I am delighted to introduce a guest blog post by Dr Philip Tam, a Child and Adolescent Psychiatrist based in Sydney, Australia. Philip has an interest in ‘internet addiction’  in young people, and has appeared in the media discussing this subject. He has written a fantastic post below. Please do comment: it would be great to get a discussion going on this controversial topic…

Problematic Internet Use – A 21st-Century Affliction?

In recent months, there has been much interest in the Australian media and in the broader public about the modern phenomenon of ‘problematic internet use’, or internet addiction as it commonly termed. In my own clinical practice, and that of some colleagues, we have been seeing young people – generally male, but often female – presenting to us for about the past 5 or 6 years; it may come as a surprise that the first ‘cases’ of problematic internet use, or PIU, were being described in the psychiatric literature back in 1996 in the USA. As with other modern-day afflictions with a ‘pop-cultural’ element, such as ‘sex addiction’ and ‘shopping addiction’, there is heated debate within my profession as to whether this a real mental condition, deserving of diagnosis, research and treatment, or simply a form of human behaviour responding to the huge changes brought about by the ‘internet revolution’ of the past 2 decades. Diagnosing a mental condition requires a concise definition, so here is one suggestion : PIU is the pervasive, long-term and heavy use by a person of internet and computer-based technologies, including gaming, which is out of keeping with one’s educational, social or occupational role, and which results in a clinically significant negative impact on schooling, work, relationships or general well-being and health.

As a colleague of Dr. D, and also as another ‘Psychiatrist Parent’, I’d like to start a new discussion thread about this issue if anyone is interested. I’d be keen to hear of anyone’s clinical experience with the condition, or even if they could share any personal/ family experience of the problem! As I note below, we still don’t know much about the phenomenon, let alone how best to address it, and the best way is to listen to people’s own stories.

The 3 questions I am most commonly asked by concerned families, other clinicians, or media commentators are: How extensive is the problem in Australia? How do we recognise the signs of a problem in a teenager or young adult? What can be done to assist these people? Unfortunately, the short answer is: we don’t really know. While formal research has been done for some years in China, South Korea and the USA, Australia appears to lag behind in investigating the issue at a ‘population-based’ level. Good quality surveys are expensive, time-consuming and require major commitment, a situation which has affected attempts to investigate mental conditions such as depression and anxiety in the Australian community. And, as some readers will know, there is currently no official recognition of PIU in the ‘bible’ of psychiatry and classification, the DSM-IV – though it is possible it may be included in the 5th edition, due to come out in 2012.

I am also well aware that many sceptical members of the public may accuse clinicians such as myself of scare-mongering, or indeed of disease-mongering, and that the issue is primarily one about personal responsibility and common-sense, and decent, firm parenting. I must state unequivocally that I agree that, for most people with problems spending too much time online, it is about better time-management and discipline; however, there is a small percentage (probably around 5% of regular users), who do tip into true PIU as defined above, and who often do not recognise that they have a problem. Analogous to other disorders of impulse-control such as pathological gambling and alcoholism, the sufferers themselves often are oblivious that they have a problem; it is concerned family members or their teachers who refer them to specialists. Since clients with more severe PIU are at risk of dropping out of school, affecting their physical health, or losing their job, it would be unethical not to address their problems in a professional manner. In my personal experience, the key to successful treatment is getting the client to fully recognise that they have a problem – what we term ‘gaining insight’.

Clearly, the internet has brought about immense changes in human society, affecting business, recreation, education and science; it is almost impossible now to imagine going through daily life without the great benefits that it has given us. However, there are clearly a few less-desirable effects of this revolution, and since technology is likely to continue to expand rapidly, and in ways we cannot yet imagine, we need an open, active and informed debate as to how we best manage these issues! Thanks for any input you can provide.

22 Responses to Guest post: Dr Philip Tam on ‘Internet Addiction’ or Problematic Internet Use

  1. vic says:

    I think the trend of giving a specific title to problems such as Problematic Internet Use or Sex/Shopping Addiction is odd. Without any clinical experience of these issues I am entirely unqualified to pontificate, but I do have the gut feeling they are all symptoms of a larger umbrella of poor discipline. I wonder if by giving it an official title it somehow legitimises it? IE It’s not that my son/daughter is just a couch potato who spends hours on the internet etc…they have a ‘Problem’ and therefore need professional help and it is now Out Of My Hands.

