Are We Hooked to Our Screens? A Reflective Review on Current Evidence and New Directions

Abstract

There is an increase in the amount of time spent on our screen devices over the last couple of decades. More aspects of our daily lives have shifted to internet-based services, schooling, and work, especially since the COVID-19 pandemic. Many people are finding it hard to step away from social media, gaming or other screen-based entertainment. When overuse of screens starts having severe consequences, the diagnosis of a behavioral addiction should be considered. Nonsubstance addictions have been studied for brain imaging characteristics as well as diagnostic reliability. Resources for evidence-based treatment are hard to find. Treatment is based on a biopsychosocial approach, with therapy, medication, mindfulness, support groups as primary sources of help. Ill effects of youth and social media use are a growing concern and a focus of future work as well as advocacy. Lifestyle medicine focuses on building our internal as well as external resources for recovery, similar to the concept of recovery capital in addiction medicine. Future research on diagnostic criteria, treatment methods and treatment retention are needed to form robust treatment approaches for a growing problem.

“Gambling disorder is perhaps the most recognized of all the behavioral addictions, and with the availability of online gambling, likely will need more resources in the future.”

Introduction

Humans are spending an unprecedented amount of time on their screen devices, for a multitude of purposes. Innovation has driven disruption of how we lead our lives with positive and negative consequences. Given the shift in dynamics of work and education, as well as activities of daily living, we are all increasingly online. It is a privilege and a wonder to be able to communicate effortlessly across the globe with family, friends and colleagues and have a global community to work with. When this shifts to being a problem, spending not hours but days, years and lifetimes in a digital sphere, it is concerning. The data is startling. Being constantly online has effects on mood, cognition, memory, emotional regulation, interpersonal interactions and changes our lived experience. Younger generations have a different interaction with their physical environment and peers than ever before. Since the COVID-19 pandemic shifted many interactions online, the true strengths and limitations of using the internet to communicate became apparent. ¹ While many preferred having less time commuting, it sharply increased the feelings of loneliness. Humans are innately wired to interact with each other and longer periods of isolation have consequences on physical and mental well-being. The US Surgeon General Dr. Vivek Murthy has called loneliness and isolation an epidemic of our current time.^2,3 The younger generations who have grown up with using devices have different perspectives on balance in digital sphere vs real life. They increasingly seek more authentic imperfect interaction rather than what is manufactured for online consumption and clout. ⁴ The tide may have begun to change from pretend reality to being real.

Terms such as FOMO, that is, Fear of Missing Out, or Doom Scrolling, are now part of everyday vocabulary. ⁵ Also catching on are ideas of the Joy of Missing out, a counter movement to help focus on things that matter and to address security concerns on apps. ⁶ Increasingly prevalent are reports of excessive fatigue, brain fog, and decreased attention span. ⁷ Many people across the world are feeling the loss of time, motivation and interaction. Time and energy are in short supply in a fast-paced world and overuse of screens makes the problem more dire. There is a need to understand, define, and manage this issue.

Many articles have appeared internationally in the print media over the last decade citing harms of usage of phone or gaming in children and teens. An evidence-based approach is needed to understand the true prevalence of such issues—whether these are outliers or norms. Over this time, while the apps are getting more engaging in nature, science is catching up with evidence to support or disprove claims.

A cohort study in China looked at screen time including television use from 6 months to 6 years of age and found that earlier and heavier exposure to screens was associated with poorer cognitive and social-emotional development. ⁸ Use of screen likely decreases interaction with caregivers and also learning from interactions that children in the age group need. What does this mean over long term? Chronic sensory stimulation via screen exposure can change the trajectory of brain development. Few studies have found that excessive use of screens can bring on early aging signs in brain imaging—thinning of brain matter and changes in the sulci of brain. ⁹ Scientists are worried that the rates of Alzheimer’s disease will be much higher in 2060 compared to current as a result of screen exposure in early life. ⁹

