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Internet Abuse : Addiction? Disorder? Symptom? Alternative Explanations?

Janet Morahan-Martin Social Science Computer Review 2005 23: 39 DOI: 10.1177/0894439304271533 The online version of this article can be found at: http://ssc.sagepub.com/content/23/1/39

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SOCIAL SCIENCE 10.1177/0894439304271533 Morahan-Martin / INTERNET COMPUTER ABUSE REVIEW

Internet Abuse
Addiction? Disorder? Symptom? Alternative Explanations?
JANET MORAHAN-MARTIN

Bryant University
As Internet use has proliferated worldwide, there has been debate whether some users develop disturbed patterns of Internet use (i.e., Internet abuse). This article highlights relevant literature on Internet abuse and computer-mediated communication effects that supports and disputes major questions about Internet abuse. Is the addiction paradigm appropriate for Internet use? Is behavior that has been labeled Internet abuse symptomatic of other problems such as depression, sexual disorders, or loneliness? What are alternative explanations for this phenomenon? Is there adequate research to support Internet abuse as a distinct disorder?

Keywords:

Internet addiction; Internet abuse; pathological Internet use; impulse control disorder; computer-mediated communication

he growth of Internet users has been exponential. Since 1989, the online population worldwide has grown from 500,000 to over 700 million users worldwide (ClickZ Stats, 2004; ETForecasts, 2000). With this growth has come a number of questions about the impact of Internet use. Among these is whether some individuals develop disturbed patterns of online behavior including Internet abuse. Anecdotal accounts of so-called Internet addicts date to the early 1990s (e.g., Rheingold, 1993) and within a few years began to appear in the popular press (e.g., Wallis, 1997). Clinicians also reported clients with Internet-related disturbances (Orzack, 1999), and some responded by instituting centers such as the Computer Addiction Service at McLean Hospital, a Harvard University affiliate, and online support groups such as the Internet Addiction Support Group. A number of researchers have also conducted research on Internet abuse and other Internet-related problems and have found that 5.9% to 13.0% of Internet users exhibit disturbed behavior on the Internet (MorahanMartin, 2001), and 15% of university students in the United States and Europe know someone who is addicted to the Internet (Anderson, 1999). Yet these efforts are not without their critics. Many criticize both the concept of Internet abuse and the research on the topic. In fact, the online Internet Addiction Support Group, though widely used by self-described Internet addicts, was founded by Ivan Goldberg as a joke because he did not believe in Internet addiction (Suler, 1998). Using relevant research on Internet behaviors and abuse, this article explores specific questions that have been raised about Internet abuse. Is the addiction paradigm appropriate for Internet use? Is what has been labeled Internet abuse better thought of as symptomatic of other problems such as depression or loneliness? Is it a new manifestation of disorders such as paraphilias or pathological gambling? What are alternative explanations for this phenomenon? Finally, the article will return to the question of whether Internet abuse is a distinct disorder.
Social Science Computer Review, Vol. 23 No. 1, Spring 2005 39-48 DOI: 10.1177/0894439304271533 2005 Sage Publications

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IS THE ADDICTION PARADIGM APPROPRIATE FOR INTERNET USE?

