Internet Addiction

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) states that Addiction/Internet gaming disorder (IGD) applies to excessive gaming through Internet and non-Internet sources such as playing on personal computers, consoles, or handheld devices.

Synonyms

Internet use disorder
Gaming Disorder

How common is Internet Addiction?

Incidence

•Estimates range from 0.8% to 11.8% in Western samples and over 10% in some Asian samples.

•Some evidence that rates of “smartphone addiction” or social media addiction can exceed 30% in some samples.

Prevalence

•Prevalence rates are not well established.
•Surveys suggest prevalence rates of 10% to 15% among young people in Asian countries and 1% to 10% of youth in Western countries.
•In children and adolescents, IGD is estimated at 2% on average.
•The mean prevalence rate approaches 5.5%.
•Using stringent criteria, IGD prevalence ranged between 0.5% and 6%; actual prevalence probably falls within this range.

Predominant Sex & Age

•Male gender is a risk factor; IGD was reported in 11.9% of boys but only 2.9% of girls.
•Rates appear to decrease slightly over time. Studies suggest that 50% to 86% of adolescents with IGD persist with their problems over 1 to 2 yr, whereas 14% to 50% recover.

What increases the risk of Internet Addiction?

•Relatively little research has looked at potential race or ethnicity or cross-cultural differences.
•IGD subjects have higher rates of depressive symptoms, and greater depression predicted more gaming as well as reduced time spent in other activities.
•Excessive amounts of playing time at the start may predict risk for persistent IGD and depressive symptoms.
•Low sociability or reduced social competence may confer a risk.
•Impulsivity and attention problems are associated with IGD.
•Some IGD may be associated with illicit drug use and cigarette smoking.

Genetics

•The study of IGD genetics is in its infancy.
•The rs2229910 of neurotrophic tyrosine kinase receptor, type 3 (NTRK3), was the only single nucleotide polymorphism (SNP) that showed a significant minor allele frequency difference and may have a protective effect against IGD. Subjects with this SNP spent less time on Internet gaming.
•The del- genotype of the- 141C of the dopamine D2 receptor (DRD2) was associated with IGD and use of gaming to avoid negative feelings.
•In a transcriptomic study, persons with more frequent positive Internet gaming-related experiences were less likely to show the elevated conserved transcriptional response to adversity (CTRA) genomic profile of the elevated gene expression of NF-kB innate immune response that leads to chronic inflammation.

Physical Findings & Clinical Presentation

•DSM-5 lists nine criteria of Internet Addiction. Many are drawn from gambling and substance use disorders.
- 1.Preoccupation relates to being all-absorbed by gaming thoughts and should be present not only while playing but throughout the day when engaged in other activities as well.
- 2.Withdrawal refers to distressing symptoms emerging when the person does not have the opportunity to play or attempts to stop.
- 3.Tolerance involves an increase in time spent playing due to a growing desire to play or need for more exciting games.
- 4.Desire to reduce playing accompanied by unsuccessful attempts to control or stop playing, often reflecting a tendency to relapse.
- 5.Loss of previously enjoyable interests with constriction of behaviors in favor of game playing.
- 6.Continued excessive play despite knowledge of clinically significant problems caused by the excessive gaming.
- 7.Concealment or overtly lying about the extent of playing.
- 8.Playing to forget about real-life problems or to relieve negative mood states.
- 9.Risking or losing a relationship or opportunity at school or work because of excessive game playing.
•DSM-5 suggests endorsing at least five of nine criteria in the past 12 mo.
•Sequelae include parental conflict, poor school performance, and worsening of mood, anxiety, and social phobia symptoms over time.

What causes Internet Addiction?

•Etiology and course of IGD are not well understood, and the neurobiologic basis of IGD is in the early stages of investigation.
•A systematic review by Kuss et al (2018) of 27 studies meeting inclusion criteria found that IGD subjects have poorer response-inhibition and emotion regulation, impaired medial prefrontal cortex (mPFC) functioning and cognitive control, poorer working memory and decision-making capabilities, decreased visual and auditory functioning, and a deficiency in their brain reward system, similar to those found in individuals with substance-related addictions.
•A review by Park et al (2017) of 84 neuroimaging and neurophysiologic studies found associations with structural or functional impairment in regions associated with the brain reward and motivation circuitries, memory, and cognitive control, including the orbitofrontal cortex (OFC), dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC), and posterior cingulate cortex.
•IGD is associated with impaired dopamine D2 receptor function, which is associated with mPFC dysregulation.
•While these results suggest that IGD and substance use disorder (SUD) share neurobiologic mechanisms, some recent studies directly report differences in biologic and psychologic markers.