Reward Based Pathways

To simplify looking at habit formation and addiction of using social media, gaming, shopping and other applications on screens, it is important to understand the concept of reward and what it does to the brain. As traditionally understood, substance use elicits a dopaminergic reward in the brain, the magnitude of which diminishes on repeated use. This sets up a use, withdrawal and craving cycle, each associated with discrete areas of the brain including prefrontal cortex, amygdala, insula, hippocampus and ventral striatum. ¹⁰ However, with studies of gambling disorder, similar behavior patterns were observed with lack of a substance being used. Gambling has a variable reward schedule, meaning if you participate in a bet, there is no set reward that you will get. This uncertainty has been studied as being addictive. ¹¹ Similar rewards or dopaminergic highs are mimicked by design in online products such as apps and games. In a setting of unparalleled and constant access to rewards, this becomes an entrenched habit. To add to this, the variable rewards are now more complex, in the form of continuous scrolling, personalized recommendations, social status online and so on. This brings both qualitative and quantitative variability to rewards which is likely to be more addictive.

Current Scenario

In 2023, the US Surgeon General Dr. Vivek Murthy released an advisory on Social Media and Youth health. ¹² The report laid out concerns on the amount of time spent by youth on social media—an average of 3.5 hours a day, prevalence of use—95% of US teens, and the impacts it may have on them. Teens on social media have adverse effects on body image, face hateful content online, and may be exposed to self-harm and suicide content. Social media use can decrease sleep, and yet the teens find it difficult to give up social media use.^12-14

In a study looking at children’s use of screens and parental guilt around this screen use, found that the guilt of having a child use screens decreases the satisfaction experienced in a parent–child relationship. ¹⁵ Given the complexity of using screens in today’s environment of education, where increasingly children have homework and schoolwork assigned on screens, there needs to be a balanced approach to look at the child and screen interaction and the purpose for which screens are used. This balance may be in setting limits in school’s use of digital devices as well. An Australian study found that increased use of screens was associated with decreased in person play time for children aged 8 to 12 years of age. ¹⁶

For adolescents, spending 3 or more hours per day on social media increases the odds of reporting internalizing and externalizing mental health issues, even after adjusting for preexisting mental illness. ¹⁷ 90% of emerging adults in the United States use social media daily and this can have some positive aspects in their lives as well—increasing access to information, connection, reach, a feeling of decreasing loneliness and a sense of online community. ¹⁸ However even if teens are perceiving having more social support by using social networking apps, when analyzed in a study, it was not found to be true. ¹⁹

A small survey of 1000 US adults conducted in December 2024 found that on an average, Americans are spending about 5 hours and 16 minutes a day on their phones, and nearly half of them reporting they feel addicted to their devices. ²⁰ This is alarming if we simply follow the math—a day and a half spent every week on devices. This is both at work and at home with adults reporting using their personal phones for work. So, on average, adults are losing about 75 days of time in a year—without time for sleep.

From a lifestyle medicine perspective, a systematic review revealed increased rates of obesity in children with internet addiction or gaming disorder. Notably they also found disturbed poor eating patterns (not an eating disorder) in this age group. ²¹ This may have long term impact on the future adults’ relationship with food and health circumstances.

Process Addiction

While many people will admit they spend an excessive amount of time on their devices, and may claim to be addicted, defining addiction is not that simple. Overuse can exist without meeting threshold to be called an addiction. Given that we increasingly use screens for daily life, parsing out truly detrimental behaviors and consequences is needed. On the flip side, technology overuse may have a slightly lower level of stigma than use of addictive substances. Our hope is that this can enable patients to seek help sooner in the course of their difficulties.

The American Society of Addiction Medicine defines addiction as follows “Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.” ²²

Addiction can occur to use of substance or to nonsubstance use activities, also known as behavioral addiction or process addiction. This means that the behavior itself develops a pattern of reward similar to substance use and may have negative consequences mounting to the level of being diagnosed as an addiction rather than a habit.

Out of the nonsubstance use addictions, gambling disorder has a consensus definition in the Diagnostic and Statistical Manual (DSM) V.^23,24 It is a persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four major features in a 12-month period. These features may be being preoccupied with gambling, chasing losses, unable to stop gambling, gambling when distressed, lying about gambling and losses, borrowing money for desperate financial situation among others. Prevalence of severe gambling disorder is thought to be 1-2% of US population. ²⁵

Gaming disorder is a condition of further study in the DSM V. ²⁶ In International Classification of Diseases 11th revision, gaming disorder is a pattern of gaming behavior with impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences. ²⁷ Gaming online now has features like gambling with “loot boxes” which are essentially gambles of real money to get props in a virtual scenario, using variable reward principles as discussed above. ²⁸ Global prevalence of gaming disorder is between 1-3%. ²⁹

Diagnostic Complexity

There is a general lack of consensus on defining an electronic addiction. ³⁰ To develop consensus on a disease process, the hypothesis needs to be supported by a wealth of evidence supporting the diagnosis. This can take the form of epidemiological studies as well as brain imaging consistently reporting similar features with statistical significance. This evidence is being gathered slowly over time in an environment where apps and other games are consistently escalating the addictive nature of their programming.