Claims of Internet addiction are based upon subjective experiences of self-reported Internet addicts as well as upon research on Internet abuse. Many feel out of control and helpless and report serious impairments in their lives as a result of their Internet use. Impairments include work and school-related problems and dismissals, interpersonal problems, separations and divorces, and even impaired health (Orzack, 1999; Young, 1998). Research also has confirmed that for some Internet users their use of the Internet has characteristics akin to those found with substance abusers and gambling addicts. These individuals are likely to use the Internet to modulate moods (i.e., when down or when anxious or as an escape), are preoccupied with using the Internet, have symptoms of tolerance and withdrawal, have tried unsuccessfully to cut back on use, and have serious disturbances in their lives because of their Internet use (Morahan-Martin, 2001). Although not all researchers in this field use the term Internet addiction or Internet abuse, they report similar types of symptoms. The extension of the model of addiction from substances to behaviors is controversial. Although researchers who endorse the broadened concept of addictive behaviors differ in their specific definition, The common denominator is that the individual appears to others to have diminished control over the behaviors or report a sense of disequilibrium, loss, distress, or craving when the object or substance is unavailable or the behaviors are curtailed (Jaffe, 1990, p. 1425). Since the 1970s, parallels have been drawn among behaviors associated with substance abuse and specific activities such as eating, exercising, watching television, shopping, playing computer games, gambling, and having sex (e.g., Cooper, Putnam, Planchon, & Boies, 1999; Jacobs, 1986; Kubey & Csikszentmihalyi, 2002; Milkman & Sunderwirth, 1982). Many question the appropriateness of the drug addiction model to explain any habitual or compulsive behavior, even those that are self-destructive behaviors. Jaffe (1990) argues that the broadened use of the term addiction trivializes the concept of substance-related addiction and is detrimental to understanding specific etiology and treatment approaches for both substance-related and other compulsive, repetitive behaviors, which some call addictions. Furthermore, the concept of addiction itself causes addictive behaviors to grow because it excuses uncontrolled behaviors and predisposes people to interpret their lack of control as the expression of a disease that they can do nothing about (Peele, cited in Jaffe, 1990, p. 1426). Internet abuse may better be conceptualized as an impulse-control disorder (Treuer, Fabian, & Furedi, 2001). Shapira et al. (2003), in a small study of 20 individuals who either answered newspaper advertisements for Internet Addicts or who were referred because their presenting complaint involved Internet abuse, found that all met the criteria for impulse disorder not other specified (NOS) in Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). According to Shapira et al. (2003), proposed criteria for problematic Internet use would include,
A. Maladaptive preoccupation with Internet use . . . . B. Use of the Internet or preoccupation with its use causes clinically significant distress or impairment . . . . C. The excessive Internet use does not occur exclusively during periods of hypomania or mania and is not better accounted for by other Axis 1 disorders. (p. 213)

It is worth noting that some activities associated with disturbed use of the Internet, pathological gambling, and compulsive sexual behavior are considered impulse control disorders

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(American Psychiatric Association, APA, 2000; Black, Kehrberg, Flumerfelt, & Schlosser, 1997). Some researchers and clinicians use the term Internet addiction but describe it as a form of impulse control disorder NOS (Orzack, 1999; Young, 1998). In fact, Youngs criteria for Internet addiction are adapted from those of pathological gambling, an impulse control disorder.

IS BEHAVIOR THAT HAS BEEN LABELED INTERNET ABUSE SYMPTOMATIC OF OTHER PROBLEMS?
Those who abuse the Internet are more likely than are others to exhibit disturbances in other areas of their lives including depression (Young & Rodgers, 1998), bipolar disorder (Shapira, Goldsmith, Keck, Khosla, & McElroy, 2000), sexual compulsivity (Cooper et al., 1999), and loneliness (Kubey, Lavin, & Barrows, 2001; Morahan-Martin & Schumacher, 2000, 2003). Furthermore, some activities such as online gambling and netsex are more common among those who develop Internet-related problems than those who do not (Greenfield, 1999; Morahan-Martin & Schumacher, 2000; Young, 1997). This has spurred debate regarding whether Internet abuse is actually a symptom of other pathology and regarding the cause and effect relationship between Internet abuse and other disorders. The Internet is redefining how pathology is expressed. For example, the Internet provides a new channel for those with sexual paraphilias or compulsivity to act out their pathologies. The relative ease of online access to sexually explicit material, the anonymity, the 24-hour availability, the online disinhibition, the wide choice of sexual partners, and the new ways of interacting sexually all open new avenues for sexual expression. It is probable that Internetrelated sexual disturbances occur when underlying pathology preexists. However, some may not have acted out this pathology without exposure to cybersex (Cooper et al., 1999), and the ready availability of netsex in an anonymous environment may alter how these pathologies are acted out. Similarly, online gambling is a new variant of an old behavior, but patterns of disturbed gambling behavior may be different online than not online. Online gambling sites have been described as seductive and realistic (King & Barak, 1999, p. 441) and are just a click away all the time. Development of pathological patterns of gambling may be accelerated online because online gambling is always accessible and provides instantaneous feedback. Some types of Internet-related problems, such as a spouse becoming involved in a cyberaffair in a chat room, may be better thought of as symptomatic of marital or interpersonal problems and/or cries for help. However, once again, the dynamics of the development and expression of behaviors are different from real life and merit continued study. There is limited evidence that people with preexisting conditions may be turning to the Internet. Using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID-IV) in face-to-face interviews, Shapira, Goldsmith, Keck, Khosla, and McElroy (2000) found that all of the 20 individuals with problematic Internet use who were interviewed had at least one lifetime DSM-IV Axis 1 diagnosis in addition to their disturbed Internet use (M = 5.1, SD = 3.5). In addition, 70% had a lifetime diagnosis of bipolar disorder; 85% had received previous mental health treatment, with 75% having been treated with psychotropic medications; 95% had family members with psychiatric disorders, with 65% having a first or second degree relative with a depressive disorder, 50% having a bipolar disorder, and 60% having a substance use disorder. However, the cause and effect relationship of findings such as the higher incidence of loneliness and depression among Internet abusers is still uncertain. The relationship may be bidirectional. People who are lonely and/or depressed may turn to the Internet to alleviate