    On that note – I better get off the internet myself…

    Vic

  2. DrD says:

    Good point Vic, and I think that’s one of the reasons why it’s so controversial. Even as a psychiatrist, I don’t agree with many of the addiction terms, such as ‘sex addiction’ and would argue that these are in fact symptoms of something else, most likely personality dysfunction. I can see that the physiological effects of substances (drugs and alcohol) can lead to a physical dependance, but I do have trouble with some of the newer concepts of addiction.

    Philip – do you have any comments about internet addiction being part of a larger disorder, rather than a disorder itself?

  3. Mary says:

    Addiction comes in all forms, from alcohol to drugs to sex to risk taking to food to gambling to the internet. Addiction is addiction. Like Dr. Tam pointed out in his definition, it’s addiction when it “is out of keeping with one’s educational, social or occupational role, and which results in a clinically significant negative impact on schooling, work, relationships or general well-being and health.”

    That pretty much describes any addiction. People seem to be finding new things to get addicted to, and by addicted I mean the clinical definition where the activity damages a person’s well-being (be it drinking alcohol, doing drugs, gambling, watching porn, or spending significant time on the internet).

    Maybe it is controversial because each addiction seems to get it’s own named disorder? I imagine (though I have no data) that people have an easier time understanding that drug or gambling additction is bad, as opposed to internet usage. But really it’s addiction if it is damaging the person’s life. Perhaps most people don’t see that addiction can be almost anything.

    • DrD says:

      Hi Mary – you are right, addiction is more about something which is so consuming that it interferes significantly with functioning. I suppose what I wonder is whether ‘addiction’ (to anything) is in itself a ‘disease’, or whether it is a symptom of something bigger. Do children become addicted to internet usage because they have social issues which stop them forming real life relationships, such as bullying, or peer issues, or do people turn to alcohol use because of depression, or are people with sex addiction actually craving attention and validation as part of a personality disorder.

      That’s what I find interesting about psychiatry: there’s not always a black and white answer, and each person is an individual with different predisposing and precipitating factors.

      I think Vic has a good point too: does society let people ‘off the hook’ so to speak, if they are ‘labelled’ with a disorder? I have certainly seen this in general child psychiatry practice, where a child is ‘allowed’ to behave in a particular way (which previously would not have been tolerated) when they have been diagnosed with something, whether or not that diagnosis would ’cause’ that behaviour…

      Great points Mary, thanks!

  4. PhilipT says:

    Thanks to all the comments and thoughts so far!

    Firstly, what the discussion shows is that there is clearly no clear boundary between a ‘mental illness’ and what might be an extreme form of ‘normal’ human behaviour. In fact, one of the main criticisms of the field of psychiatric classification (or ‘nosology’) and specifically the DSM, is that is can pathologise so much of the ‘richness’ of human behaviour. Examples might be difficult, naughty kids having ‘oppositional defiant disorder’, and ‘bad’ kids having conduct disorder. A whole industry of PhDs and research then arises to treat these. Other examples are ‘ female sexual dysfunction’ and the various ‘paraphilias’. There is an international movement ( ‘Diseasemongering’) aimed at countering the trend to pathologise much of this – and clearly ‘internet addiction’ will be in their sights!
    Another point is the role of language and definition, at a more philosophical level. Classifying the ‘world’ and investigating what it means to be a certain object, eg, a ‘chair’, has fascinated philosophers from Plato to Wittgenstein, and the point about dignifying a complex human behaviour like this into PIU, or whatever, may be simplistic. However, by naming something, it also gives us an opportunity to examine it in a systematic manner, and discuss with others the phenomenon in an agreed manner. Also at a linguistic level is how we define terms, such as ‘addiction’ – there are no ‘absolute’ and correct ways of defining this word, and for different people it can mean different things, as per Mary’s point. Of note is that ‘addiction’ is not used in DSM 4 for this reason, and I don’t like using the term internet addiction, prefering PIU. However, psychiatrists certainly shouldn’t hold a monopoly on how we use language, so snappy, ‘pop-cultural’ terms like sex and shopping addiction are likely to stay, in general usage.
    I would certainly agree that PIU is, in my clinical experience, almost always part of another mental health issue, notably depression, anxiety, family dysfunction, or ‘teenage anomie’ – so treatment must be directed at these issues also.
    Finally, there is emerging research about what is actually going on in the neurobiology of PIUsers – to do with dopamine and reward systems etc. There clearly may be similarities with addictions such as gambling and cocaine, which also involve these brain systems!