In the case of gambling disorder, functional studies have shown a change in the prefrontal cortex as well as right ventral striatum during decision-making and gain processing. ³¹ Young males with excessive use of violent video games have changes in both white and gray matter in the brain. ³²

There are several scales being tested for diagnosing internet addiction. Smartphone addiction scale—short version, Internet Addiction Scale, and Young Internet Addiction Test are a few of them being used in research studies.^33,34 There is no consistent scale being used in a clinical setting at this time. Features of loss of control, craving, use despite consequences and overall impairment are used to help guide treatment. Underlying mental health issues are also explored, diagnosed and managed as appropriate.

Options for treatment

Approach to treatment for screen-based behavioral addiction is multi-faceted. Biopsychosocial model of treatment is generally employed as in the case of substance use disorder. One of the difficulties patients face while accessing care, is the lack of consensus for diagnosis and treatment. This gives rise to difficulty for access to services and coverage for such care. Currently the diagnostic codes used in the United States are based on International Classification of Disease 10^th edition, which does not include gaming disorder or other internet-based addictions. ³⁵ Gambling disorder on the other hand is recognized, yet may have a paucity of resources outside of specific centers set up for this purpose.

Treatment for other internet-based problems such as buying shopping disorder, internet overuse, pornography addiction as well as gaming disorders is more center and resource dependent. Data on how to treat these issues is slowly emerging and currently there is not one consensus approach to treatment. The severity of the problem informs the choice of the level of treatment to be used. For example, overuse which is not having severe consequences can be approached differently vs an issue disrupting daily functioning in an individual.

Approaches can be based on psychological interventions such as cognitive behavioral therapy with a qualified mental health practitioner. Centers may use peer-based groups for treatment, on the lines of general addiction medicine care. Approaches include setting boundaries, understanding coping skills needed to decrease interaction with screens. Setting boundaries may involve setting screen time limits for use of electronic devices. A study found that turning off notifications on the phones in a small sample of individuals did change the interaction with phones to be perceived as more intentional. ³⁶ However, it did not decrease the time spent and increased the fear of missing out for the individuals in the study. This may reflect on the design of apps and our learned behavior over time. Longer trial with multitude of changes may be better suited to assess the strength of interventions. There are several studies looking at small aspects of treatment for internet overuse. Psychological treatment and exercise were found to be beneficial in short term for treating electronic addiction. ³⁰

Motivational interviewing is a key first step in engaging with patients for behavioral change as we know in lifestyle medicine. Personal and specific motivation helps propel interventions and increases chances of continuing the efforts towards the goal.

Mindfulness approaches can help redirect attention away from screens. A Chinese study ³⁷ on internet gaming disorder compared mindfulness meditation training over 8 sessions and progressive muscle relaxation as approaches. The mindfulness training included education and training for body scan, recognizing triggers, urge surfing, wise response, pebble and raisin meditation, inner critic, self-compassion and acceptance. They were then assigned a cue craving task and underwent functional magnetic resonance imaging (fMRI). On statistical analysis, the Mindfulness Meditation group had significantly lesser internet addiction test scores compared to the PMR group. What is fascinating to note is that the fMRI showed significant changes in the frontal brain regions and bilateral brain connectivity.

Approaches using medications such as selective serotonin reuptake inhibitors (SSRIs), anti-opioids like naltrexone, glutamatergic agents, mood stabilizers and others can be used for treatment of behavioral addictions as well as the treatment of underlying mental health diagnoses for mood disorders and anxiety disorders. ³⁸ Given the lack of consensus around the evidence, use of medications for treatment of gambling, gaming and other behavioral addictions should be closely monitored.

