours, it is laudable that online gaming-related problems are not likely to find a home in DSM-5 as an official diagnostic category. Doing so would be premature in view of so many uncertainties and controversies. The proposed Internet use disorder in Section III of the DSM-5 might be renamed online video game use disorder, with the criteria modified to ensure consistency and coherence and avoid a premature closure of the issue of whether online video game addiction exists. Future research in this area needs to tackle several key issues, as follows: The first task is to determine under what circumstances excessive online video game use constitutes a mental disorder (online video game use disorder), thereby delineating it from normality. Diagnostically subthreshold forms could be labelled online video game use problem, still allowing individuals to seek and receive help and care. The relationship with other psychopathology needs to be studied further to determine whether various aspects of psychopathology are non-specifically related to online video game use problem or online video game use disorder (e.g. Starcevic et al., 2011), or

ANZJP Perspectives whether certain forms of psy chopathology such as depression, excessive social anxiety and attention deficit and hyperactivity disorder (Ko et al., 2012) may be a risk factor for or predispose to such a problem or disorder. A related issue is whether online video game use disorder represents a separate condition or whether it can be better understood as a manifestation of the underlying psychopathology. There is clearly a need to establish whether online video game addiction exists and, if it does, the nature of its relationship (dimensional or otherwise) with online video game use problem and online video game use disorder should be elucidated. Thus, a proposal that online video game use problem, online video game use disorder and possibly online video game addiction may exist on a continuum of severity needs to be tested. The classification of online video game use disorder and online video game addiction may need to be revisited. Current thinking is that they belong to the group of addictive disorders, but there are also views that these conditions might alternatively be conceived of and classified as impulse control disorders (e.g. Liu and Potenza, 2010; Sim et al., 2012).

Conceptual and classification issues related to DSM-5 and beyond

The trend of replacing the concept of dependence with that of addiction is also reflected in the proposals for the upcoming DSM-5, with the suggestion to create a broader diagnostic group called substance use and addictive disorders. This group would include pathological gambling, renamed as gambling disorder and moved from its current classification as an impulse control disorder. Internet addiction was considered for inclusion into the same group, but it was decided not to include it in the list of the official DSM-5 diagnoses. Instead, Internet use disorder was proposed to be classified in Section III of the DSM-5 and thereby recommended for further study. While such placement of Internet use disorder may seem like a reasonable compromise, there are several problems with this concept. The first pertains to the retention of Internet in its name, which is over-inclusive and unsuitable in light of the above discussion. Also, nine criteria have been listed for Internet use disorder, of which seven mention Internet gaming, while two refer to Internet use and Internet. Therefore, these criteria imply that the disorder in question is in fact about Internet (online) gaming, not Internet use in general. Furthermore, the proposed respond to all the criteria criteria cor for behavioural addiction, prematurely suggesting that Internet use disorder is in fact an addiction. The inclusion of tolerance is controversial, as noted above. Finally, one of the proposed criteria is also problematic: use of the Internet gaming to escape or relieve a dysphoric mood.

Conclusion
Internet addiction is a misleading term and should be replaced by addictions to the Internet-related activities if the pattern of such activities meets the criteria for behavioural addiction. Of all the activities performed mainly on the Internet, video gaming has apparently been the one with most potential to lead to a problematic and perhaps addictive use. This calls for further study of the patterns of pathological online video game use and clarification as to whether online video game addiction exists.

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Starcevic Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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Declaration of interest
The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.

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