Journal of Affective Disorders 57 (2000) 267–272

www.elsevier.com / locate / jad

Preliminary communication

Psychiatric features of individuals with problematic internet use

a, a b
Nathan A. Shapira M.D., Ph.D. *, Toby D. Goldsmith M.D. , Paul E. Keck Jr. M.D. ,
b b
Uday M. Khosla , Susan L. McElroy M.D.
a
Department of Psychiatry, University of Florida, P.O. Box 100256, Gainsville, FL 32610 -0256, USA
b
Department of Psychiatry, University of Cincinnati Medical Center, P.O. Box 670559, Cincinnati, OH 45267 -0559, USA

Received 15 February 1999; accepted 1 June 1999

Abstract

Background: Problematic internet use has been described in the psychological literature as ‘internet addiction’ and
‘pathological internet use’. However, there are no studies using face-to-face standardized psychiatric evaluations to identify
behavioral characteristics, psychiatric comorbidity or family psychiatric history of individuals with this behavior. Methods:
Twenty individuals with problematic internet use were evaluated. Problematic internet use was defined as (1) uncontrollable,
(2) markedly distressing, time-consuming or resulting in social, occupational or financial difficulties and (3) not solely
present during hypomanic or manic symptoms. Evaluations included a semistructured interview about subjects’ internet use,
the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV (SCID-IV), family psychiatric
history and the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) modified for internet use. Results: All (100%)
subjects’ problematic internet use met DSM-IV criteria for an impulse control disorder (ICD) not otherwise specified (NOS).
All 20 subjects had at least one lifetime DSM-IV Axis I diagnosis in addition to their problematic internet use
(mean6SD 5 5.163.5 diagnoses); 14 (70.0%) had a lifetime diagnosis of bipolar disorder (with 12 having bipolar I
disorder). Limitations: Methodological limitations of this study included its small sample size, evaluation of psychiatric
diagnoses by unblinded investigators, and lack of a control group. Conclusions: Problematic internet use may be associated
with subjective distress, functional impairment and Axis I psychiatric disorders.  2000 Elsevier Science B.V. All rights
reserved.

Keywords: Internet; OCD; Impulse control disorder; Bipolar

1. Introduction causes marked distress and / or functional impair-

Problematic internet use, wherein an individual’s
inability to control his or her use of the internet
*Corresponding author. Tel.: 1 1-352-392-2831; fax: 1 1-352-
392-2579.
ment, has been described in the psychological litera-
ture as ‘internet addiction’ and ‘pathological internet
use’, based on the DSM-IV definition for substance
dependence and pathological gambling, respectively
(Griffiths, 1996, 1997; O’Reilly, 1996; Stein, 1997;
Young, 1996, 1998; Young and Rogers, 1998).