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painful feelings because they can find companionship and support, which is lacking in real life, online. Once online, they may find the companionship, social support, and sense of fostering real-life contacts and support, which may exacerbate negative affect (MorahanMartin, 1999; Morahan-Martin & Schumacher, 2000, 2003). Longitudinal studies are needed to clarify the cause and effect relationship. Limited longitudinal research supports the belief that the impact of Internet use on psychological well-being is dependent on characteristics of the individual, with positive outcomes for extroverts and negative outcomes for introverts (Kraut et al., 2002). For extroverts, increased use of the Internet over time is associated with increased sense of well-being, including decreased levels of loneliness, decreased negative affect, decreased time pressure, and increased self esteem (p. 64) and with social involvement. However, for introverts, the effects were opposite in each of these measures of self-esteem. Similarly, separate analyses that control for previous levels of loneliness and social involvement find increased use of the Internet amplifies loneliness and minimizes social involvement for introverts but has the opposite effects for extroverts. The authors suggest a rich get richer hypothesis to explain the differential impact of the Internet for introverts and extroverts. That is, having more social resources amplifies the benefits that people receive from Internet use with opposite results for those with fewer social resources. Research has found that Internet abusers use the Internet to modulate negative moods. They are more likely than others to use the Internet to escape pressures, to improve their moods when down, anxious, or socially isolated, and to control moods (Anderson, 1999; Morahan-Martin & Schumacher, 2000). This provides support for those who argue that Internet abuse is symptomatic of other problems. However, people have long self-medicated with substances or other compulsive behaviors such as eating disorders, gambling, and sexual compulsivity. Depression often is comorbid with a number of other disorders such as substance abuse, pathological gambling, eating disorders, anxiety disorders, and borderline personality disorder (APA, 2000; Becona, Lorenzo, & Fuentes, 1996). Loneliness, too, is associated with a number of other psychological problems such as depression, interpersonal hostility, anxiety and personality disorders (Forsyth & Elliott, 1999), and sexual compulsivity (Cooper et al., 1999). Comorbidity of two disorders does not determine etiological direction. Given the limited state of research on Internet abuse, it may be more productive at this point to acknowledge coexistence of Internet abuse with other psychopathologies without specifying one as the cause or the symptom of the other.

WHAT ARE ALTERNATIVE EXPLANATIONS FOR INTERNET ABUSE?

Three other themes dominate criticism of the concept of Internet abuse. Some argue that fear of new technology underlies the appeal of Internet abuse. Others believe that Internet abuse research pathologizes the quality of online relationships, whereas others highlight the therapeutic aspects of online interactions.

Fear of New Technology

Alarm about the Internet being addictive may reflect fears about a new form of technology by people who are intimidated by that technology (Turkle, 1995). The expansion of the Internet to the general population has been unprecedented; worldwide, Internet users went from one half million in 1989 to over 700 million in 2004 (ClickZ Stats, 2004; ETForecasts, 2000). This new technology is rapidly changing our lives in ways unimaginable a decade

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ago. Although there is much enthusiasm for the Internet, there is also much apprehension. Many are disturbed about what kind of information can be accessed and with whom one socializes online. Parents and others have been frightened by reports of pornography and pedophiles online and distressed by a loss of ability to monitor childrens Internet use. These concerns can be worsened by parents relative lack of Internet sophistication compared to their children (National Public Radio/Kaiser/Kennedy School, 2000). Some critics of the concept of Internet abuse argue that the Internet is no more addictive or compulsive than is watching television, talking on the telephone, or doing other leisure activities (Grohol, 1999). People engage in each of these activities to the point of interrupting other aspects of their lives, yet there is little alarm about television or telephone addiction. In the United States, people spend more time watching television than being on the Internet, and parents are twice as likely to say that their children spend too much time watching television (44.9%) than being online (18.3%; UCLA Center for Communication Policy, 2003). Yet research on television addiction (e.g., Kubey & Csikszentmihalyi, 2002) has not caught the publics attention as has Internet addiction. In a September, 2003, search of ProQuest, an electronic database, Internet addiction retrieved 1,047 citations including 66 in scholarly journals, whereas television addiction retrieved 139 citations including 18 in scholarly journals. Telephone use also can be excessive. Teenagers spend hours on the phone with friends sometimes neglecting schoolwork, social interactions with their families, and other responsibilities as a result. Yet this generally is not considered an addiction. Telephone addiction, when entered as search term in ProQuest, retrieved only 19 citations, none of which were in scholarly journals. Historically, fear of the effect of new technology has accompanied the introduction of other communication technologies as well. The introduction of the telephone and television, technologies that, like the Internet, dramatically altered access to information and people, also were accompanied by widespread alarm that in some ways is parallel to that expressed now about Internet abuse.