Twelve step and self-help groups exist for multiple behavioral addictions. Gamblers anonymous has meetings in many countries. Debtors Anonymous can help participants understand their relationship with money, which is frequently a consequence of overspending for gambling, gaming, shopping and other issues. There are both 12 step and other models for groups helping people with excessive use of the internet. Internet and Technology addicts anonymous, formed in 2017, is based on the 12 step principles of alcoholics anonymous and participants work with a sponsor in a fellowship environment. ³⁹ Self-Management and Recovery Training (SMART Recovery) is an alternative to the 12 step-based approach which uses tools from Cognitive Behavioral Therapy and Rational Emotive Behavioral Therapy.^40-42 There are online and offline meetings of SMART recovery for a range of substance and nonsubstance addictions.

As with other addition treatments, there are centers that explore treatments outside of the medical treatment model, with retreats and camps designed to help you distance from technology, however there is lack of evidence to support that approach at this time. Also, there is unclear regulation of such efforts, and unclear safety parameters put in place. A lot more work needs to be done for setting standard operating procedures for the facilities being utilized for this purpose.

While many worldwide are spending a tremendous amount of online, it is at the cost of decreased capacity for functioning and recovery in real life. As lifestyle medicine practitioners, we know the evidence behind social connections and health. The office of the surgeon general has issued guidance on the healing effects of social connection and community. ² However, social connection is generally difficult to measure in a manner conducive to statistical analysis in an addiction framework. Recovery capital is a concept, and a measure developed for this purpose, and looks at factors in a patient’s life that can help them manage their addiction better. Several ways of measuring recovery capital exist. The recovery capital index (RCI) ⁴³ has 3 arms, personal recovery capital, family and social recovery capital and cultural recovery capital. There are other validated measures for this purpose as well. Spirituality is a part of personal recovery capital. This concept is similar to having a social capital, a framework of support system in the face of difficulties.^43,44 RCI gives a measurable framework for recovery from a substance use disorder. Low recovery capital is associated with increased overdose risk in patients with opioid use disorder. ⁴⁵ Recovery capital and spirituality were found to have a positive role in treatment of gambling disorder in a small sample study. ⁴⁶ This is a slowly growing body of research, and it would be curious to see if there is an impact of recovery capital in helping cut down screen-based addictions.

One of the most important reasons screen use continues is because entire social network of younger individuals resides online. This means that disconnecting use, may disconnect from your peers who are also constantly online. For moving the needle, approaches need to be community-based where teens and young adults support each other in finding other ways to connect. This would also involve creating digital safe spaces. There are emerging volunteer based organizations educating and advocating for safe spaces and creating safety resources for teens.

Conclusion

Overuse of screens has affected millions across the world who have access to smart devices. Given the increasingly online nature of our lives, this poses a valid quest in achieving balance between our online and offline lives. When the use of apps and other screen-based products is engineered towards grabbing our attention constantly, this balance gets disturbed. Gambling disorder is perhaps the most recognized of all the behavioral addictions, and with the availability of online gambling, likely will need more resources in the future. Gaming disorder has been recognized by ICD-11 and slowly the evidence for treatment is emerging.^24,47 Internet addiction and other online based addictions are being researched for diagnostic criteria as well as treatment. Not all use or overuse of screens is pathological. Being constantly online has repercussions on our health as well as on our social interactions and structure. Social media use in teens can have detrimental effects, as well as screen time use in early childhood. Adults too can be adverse affected by overuse of screens and sometimes use other substances along with their gaming or other screen use as a coaddiction. Treatment strategies are based on the biopsychosocial model, using behavioral as well as psychopharmacological approaches. Advocacy is needed to create balance between our online and offline lives. This can include advocating for more work in schools being on paper, having guardrails on social media especially for the youth, and developing health online communities with resources to combat misuse online. Boundary setting can be used both at a personal level as well as community level.

As lifestyle medicine practitioners, we may consider asking our patients about their digital health. Setting SMART goals can be good first step for those wanting to regulate any overuse of screens. Our domain-based approach is similar to the understanding of recovery capital, which can help us reconnect in real life.

Lifestyle medicine professionals are at a unique position to help advocate for a balanced use of screens, and help our patients lead a healthy and prosperous life.

ORCID iD

Mitika V Kanabar https://orcid.org/0009-0006-1190-9924