0165-0327 / 00 / $ – see front matter  2000 Elsevier Science B.V. All rights reserved.
PII: S0165-0327( 99 )00107-X
268 N. A. Shapira et al. / Journal of Affective Disorders 57 (2000) 267 – 272
Proposed treatments for afflicted individuals have
included time-management techniques (Young,
1998) and participation in support groups (O’Reilly,
1996; Young, 1998).
Persons with problematic internet use have been
reported to have high rates of depressive symptoms.
An on-line survey utilizing the World Wide Web
(WWW) and the Beck Depression Inventory in 259
individuals classified as having pathologic internet
use demonstrated mild to moderate depression with a
mean (SD) of 11.2 (13.9) (Young and Rogers,
1998). In addition, a recent prospective study of 169
subjects demonstrated an association between exces-
sive internet use and depression (even when previous
depression scores were controlled for), loneliness,
declines in communication with household family
members and social withdrawal (Kraut et al., 1998).
However, the relationship between problematic inter-
net use and formal mental disorders is unknown as
there have been no studies utilizing standardized
structured interviews to identify behavioral charac-
teristics, co-occurring Axis I disorders, or family
history of psychiatric illness in individuals displaying
this behavior (Stein, 1997).
Over the last 15 years, a broad range of pathologi-
cal repetitive behaviors have been hypothesized as
possibly being related to obsessive–compulsive dis-
order (OCD), and are referred to as obsessive–
compulsive (or OCD) spectrum disorders (Goldsmith
et al., 1998). Many of these behaviors are associated
with comorbid OCD and depressive disorders and
possible preferential response to serotonin re-uptake
inhibitors (SRIs). Examples include body dysmor-
phic disorder (BDD), hypochondriasis, anorexia
nervosa, Tourette’s syndrome and possibly some
impulse control disorders (ICDs). We hypothesized
that problematic internet use might be another form
of an OCD spectrum disorder and, in addition to
repetitive behavior, be characterized by obsessive
thinking, comorbidity with OCD and depressive
disorders, and preferential response to SRIs. To
further study individuals with problematic internet
use, we systematically evaluated a consecutive group
of users whose internet usage met criteria as de-
scribed below utilizing face-to-face structured diag-
nostic interviews and rating instruments. We also
systematically assessed treatment response histories
in those subjects receiving prior treatment.
2. Methods
2.1. Subjects
Men and women, 18 years of age or older, who
had problematic internet use for at least six months
were recruited. Problematic internet use was defined
as (a) uncontrollable, (b) markedly distressing, time-
consuming or resulting in social, occupational or
financial difficulties and (c) not solely present during
hypomanic or manic symptoms. Subjects provided
written informed consent to be interviewed.
2.2. Assessments
Evaluations included a semistructured interview to
assess demographic information, the nature of inter-
net use, including time spent on ‘essential’ (required
job / school functions) versus ‘nonessential’ (plea-
sure / recreational or personal) use, and a retrospec-
tive rating of response of problematic internet use to
any previous mental health treatment. Response of
problematic internet use was defined as: none (0– ,
25% decrease in internet usage or urges to use), mild
(25– , 50% decrease), moderate (50– , 75% de-
crease) or marked (75–100% decrease). Evaluations
also included the Structured Clinical Interview for
DSM-IV–Patient Version (SCID-IV) augmented
with additional DSM-IV modules for ICDs not
otherwise specified (NOS), paraphilias and
somatoform disorders (available from the authors
upon request) to assess Axis I psychiatric comorbidi-
ty, family history evaluation for psychiatric disorders
in first- and second-degree relatives done via the
family history method (Andreasen et al., 1977) and
the Y-BOCS (Goodman et al., 1989) modified for
internet use to assess the obsessive–compulsive
nature of the use.
3. Results
The study sample consisted of 20 subjects (eleven
men and nine women) with a mean6SD of
36.0612.0 years of age. Twelve subjects (60.0%)
responded to newspaper advertisements for proble-
matic internet use and eight (40.0%) were clinically
referred with a ‘chief complaint’ of problematic
 N. A. Shapira et al. / Journal of Affective Disorders 57 (2000) 267 – 272
internet use. Age of onset of problematic use was
33.3612.2 years. All subjects completed high school
or had a GED equivalent and 17 (85.0%) had
attended college. Fourteen (70.0%) subjects were
employed. Thirteen (65.0%) had used computers
prior to the availability of the internet, with two
individuals reporting problematic computer use prior
to availability of the internet. ‘Essential’ use was
(mean6SD) 2.864.8 hours per week, but ‘nonessen-
tial’ use was 27.9620.5 hours per week. ‘Nonessen-
tial’ use occurred in the following domains: chat
forums (17.7%), e-mail (15.1%), WWW ‘surfing’
(14.0%), multi-user domains (12.7%), miscellaneous
uses including games and designing web pages
(9.2%), pornography (8.1%), news / current events
(6.8%), newsgroups (6.1%), file transfers (3.7%),
music (3.2%), shopping / buying (2.5%), card
catalogs (0.6%) and political uses (0.3%).
Problems associated with internet use were: sig-
nificant social impairment (e.g., family strife or
divorce) in 19 (95.0%) subjects, marked personal
distress over their behaviors in 12 (60.0%) subjects,
vocational impairment (e.g., failing in college, de-
creased job productivity or loss of job) in eight
(40.0%) subjects, financial impairment (e.g., substan-
tial debt due to heavy use of the internet) in eight
(40.0%) subjects and legal problems (e.g., caught
harassing someone online) in two (10.0%) subjects.
An unexpected finding was that every subject’s
problematic internet use (100%) met DSM-IV
criteria for an ICD NOS. By contrast, only three
subject’s (15.0%) problematic internet use meet
DSM-IV criteria for OCD. The average (mean6SD)
Y-BOCS score modified for internet use was
19.665.6. Consistent with subjects meeting the
DSM-IV definition of an ICD (as opposed to OCD),
the Y-BOCS question concerning distress associated
with thoughts, impulses or urges to use the internet
was rated lowest of all of the ten questions
(mean6SD 5 0.660.7), indicating a low level of
distress. Furthermore, subjects rated the Y-BOCS
question concerning degree of effort made in re-
sisting the excessive internet use the highest of all
ten questions (mean6SD 5 2.96.9), indicating a low
level of resistance.
All subjects met criteria for at least one lifetime
DSM-IV Axis I diagnosis (mean6SD 5 5.163.5
diagnoses) (Table 1). As expected, mood and anxiety
269
disorders were the most common associated Axis I
disorders. However, to our surprise, bipolar disorders
(as opposed to depressive disorders) were the most
common mood disorders, and phobias (as opposed to
OCD) were the most common anxiety disorders.
Nineteen (95.0%) of 20 individuals had histories
of psychiatric disorders in family members. Thirteen
(65.0%) had at least one first- or second-degree
relative with a depressive disorder, ten (50.0%) with
a bipolar disorder and 12 (60%) with a substance use
disorder.
Seventeen (85.0%) subjects had received previous
mental health treatment and 15 (75.0%) had received
treatment with psychotropic medications. As shown
in Table 2, 5 (35.7%) of 14 antidepressant mono-
therapy trials resulted in moderate or marked reduc-
tion in problematic internet use, with only two
(22.2%) of nine selective serotonin re-uptake inhib-
itor (fluoxetine, paroxetine and sertraline) trials
resulting in favorable responses. By contrast, 14
(58.3%) of 24 single- or combination-agent mood
stabilizer trials were associated with favorable re-
sponses. Moreover, this favorable response rate
increased to 12 (75.0%) of 16 trials when trials
involving concurrently administered antidepressants
or stimulants were excluded from analysis.
4. Discussion
In this small group of subjects, problematic inter-
net use was found to be associated with subjective
distress, considerable social, vocational and / or finan-
cial impairment, as well as substantial psychiatric
comorbidity. These findings are consistent with other
studies reporting depressive symptoms and social
impairment in excessive internet users (Kraut et al.,
1998; Young and Rogers, 1998).
However, we had several unexpected findings.
First, the problematic internet use of this small group
was more impulsive and ego syntonic than compul-
sive and ego dystonic in nature, and more closely
resembled the DSM-IV definition of an ICD than that
of OCD. Individuals described an increasing sense of
tension or arousal before successfully logging onto
the internet, which was difficult or impossible to
resist, and a relief of that tension that was often
pleasurable as they logged on. Of note, this observa-
270 N. A. Shapira et al. / Journal of Affective Disorders 57 (2000) 267 – 272

