Problematic Internet use: a distinct disorder, a manifestation of an underlying psychopathology, or a troublesome behaviour?

Aboujaoude’s review of problematic Internet use is a timely contribution to the literature on a poorly understood behaviour that has apparently caught the attention of the media more than that of mental health professionals. And, while psychiatrists and clinical psychologists seem to be sceptical about many aspects of the problematic Internet use, concern in the community about the adverse effects of the Internet use seems to be growing exponentially. This revolves mainly around two issues. The first is the impact of violent video games and other violent online content; the second is what has increasingly been referred to as “Internet addiction”. The focus of this commentary will be on the latter issue.

The problem starts with terminology, as the appropriate name for the condition or behaviour often labelled “Internet addiction” is not clear. Progress in this area can hardly be made without first reaching a consensus as to what terms to use. “Internet addiction” is a troublesome term, not only because of its pejorative connotations, but also because there is no evidence that this is really an addictive disorder, i.e., that it is characterized by the hallmarks of substance addiction such as tolerance and withdrawal. If adopted without sufficient evidence, “Internet addiction” will clearly be an arbitrary term. It is appropriate to be cautious and retain more descriptive and “neutral” terms, such as problematic (or problem) Internet use. Other terms have also been proposed, e.g., “pathological use of electronic media” 1, but “Internet addiction” still seems to dominate the literature and professional jargon.

The terminological rigour should go hand in hand with conceptual clarity. A part of the reason for the ongoing struggle with terminology is the lack of clarity about the key features of problematic Internet use. Several features have been proposed, but many of them seem to overlap and boil down to the basic two characteristics. The first pertains to the aspects of Internet use, described as excessive or compulsive, along with preoccupation with and loss of control over the Internet use. The second refers to various adverse consequences of spending too much time on the Internet, such as neglecting social activities, relationships, health and work or school duties, and altering sleep and eating habits in a detrimental way. Further research is needed to ascertain more precisely to what extent these features characterize problematic Internet use.

Problematic Internet use appears to be too heterogeneous as a concept. It has been suggested that it consists of at least three subtypes: excessive gaming, problematic sexual behaviour, and e-mail/text messaging 2. The Internet may also be used excessively and with negative consequences to gamble, shop, or chat. These different purposes of using the Internet may be associated with different patterns of use, different underlying psychopathology, and different adverse consequences. It may then be inappropriate to lump together all the instances of problematic Internet use and perhaps more useful to consider online gambling as a manifestation of pathological gambling, Internet-related problematic sexual behaviour as a feature of a sexual or some other disorder, and so on. In accordance with this approach, we have formulated and tested preliminary criteria for problem video game use 3, but these require further study.

“New” disorders or patterns of behaviour may be no more than alternative expression of various psychopathological entities. Accordingly, it has been debated whether addictive disorders, including problematic Internet use, represent primary conditions in their own right or whether they can be better understood as a manifestation of some underlying psychopathology or poor coping, that is, a “secondary addiction” 4,5. Various mental and other disorders often co-occur with problematic Internet use, which suggests that in many cases the latter may be conceived of as being related to the former. The co-occurring conditions and corresponding dimensions of psychopathology include depressive and bipolar disorders, anxiety disorders (especially social anxiety disorder, generalized anxiety disorder, and obsessive-compulsive disorder), sleep disturbance, substance use disorders, impulse control disorders, attention deficit and hyperactivity disorder, personality disorders and traits (especially borderline, narcissistic, antisocial, and avoidant), and psychotic disorders.

Several issues should be addressed when elucidating whether and when problematic Internet use is primary or secondary. First, prospective studies need to ascertain the sequence in the development of problematic Internet use and psychiatric disorders. Second, it is important to understand to what extent the relationship between problematic Internet use and the associated psychopathology is specific. Finally, treatment of individuals with problematic Internet use crucially depends on whether an underlying condition accounts for problematic Internet use, as that condition should then be targeted by treatment.

There have been calls to conceptualize problematic Internet use as a mental disorder, include it in the DSM-V, and classify it as a “compulsive-impulsive spectrum disorder” 2. However, doing so seems premature in view of the following: a) it is not yet clear whether and how problematic Internet use can be distinguished from a pattern of behaviour usually labelled by others as undesirable or disturbed; b) the boundary between normal and problematic Internet use has not been established; c) it remains to be ascertained whether problematic Internet use possesses conceptual validity, including distinct presentation and sociodemographic and neurobiological correlates, internal homogeneity, and sufficient longitudinal stability with distinct course, prognosis, and response to treatment.

Not endowing problematic Internet use with the status of a mental disorder would prevent its psychiatric reification at the time when so little is known about it, while fostering an open-minded attitude towards further research.