Differential Diagnosis

•Significant correlations exist between IGD and other mental health problems including disorders that are part of the differential diagnosis.
- 1.92% correlation with anxiety
- 2.89% correlation with depression
- 3.85% correlation with attention deficit hyperactivity disorder (ADHD)
- 4.75% correlation with social phobia/anxiety and obsessive-compulsive symptoms
•At present, due to lack of quality longitudinal studies, directionality is not discoverable and is further complicated by the complex interrelationship among phenomenologies.

How is Internet Addiction diagnosed?

•Screening instruments have been developed.
•Greater gaming time, loneliness, aggression, and poorer prosocial behaviors correlated with higher IGD scores.
•Life satisfaction and self-esteem negatively correlated.
•Endorsement of five or more DSM-5 criteria had high classification accuracy. The threshold of five appears appropriate for distinguishing clinically significant levels of gaming.

Imaging Studies

•Voxel-based morphometry demonstrates decreased gray matter in brain areas involved in cognitive control, error processing, decision-making, and reward in persons with IGD relative to controls.
•Functional magnetic resonance imaging (fMRI) using the cue-induced craving paradigm in IGD show reactivity in the ACC, DLPFC, and parahippocampus.
•Other fMRI results using the Go/No Go task suggest there is altered response inhibition in IGD that resembles that in SUD.
•Conclusions regarding IGD brain mechanisms are premature due to self-report–based diagnoses and small sample sizes. The large number of different regions identified and inconsistencies are problematic.

How is Addiction treated?

•Little is known about the effective treatment. There are few randomized controlled studies.
•Treatment camps for adolescents have generated anecdotal reports of effectiveness.
•There are inpatient and residential programs for Internet addiction in the United States.
•Individual, group, and family therapy are used to strengthen motivation to change and improve social and cognitive-behavioral skills to better control Internet use urges.
•Clinicians also promote alternative activities, including work and exercise.
•Psychiatric assessments are made and medications are prescribed for comorbid mental disorders.
•IGD symptoms are reported to decline but studies are uncontrolled and not randomized. In one of the few randomized trials, Internet use decreased similarly in both the active treatment group and the control group, but those assigned to cognitive-behavioral therapy (CBT) displayed improvements in time management skills and reductions in psychosocial symptoms.

Pharmacologic Treatment

•Screening for and treating comorbid psychiatric conditions in the context of addressing IGD is critical.
•As patients with IGD tend to have other psychiatric conditions, effective treatment for the comorbid condition, which may be delivered concurrently, may have pronounced effects on gaming problems.
•Medication trials for IGD have examined psychotropic drugs typically used for treating depression or ADHD.
•A methylphenidate pre–post trial involved a sample with comorbid IGD and ADHD and found that improvements in IGD improvements were positively correlated with ADHD improvements.
•A bupropion pre–post trial showed that it was superior to both a no medication control group and a placebo condition in reducing IGD symptoms in young adult subjects.
•An escitalopram trial showed it to be superior to no medication, but inferior to bupropion in reducing IGD.
•A 12-wk randomized controlled trial (RCT) found that adolescents receiving either atomoxetine or methylphenidate (but no placebo group) showed reductions in IGD symptoms with an advantage for methylphenidate over atomoxetine in improving ADHD symptoms.

Nonpharmacologic Therapy

•CBT has been associated with significantly fewer weekly gaming hours and IGD symptoms compared with no-intervention control groups.
•In a randomized study, both CBT and basic supportive counseling produced significant reductions in IGD symptoms, with no significant difference between groups.
•In another randomized study, CBT plus bupropion was superior to bupropion alone in adolescents with comorbid IGD and major depression.
•CBT for IGD may be an effective short-term intervention for reducing IGD with and without depressive symptoms, but there is need for rigorous studies to determine potential long-term benefits of CBT given the scarcity and limitations of the evidence.
•Family therapy has been tried in IGD, but more research is needed to evaluate results.
•A 2017 systematic treatment review by Zajac et al (2017) summarized 26 psychotherapy studies that met criteria. The conclusion was that well-designed treatment outcome studies were limited by methodological flaws, small sample sizes, lack of control groups, and little information on treatment adherence with lack of evidence for the effectiveness of any treatment modality. Additional treatment for IGD is sorely needed.