Pathologizing Online Relationships

Some criticize research on Internet abuse because they argue that it implicitly pathologizes online relationships. Research consistently has found that there are distinct differences in social behavior online between those who abuse the Internet and others. Internet abusers are more likely to be prosocial online, with some saying they prefer online friends to real life friends, and they are more likely to spend time online in social channels such as chat rooms and multiuser domains (MUDs, a term used generically to describe interactive, roleplaying online games where users can take on an identity and interact with one another; e.g., Anderson, 1999; Morahan-Martin & Schumacher, 2000; Young, 1998). Critics of Internet abuse argue that many Internet researchers make the implicit assumption that the quality of online interactions and friendships is inferior to those in real life. For example, Grohol (1999) asserts,
Researchers seem to have not considered that perhaps people who spend a lot of time online are simply engaging in normal, healthy social relationships with other human beings around the world . . . .There is very little to suggest that individuals who prefer virtual friends over realworld friends are less well-adapted or have a lower overall quality of life. It is a different way of interacting, but is not necessarily a lesser-quality interaction. In fact, because of the unique psy-

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chological components of online social interactions, online friendships and relationships may be of higher quality or value to some. (p. 399)

This argument is a variant of an ongoing debate about the value of online relationships generally. Research confirms that online communities can provide a strong sense of community, companionship, acceptance, and social support, with many online friendships transferred to real life (Parks & Floyd, 1996; Walther, 1996). However, others contend that online relationships are weak, superficial personal relationships of pseudocommunity (Beninger, 1987, p. 360) and abet a form of technological alienation inherent in the spread of alternative modes of communication. For example, Carducci and Zimbardo (1995) argue,
Voice mail, faxes and e-mail give us the illusion of being in touch but whats to touch but the keyboard? This is not a Luddite view of technology but a sane look at its deepest causes . . . . The danger, however, is that technology will become a hiding place. (p. 82)

The truth is probably somewhere in between. Online social relationships can be healthy for some but not for others. As mentioned earlier, longitudinal research has found that an increased level of Internet use has a detrimental impact for introverts but a positive impact for extroverts (Kraut et al., 2002). Furthermore, the impact of online relationships may depend on whether they supplement or substitute for real world social relationships (Cummings, Butler, & Kraut, 2002).

Therapeutic Value of Online Interactions

Others maintain that online interactions in communities such as MUDs and chat rooms can be therapeutic. Turkle (1995), in her study of MUD users, some who play over 100 hours weekly for prolonged time periods, maintains that Internet use can be beneficial and even akin to psychotherapy. It can provide users with a psychosocial moratorium during which they can explore and work through conscious and unconscious concerns and conflicts. Thus, MUD use is no more addictive than therapy when it works as a pathway to psychological growth (p. 12), and it provides privileged spaces for thinking and working through issues of personal identity (p. 13). MUDs and other interactive online activities may offer a unique way to work through developmental issues related to identity, sexuality, intimacy, separation, and other issues. Once these needs have been met, excessive online use often discontinues (Turkle, 1995). This may explain part of the appeal of the Internet to adolescents and young adults who are in the midst of identity and sexual questioning (Kandell, 1998; Tapscott, 1998). Online social interactions also allow individuals to experiment with and develop new social skills that they can transfer to real life. For example, in discussing Internet use by the lonely, Morahan-Martin (1999) suggests,
[Lonely people may] find acceptance online in a vastly expanded virtual social world. Selfesteem can be enhanced. The Internet may serve as a safe haven where the lonely can learn and practice social skills that they then may transfer to the real world. The disinhibiting effects of Internet use can reduce social inhibition and anxiety that characterize lonely individuals. Anonymous and freed of social constraints, lonely users can experiment with their self-presentation styles and social interaction patterns. In turn, if these aspects of their online self are accepted, ones self identity may be altered. (p. 430)