  5. CSMD says:

    Hi Dr D, I noticed your post on Dr McLaren’s blog and I figured I’d pay a visit.
    I think you’re right on point, Dr. T. Categorical systems of diagnosis are terribly flawed as it is really difficult to say what “is” or “isn’t” pathological. Just like beauty it’s in the eye of the beholder. Dr. Niall McLaren actually did two very recent videos which expound upon this subject.

    http://www.youtube.com/watch?v=eeEx1MqqE7M

    Now I’ll get back on point with the discussion. I’m 27 years old and about to finish up medical school. I grew up with video games and the internet, both from their infancy. I’ve also played video games extensively, even to this day. I have seen many friends who definitely had a problem with internet/video game use. The biggest problem I’ve seen yet is World of Warcraft. This and other massive multiplayer online RPGs (MMORPGs for short; http://en.wikipedia.org/wiki/Mmorpg) are essentially endless games. Most of the people who play do so responsibly, but there are always people at the extremes. The quests never end, you always have new people to play with (it’s online), the number of items you can acquire is nearly endless, and it’s an RPG so it has level up systems thus giving yet another incentive to play forever (IE, killing enemies makes your stats go higher so you can kill tougher enemies…..). I’ve seen people sink entire months on this game.

    A good place to see the problem is in South Korea. There is a brilliant documentary that expounds on this topic. It’s an episode of Frontline called “Digital Nation.” I would actually watch the whole thing but I’ve directed the link specifically to the section on internet addiction and South Korea (note: South Korea has the highest concentration of broadband internet access in the world).
    http://www.pbs.org/wgbh/pages/frontline/digitalnation/virtual-worlds/internet-addiction/

    • DrD says:

      Hi there,

      Thanks for your comments. You’re the second person to mention ‘Digital Nation’ to me, I will certainly watch it. We were planning to discuss it in our next peer group session too, so thanks for the link.
      You make interesting comments about the ‘endless’ nature of the MMORPGs, and I can see how this would drive you, a little bit like gambling: “just one more”, “I’ve put so much into this now, I have to win soon”. I can imagine that the cognitive distortions are very similar.
      I am only a few years older than you, but the internet didn’t really take off until I was at Uni. I did see people playing the old fashioned ‘Dungeons and Dragons’ type games, although I suppose a difference was that they would actually meet up in the evenings and play this together, albeit in a particular ‘role’.
      One thing that I’m interested in is that we tend to stereotype RPG players, (overweight, long hair, socially awkward, black clothes…) and I wonder if this still fits now that the internet has made these games much easier to access. I suppose I am really wondering if there is a particular personality type that is more attracted to this online world…(thought you are a good example of a challenge to this stereotype – as a near medical graduate, presumably your social skills are very good!)

      Thanks again for your comments :)

      • CSMD says:

        MMORPGs are so popular that there are things called “gold farms” (http://en.wikipedia.org/wiki/Gold_farm) where persons in third world countries will play the game and then sell the virtual gold online to people who can pay actual money for it. I also had a friend who sold one of his characters from a MMORPG for ~$2000.

        In regards to your question, overall, the stereotype still fits for the most part. Video games are much more accessible now but the people who play RPGs still fit your description, at least in the US. The “normal” people tend to play sports games or first person shooters etc.

        Also, if you’re going to watch digital nation you may want to precede that with the 2007 Frontline episode “Growing up Online.” Digital nation is actually a kind of continuation of that episode.

        Neuroskeptic had an interesting post about a South Korean paper on buproprion for Starcraft addiction. Starcraft is actually NOT a MMORPG. It is classified as a real time strategy game (RTS for short). Starcraft is HUGE in South Korea.
        http://neuroskeptic.blogspot.com/2010/08/drugs-for-starcraft-addiction.html

  6. David Wyatt says:

    Thanks for all the information Dr. Tam and others. Although I am 37 and a PR professional in the wired city of Austin, Texas, I have ben compelled to curb the distractions of technology in my daily life by getting rid of my smartphone and laptop for the very reasons you mention above. Thanks for your work and insight on the subject.