Table 1
DSM-IV Axis I diagnoses in 20 subjects with problematic use of the internet
Diagnosis Current diagnosis Lifetime diagnosis
n % n %
Mood disorders 14 70.0 17 85.0
Major depression 2 10.0 3 15.0
Bipolar I 11 55.0 12 60.0
Bipolar II 1 5.0 2 10.0
Psychotic disorders 2 10.0 2 10.0
Schizoaffective disorder, bipolar type 2 10.0 2 10.0
Substance use disorders a 2 10.0 11 55.0
Alcohol abuse or dependence 2 10.0 9 45.0
Other substance abuse or dependence 1 5.0 9 45.0
Anxiety disorders a 12 60.0 14 70.0
Panic disorder with or without agoraphobia 2 10.0 5 25.0
Agoraphobia 0 0.0 1 5.0
Specific phobia 4 20.0 7 35.0
Social phobia 8 40.0 9 45.0
Obsessive–compulsive disorder 3 15.0 4 20.0
Post-traumatic stress disorder 5 25.0 5 25.0
Generalized anxiety disorder 2 10.0 2 10.0
Paraphilias a 3 15.0 3 15.0
Exhibitionism 1 5.0 1 5.0
Sexual Masochism 1 5.0 1 5.0
Sexual Sadism 2 10.0 2 10.0
Transvestic fetishism 1 5.0 1 5.0
Voyeurism 1 5.0 1 5.0
Eating disorders 3 15.0 7 35.0
Anorexia nervosa 0 0.0 1 5.0
Bulimia nervosa 1 5.0 2 10.0
Eating disorder NOS b 2 10.0 4 20.0
Impulse control disorders a 7 35.0 10 50.0
Intermittent explosive disorder 2 10.0 3 15.0
Kleptomania 1 5.0 2 10.0
Pathological gambling 1 5.0 1 5.0
Impulse-control disorder NOS c 4 20.0 6 30.0
Other
Body dysmorphic disorder 2 10.0 2 10.0
a
Total is less than the sum of disorders; patients had more than one disorder in category.
b
All patients had binge eating disorder.
c
All patients had compulsive buying.

tion is similar to the report of an individual with
‘compulsive computer use’ who also had excessive
use of the internet (as well as video games when he
did not have access to the internet) (Belsare et al.,
1997). Second, nearly all individuals (80.0%) met
lifetime criteria for bipolar disorder or schizoaffec-
tive disorder, bipolar type, and there were compara-
tively low lifetime rates of comorbid major depres-
sive disorder (15%) and OCD (20%). Third, in-
dividuals with problematic internet use appeared to
show a preferential treatment response to mood
stabilizers over antidepressants. Taken together,
these findings were contrary to our original hypoth-
esis that these individuals would demonstrate high
degrees of compulsivity, high rates of OCD and
depressive disorders, and a favorable response to SRI
antidepressants. However, our finding that proble-
matic internet use resembles an ICD and is associ-
 N. A. Shapira et al. / Journal of Affective Disorders 57 (2000) 267 – 272 271

