Q: I am a clinician who teaches psychiatry at a major medical school, where I lead a class on assessment and diagnosis of mental health and behavioral disorders. Recently my students asked me what kind of diagnosis one should give to designate Internet Addiction. What is the current understanding and clinical best practice?
~ Befuddled on Behaviors, Boston, MA
A: Dear Befuddled,
As internet-connected mobile screen devices, such as smartphones and tablets, have become ubiquitous, there are some teens, young adults, and, increasingly, younger children who get caught up in the interactive screen media environment. In part because the clinical community has yet to address this phenomenon effectively, compulsive use of or dependence on interactive electronic media from video games to the internet is becoming more prevalent and more severe. As your students have astutely observed, today’s clinicians need a systematic diagnostic and therapeutic approach to problematic interactive media use in order to alleviate significant dysfunction, developmental distortion, and familial disruption.
I am currently being asked to evaluate more and more new patients for internet or video game “addiction”. I put quotes around the word addiction, because while it definitely gets people’s attention, it is a colloquial, arguably inaccurate description rather than a formal diagnosis. Although clinicians have reported pathological behaviors with interactive media and debated a diagnosis since the 1990s, the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-5) has reviewed the science and determined that further research is needed in order to establish evidence-based criteria for diagnosis and treatment.
There are several problems with using the word “addiction” to describe dysfunctional behavior with interactive media. As an adolescent medicine specialist, I see many young people who are on a continuum of problematic interactive media behaviors. Unfortunately, the word “addiction” is both extreme and stigmatizing, so neither they nor their parents identify their behaviors as a problem requiring clinical intervention until late in the process. This is often when the behaviors have caused sleep deprivation, alienated friends and family, disrupted their academics to the point of dropping out of school, and even led to attempted suicide. The severity and stigma of the word “addiction” may discourage many from seeking help earlier, when the problem may be more manageable.
Secondly, the DSM-5 has dubbed “Internet Gaming Disorder” as the condition requiring further study, a name that builds on their recognized behavioral addiction diagnosis of gambling, but lumps a variety of behaviors under a single rubric. There are youth who have problems controlling their internet gaming certainly, but there are also problem gamers who are not online, and others that struggle with a diversity of non-gaming online behaviors such as social media, pornography, cyberstalking, and compulsive information-seeking. This nomenclature combines different behaviors with interactive screen media into a monolithic problem caused by the internet, in much the way that narcotics addiction is caused by opiates.
Finally, there is controversy in the academic medical community over naming any out-of-control behavior, including gambling and sex, as an addiction, because of the absence of measurable physiologic changes that are seen with narcotics or alcohol addiction.
But young people struggling with their interactive media use need help. They do not need to wait until we resolve our academic debate over nomenclature. Would it not be better to find an accurately descriptive diagnosis that allows us to assess and treat those who are struggling? Effective diagnosis and treatment requires both an evidence base and clinical consensus on how to describe what we are seeing, communicate about it with each other and with patients, and evaluate outcomes of therapy. None of the wide variety of proposed names from a comprehensive review of the clinical and research literature, from Internet Addiction Disorder to Problematic Internet Use, accurately describe the problem; it is neither an accepted addiction nor is the internet its sole locus or cause. In order to describe the critical features without triggering negative reflexes from fellow clinicians and patients, I call it Problematic Interactive Media Use (PIMU).
PIMU presents in a variety of ways, depending on the application or content with which the patient is interacting. Compulsive gamers, particularly those who play Massively Multiplayer Online Role-Playing Games (MMORPGs) present with different behaviors and face different outcomes from youth who frequent pornography sites, those who “live on” social media, or those overusing interactive media in a host of other ways. In virtually all of the cases I’ve seen, the young person is struggling with underlying issues that range from attention deficit disorder (ADD) to social anxiety, depression, or Oppositional Defiant Disorder (ODD) – conditions that are recognized by the medical community. These may not be comorbidities or risk factors as previously thought, but the primary problem that presents as PIMU. As we have seen in other areas where media use affects health, media may not be the cause or vector of a health condition, but the environment in which a condition expresses itself. PIMU may not be caused by the devices or the ways in which young people use those devices so much as pathologies that we already know well – playing themselves out in an entirely new environment.
Understanding PIMU as syndrome rather than diagnosis not only helps us assess and treat already well-characterized conditions, but has practical implications as well. Because this is not a diagnosis recognized by the DSM-5, treatment is not covered by medical insurance, which precludes many patients from obtaining the help they need. In my experience, recognition and treatment of the underlying problem leads to resolution of PIMU. As with substance abuse, therapy often needs to include a “detox” or a cessation of the problematic behavior. Unlike substance abuse, however, abstinence from the problem behavior is not a realistic long-term solution for affected individuals. As our society has evolved, connectivity and facility with interactive screen media are necessary to function in school, work, and social situations. So treatment must include thoughtful, gradual and clinically monitored re-establishment of interactive media use. For detailed information, guidance, and tools regarding the treatment of media-related health concerns, please use CMCH’s Clinician Toolkit.
The goal of characterizing PIMU, as in all health care, is to understand it well enough to prevent, as well as intervene on, negative outcomes. Interactive media are powerful tools and nearly everyone uses them. Media are not the problem, they are neutral – it is how we use them that result in help or harm. Mindful, focused, self-regulated use of interactive screen media can support healthy adolescent development, but undirected use can give rise to harmful behaviors.
With this understanding, we can enjoy our media and use them wisely,