    Thanks,
    David Wyatt
    Austin, Texas

    • DrD says:

      Hi David,

      Thanks for your comments. Your point is a good one: the internet has crept into our lives and is everywhere, and can really interfere with the functioning of professional adults, never mind young people who have much less control. I have an iPhone, and do find myself reaching for it first thing in the morning to check my emails. When I was working, I used to find the constant ‘bleep’ of my computer as emails came through both incredibly distracting and ‘addictive’ – creating a need for immediate gratification! Now, when I need to concentrate on something like writing, I have to switch my modem off at the wall, or take my notebook out into the garden or the bedroom. I wonder how this affects the developing brain of our youths? I do look forward to the studies on brain chemicals etc that Dr Tam mentioned…

      Thanks again,

      D

  7. Philip Tam says:

    Thanks for all the comments, and to the links to the useful videos from CSMD. For any readers in Australia, by coincidence there was an excellent programme just a few nights ago, ‘The Virtual Revolution’ which focussed on internet addiction. Featured interviews with the ‘usual suspects’ : Prof Susan Greenfield from UK, who holds rather extreme views which are not evidence based and goes around the world bashing the Internet; the Internet clinics in S Korea, and the Founder of Facebook (and now movie star) Marc Zuckerburg. It’s a BBC series (with a US presenter), which could be found online.
    Following DrD lead of ‘interesting books I’ve read’, I thought I’d post some good recent titles I have found useful in my work on this topic: “Cyburbia” by UK journo James Harkin ; “Grand Theft Childhood” – Kutner and Olson from Harvard ; “Real Wired Child” by Michael Carr-Gregg from Australia. Gee, aren’t they great puns! I have also heard of “Life Inc” by Daniel Rushkoff in NY (he was interviewed for the above series) – has anyone read this?

    I thought I’d make a few observations that might invite comment:
    - The internet was meant to celebrate diversity, the oddball, the hippy and the rebel etc. but as time goes on there is clearly a global ‘regression to the mean’ – we nearly all are now using just a handful of key sites to connect (Google, Facebook, Twitter are obvious ones) which serves, I think, to homogenise us and clearly gives these sites huge power.
    - What is it about the East Asian societies that appears to make them prone to the more severe (indeed fatal) forms of PIU. My guess it is a combination of cultural, economic, educational, physical and technological factors.
    - DrDs point about the ‘archetypal user’ – I think that the nerdy, socially awkward type is not true; typical users are greagarious, fun-loving, have stable jobs and a high disposable income. More work needs to be done about what factors within that group make one ‘vulnerable’ to developing PIU ( the focus of my planned research).

  8. pablo says:

    I’m not a professional in the field but have seen many people with obvious signs of internet/game/social network addiction … it appears they are like other addictions as you get an instant “hit” when use them , you connect with a group of “friends” with similar knowledge … it takes you away from other issues in your life even if just for a short while … It appears the behaviour is obviously having a negative influence on the rest of life even to the people who are suffereing from those effects and is more a symptom of other issues …. the internet is just another way to distract ourselves from issues worrying us just like other addictions.

  9. DrD says:

    Hi Pablo, thanks for your comment. I agree that it seems that addictions in general (though not always) are a symptom of other issues in our lives. I do worry that adolescence is a time of turmoil, when teenagers have to find their identity and are very likely to go through periods of feeling disconnected and isolated, as a very normal part of adolescent development. If these young people are already exposed to internet/gaming/social networking etc, then there is a risk that this is what becomes their identity…

    Thanks again for your comment

  10. Barnaby says:

    Internet is an easy way out. It’s indicative of the state of society today..withdrawn, non-committing, wandering.

    Use of the internet is easy as you don’t need a goal, it is free, and it is a way of frittering away time. And unlike television it creates an illusion of actually doing something, learning something, achieving something.

    It’s good because there are no limits. no-one tells you to stop, and your time never runs out. This endlessness creates a vacuum which gets people sucked in.

    What is fascinating is why and how a computer trumps and replaces former physical methods of communication such as a book, or a newspaper, or sitting down to write a letter.

    However modern life is now less about doing something, or making something, or taking part in something but about processing, sifting through and regurgitating data.