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However, it is important to highlight that although excessive Internet use and/or abuse can be therapeutic for some, it also can have aversive effects for others. Turkle (1995) acknowledges that some people use the Internet not for reworking but for reenacting the kinds of difficulties that plagued [them] in real life (p. 199). Thus, social interactions online can
provide rich spaces for both acting out and working through. There are genuine possibilities for change and there is room for unproductive repetition. The outcome depends on the emotional challenges the [individuals] face and the emotional resources they bring to the game . . . . [The Internet] can provide occasions for personal growth and change, but not for everyone and not in every circumstance. (Turkle, 1995, p. 200)

IS INTERNET ABUSE A DISTINCT DISORDER?

The question still remains, is Internet abuse a distinct disorder? The evidence thus far indicates that a small percent of people develop problems from their use of the Internet. This does not, however, necessarily support that Internet abuse is a distinct disorder. The association between disturbed use of the Internet and other pathologies such as depression, loneliness, and social anxiety suggests that Internet abuse may be symptomatic of other disorders for some. However, the same is true for established disorders such as pathological gambling and eating disorders. It is difficult to determine causality. Even among those who contend that Internet abuse is a distinct disorder, there is disagreement. Some contend that it should be considered a variant of an impulse control disorder NOS (Shapira et al., 2000, 2003; Treuer et al., 2001), whereas others have proposed models based on addiction and substance abuse (Charlton, 2002; Pratarelli & Browne, 2002). There is no consensus of appropriate criteria, although some have been proposed (e.g., Davis, Flett, & Besser, 2002; Shapira et al., 2000, 2003; Young, 1998). Research on the construct validity of Internet-related disturbance is imperative. Rather than focus on a unified concept of Internet abuse, it may be more helpful to conceptualize and study disturbed patterns separately according to specific Internet activities. As discussed earlier, online pathological gambling and compulsive online sexual behavior are better thought of new variants of old behaviors, but future research should focus on how these behaviors differ from their real life counterparts. Similarly, MUDs are an extension of computer and video games. However, activities such as compulsive chat room and newsgroup use are novel to the Internet and may represent a new form of communication that creates problems for some individuals. Focus on the Internet rather than on the specific activity is misleading. The problem is not the Internet per se but the specific activities that people pursue online (Shaffer, Hall, & Bilt, 2000). Holmes (1997) cautions,
People develop problems with certain activities which they do online. There are people who compulsively chat online, people who compulsively download pornography and people who compulsively play games. If the word addiction is even appropriate, Id like to suggest that people become addictedto these activities and not to the Internet itself. The term sex addictis not an official diagnostic term, but it is sometimes used to describe someone who is compulsively sexual and seems to be addicted to sex. Many of these people buy pornographic magazines and videos. We dont consider them to be addicted to magazines or videos, but to sexthe content of the magazines and videos.

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Although this statement is appropriate at some level, it ignores the fact that the Internet is a unique medium that allows behaviors, normal and pathological, that otherwise might not be possible. Much of the debate about Internet abuse is framed in absolutes: Either there is a disorder of Internet addiction or there is not. Yet the evidence is more nuanced. Some people clearly do develop problems from their practice of certain Internet activities. It may be more appropriate to describe these behaviors, when disturbed, as Internet-enabled pathologies. Some researchers have preferred to use terms that do not imply addiction or a specific disorder such as pathological Internet use (Morahan-Martin & Schumacher, 2000) and problematic Internet use (Caplan, 2002; Shapira et al., 2001, 2003). The difference between these terms and Internet addiction disorder is more than semantic; it reflects an appropriate cautiousness given the current state of research. Research on disturbed Internet use is in an early stage of development. Thus far, it has begun to delineate some patterns of disturbed users and uses of the Internet, but much more research is needed. It would be unfortunate if the debate of whether these patterns of behavior should be called a separate disorder squelches further research. Ultimately, it is hoped that, based on ongoing research, unified, empirically based theory and theory-based criteria will emerge.

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SOCIAL SCIENCE COMPUTER REVIEW Janet Morahan-Martin, Ph.D., is a professor of psychology in the Department of Psychology at Bryant University, Smithfield, Rhode Island. Since 1996, her research has focused on psychological aspects of the Internet. Her current research interests include pathological use of the Internet; loneliness, social anxiety, and social uses of the Internet; gender and the Internet and information technology; and retrieval, evaluation, and uses of online health information. She can be contacted by e-mail at jmorahan@bryant.edu.

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