Does Complementary & Alternative Medicine cure Internet Addiction?

•Recreational therapies, music therapy using drumming activity, and art therapy are being considered as complementary treatments for IGD, though no real evidence base exists.
•Exercise rehabilitation using systematic and comprehensive activities to aid in healthy living is being tried in connection with family and outdoor activities, but research is not yet available.
•Parental engagement in the course of shared daily routines and participation is encouraged, with the goal of encouraging a positive attitude toward leisure and the skills to reduce overdependence on online gaming behaviors.
•Mindfulness programs based on yoga or tai chi combine physical activity with meditation and can be embedded in an exercise rehabilitation approach to IGD.

Conclusions

The inclusion of IGD as a research category in the DSM-5 is helpful as it allows researchers and clinicians a process for studying and treating this condition. Evidence of the clinical morbidity associated with IGD suggests it may have important public health consequences. Achieving clarity of the clinical definition will enhance research and treatment, and an important related issue will be to clarify the comorbid association of IGD with other mental disorders

How is Internet Addiction Prevented?

•Pediatricians and child mental health clinicians are in a position to educate parents and patients about the potential harmful effects of Internet gaming. They can help parents feel they have the agency to make guidelines and set limits around gaming.
•Clinicians can help parents understand when use becomes excessive and help them halt a slide into dysfunctional use. A timer can be set before starting play, for example.
•Electronic media should not be located in the child’s bedroom, and video game use before bedtime is to be discouraged.
•Regular media-free and rewarding family time can be encouraged.
•Recommendations can be made to use rating systems for video games, and parents can limit use to age- and content-appropriate games (e.g., www.esrb.org/ratings/search.aspx).

Patient & Family Education

Parents can learn to spot the signs of IGD

•Talking incessantly about their game.
•Playing for hours on end and getting defensive or even angry and aggressive when made to stop.
•Neglecting other activities including their daily needs such as food and sleep.
•Developing physical symptoms such as dry or red eyes; soreness in the fingers, back, or neck; or complaints of headaches.
•Appearing preoccupied or depressed.
•Becoming socially isolated.

Parents can take steps to prevent IGD

•Establish limits when it comes to how long children are allowed to play.
•Do not allow children to have tech in their room after lights out.
•Provide opportunities for rewarding activities such as sports or clubs that provide social engagement with their peers.
•If still concerned about overuse, they should seek the help of a mental health clinician.

However, it should be noted that one recent RCT found no evidence for the effectiveness of the psychoeducational parental guidelines on preventing problematic video gaming in children.

Wilderness Therapy

•Unplugged @ Outback (https://www.outbacktreatment.com/unplugged-internet-addiction-therapy/)
•Pacific Quest (https://pacificquest.org/whom-we-serve/adolescent-profile/video-game-addiction/)
•Trails Carolina (https://trailscarolina.com/video-game-addiction-help-struggling-teens/)
•Camp Pocono Trails (https://www.summerlandcamps.com/gaming-addiction/summer-camp-video-game-addiction/ • https://trailsmomentum.com/video-game-addiction-fortnite-league-of-legends-call-of-duty/)

Family & Individual Therapy

•Perspectives Counseling (https://perspectivesoftroy.com/michigan/gaming-addiction-treatment/)
•Rise Gaming Recovery (https://www.risegamingrecovery.com/)
•Tech Addiction (http://www.techaddiction.ca/video_game_addiction_books.html)
•Book: Overcoming Video Game Addiction (Author: Simon Somlai)
•Book: Gaming Addiction, Online Addiction, Internet Addiction (Author: Ace McCloud)

School-Based Screening & Prevention

•School-based education: Schools should include education about IGD and expand the infrastructure they have in place for other potentially problematic behaviors (drugs, alcohol, risky sex, gambling, etc.) to include problems with electronic media.
•School-based screening: Because of links between IGD and poor school performance, schools may be an effective place for screening for IGD and for providing referrals for services when problems are discovered.
•School-based parental training: Schools should provide training to parents to recognize potential problems.
•School-based activities: Schools and community centers can aid parents in identifying nongaming creative opportunities.

Internet Addiction