    • DrD says:

      Hi Barnaby,

      Thanks for those comments – you raise some good points about it being a reflection of society, and that it’s a symptom of this rather than a cause. The only ‘letters’ I write these days are thank you letters, but you’re right, email/messaging has taken over. I think that the computer has taken over from verbal communication too – I know I tend to email rather than phone someone – it is quicker, easier, and I know it won’t interrupt someone who might be otherwise busy. But it’s not the same, and we must be losing a lot.

      D

  11. Not Comfortably Numb says:

    I have a 13yr old son who has a serious addiction to online games. This has been fuelled by his estranged father who introduced him to violent games at the age of 5yrs of age. When his father and I seperated, my son was continually the victim of broken promises from his father concerning contact or phone calls for many years between the ages of 5yrs and 10yrs. Now they do have contact however it is through online games on the xbox and facebook, hence this seems to be the only commonalitiy they share.

    Furthermore, all my son’s friends are avid online players, therefore sending him to school has become very stressful knowing he is surrounded by constant conversations about gaming. As peer groups and pressure are a huge factor in the life of teenagers and not playing games (as I have restricted them) has excluded him causing significant stress.

    My son has never had a computer in his room and plays in the lounge room however, homework has become a nightmare as he is unable to delay gratification and continually multi tasks between facebook games, music and minimal homework.

    For over two years I have fluctuated between giving him conditional use of the xbox and restricting all together, however more often than not he is unable to stop playing without anger and aggression towards me.

    Often I have restricted him from the xbox for weeks at a time however the addiction is transferred to the computer games when homework should be completed.

    I am fully aware of the pre frontal cortex reconstruction and the “use it or lose it” component evident in the teenage brain hence I believe my role as a parent is to apply the brakes for his own well being as he is unable to delay gratification and make rational decisions. However in doing so I feel quite unsafe as he has become quite violent towards me when I take the xbox away. I am aware of the emphasis of the development of the amygdala during teenage years however this knowledge does not protect myself or my son and I am literally begging for help here. I am very sceptical about the overuse of labelling and medicalisation of our youth hence am not keen for my son to be assisted from a medical model framework.

    My son is a very kind, compassionate and bright boy who has achieved an academic scholarship in year six which has assisted me to fund his education. However, he has become excessively angry and violent and is suffering extensive pain that I have never before seen.

    It is a very difficult situation for some teenagers as they are surrounded by gaming at school and when attempting homework. I am very worried about his welfare and if there was a game addiction program available here on the gold coast then I certainly would be enrolling him. However unlike adults who suffer addictions and can choose to not to enter the hotel, or contact the drug dealer, our kids do not have that luxury as there is no escaping their addictive world when they are continually confronted and entrenched in it everytime they go to school or turn on a computer.

    This is a huge problem with many factors that are sometimes a bit too overwhelming for me to comprehend so I have written to you in a desperate attempt to voice my concerns and actually plead for help.

    Thank you for reading this….

  12. [...] let’s put the media to work and look at comments made online from the blog of Dawn Barker – psychiatrist and writer. In her blog, in which the comments reveal a quite different story from [...]

  13. Monica Wickham says:

    Dear Dr. Tam

    I am currently writing my dissertation on social network addictions, but have been unable to find substantial published research on the subject. Do you have any suggestions?
    Your guidance would be very much appreciated.
    Many thanks

    Monica Wickham

  14. [...] of ‘internet addiction’ in young people. Dr Philip Tam, who has previously written a guest post on this blog on the topic of overuse of the internet, has launched a new website NIIRA with his [...]

  15. Liz says:

    Hi Dr Tam,
    I am a Master of Applied Social Science student doing my last subject, I am also a School Counsellor who daily hears about the different range of games that students are using. I have started to document and analyse the different games that students use and the age appropriateness of those games. Many students are in Kindergarten and playing games that their fathers play and think it is fun for the child to join in. What we really need is a Parenting Course on Children and Gaming. I am currently working with our IT technican who is a gaming specialist. Has played them for many years but is not addicted to prepare informatioin for parents of our school. Would appreciate your contact to talk about this.

    Liz e.berger@maitlandcs.nsw.edu.au

Leave a Reply

Your email address will not be published. Required fields are marked *

* Copy This Password *

* Type Or Paste Password Here *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Follow Me