Table 2
Responses of 15 subjects with problematic use of the internet to psychotropic medications
Medication Number of Favorable response a
trials (no. of patients)
Antidepressant monotherapy
Fluoxetine 3 0
Paroxetine 2 2
Mirtazapine 1 1
Sertraline 4 0
Nefazodone 1 0
Venlafaxine 2 1
Bupropion 1 1
Mood stabilizer monotherapy
Lithium 2 2
Gabapentin 1 1
Divalproex 4 1
Mood stabilizer dual-therapy 1 1
Antipsychotic monotherapy 1 1
Anxiolytic monotherapy 3 1
Antidepressant / anxiolytic combination 1 0
Mood stabilizer / antidepressant combination 5 1
Mood stabilizer / antipsychotic combination 7 6
Mood stabilizer / anxiolytic 1 1
combination
Mood stabilizer / stimulant 1 0
combination
Other therapy b 1 1
Other therapy c 1 0
a
Favorable response defined as moderate or marked response in terms of decreased internet usage.
b
Other therapy 5 divalproex, buspirone and imipramine combination.
c
Other therapy 5 lithium and hypericum combination.

ated with bipolarity is consistent with earlier ob-
servations that ICDs and bipolar disorder may be
related due to similarities in phenomenology, comor-
bidity, family psychiatric history and treatment re-
sponse (McElroy et al., 1996).
These findings must be viewed critically, as this is
a preliminary study with many limitations. These
include its small size, self-reported interviews, un-
blinded investigators, lack of a control group, and the
possibility of overestimating certain psychiatric dis-
orders, particularly bipolar disorder. However, sever-
al aspects of the data support the findings of the high
rate of bipolarity. First, although 60.0% of subjects
were self-referred for evaluation of their internet use,
many had already received psychiatric diagnoses and
psychiatric care, specifically for bipolar disorder. For
example, of the 12 individuals who received the
SCID diagnosis of lifetime bipolar I disorder, eight
(66.7%) had received previous treatment with mood
stabilizers and / or antipsychotics. Moreover, one of
the other four individuals subsequent to her evalua-
tion required treatment with a mood stabilizer after
experiencing a mixed manic episode while receiving
an antidepressant. Second, individuals displayed a
high rate of psychiatric disorders in their families
(95%), with ten (50%) individuals having at least
one relative with bipolar disorder. Five of these ten
subjects had multiple relatives with bipolar disorder.
Furthermore, the family history method has been
shown to underestimate the degree of psychiatric
illness in family members (Andreasen et al., 1977).
Third, more individuals retrospectively reported
moderate or marked improvement in control over
their internet use that was better with mood stabi-
lizers than with antidepressants.
It is important to note, however, that of the 12
individuals with a current diagnosis of bipolar I or II
disorder, all had or most recently experienced a
depressed or mixed episode; none met criteria for a
current or recent manic episode. Moreover, when
272 N. A. Shapira et al. / Journal of Affective Disorders 57 (2000) 267 – 272
evaluating subjects, they would spontaneously dis-
cuss their depressed symptoms, whereas their hypo-
manic and manic symptoms usually became apparent
only with standardized structured interviews. This
might explain why previous researchers utilizing
online surveys, which focus on depressive but not
manic symptoms, have failed to report bipolarity in
persons with problematic internet use. Indeed, over
the last several years, there has been greater ap-
preciation that the true bipolar phenotype may be
much broader than how it is defined in DSM-IV and,
hence, that bipolar disorder in all its many forms
may be far more common than realized in popula-
tions with depressive symptoms (Akiskal, 1996). For
example, when hypomania was systematically
searched for in patients with at least one DSM-IV
major depressive episode utilizing a French multi-
center study (EPIDEP), 40% of patients with a major
depressive episode(s) were classified as having bipo-
lar II disorder (Hantouche et al., 1998). Only half of
these patients were known bipolar II patients to the
clinicians at study entry (Hantouche et al., 1998).
Another example includes the evaluation of 108
consecutive anxious and / or depressed patients in a
naturalistic family practice setting, in which 28
(25.9%) were diagnosed with a bipolar spectrum
disorder (e.g., bipolar I, II or III disorder or
cyclothymia) (Manning et al., 1997).
In summary, problematic internet use may repre-
sent a clinically important syndrome that is associ-
ated with distress, functional impairment and psychi-
atric disorders. A more precise understanding of the
psychopathology and psychiatric comorbidity of
problematic internet use would help delineate
whether it is a distinct disorder (e.g., an ICD), a
symptom of an already characterized psychiatric
illness (e.g., a mood disorder, especially bipolar
disorder), or both.
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