DEPRESSION AND ANXIETY 17:207–216 (2003)

Research Article
PROBLEMATIC INTERNET USE: PROPOSED
CLASSIFICATION AND DIAGNOSTIC CRITERIA
Nathan A. Shapira, M.D., Ph.D.,1n Mary C. Lessig, B.S.,1 Toby D. Goldsmith, M.D.,1 Steven T. Szabo, Ph.D.,2
Martin Lazoritz, M.D.,1 Mark S. Gold, M.D.,1and Dan J. Stein, M.D., Ph.D.,1,3

Since the mid-1990s, there have been frequent reports of individuals whose use
of the computer and internet is problematic. Given the recent expansion and the
expected increase in internet availability and usage in the coming years, it is
important that healthcare professionals be informed about this behavior and its
associated problems. Recently, psychological and psychiatric literature has
described individuals that exhibit problematic internet use who often suffer
from other psychiatric disorders. In the face of this comorbidity, it is essential to
evaluate whether these individuals represent a distinct class of disorder, or a
manifestation/coping mechanism related to other underlying diagnosis. In
either event, problematic internet use negatively impacts social and emotional
functioning. Based on the current limited empirical evidence, problematic
internet use may best be classified as an impulse control disorder. It is therefore
imperative that problematic internet use be appropriately identified among
symptomatic individuals. For these reasons, we propose specific diagnostic
criteria that will allow for consistent identification and assist in further study of
this behavior. Depression and Anxiety 17:207–216, 2003. & 2003 Wiley-Liss, Inc.

Key words: addiction; comorbidity; impulse-control disorder; pathological gambling;

mania

mania, and Pathological Internet Use [Bai et al.,

INTRODUCTION
In the year 2000, President Bill Clinton’s adminis-
trative office released the report, Falling Through the
Net: Toward Digital Inclusion, produced by the Com-
merce Department’s National Telecommunications and
Information Administration [NTIA Release, 2000] and
its Economics and Statistics Administration (ESA).
This report noted that over half of all American homes
have a computer and the proportion of U.S. homes
with Internet access has increased significantly from
26.2% in December 1998 to 41.5% in August 2000.
Worldwide internet use is also expanding rapidly with
an estimate of 581 million users (B9.6% of the
population) as of May 2002, which was an increase
from 463 million (B7.6% of the population) 1 year
earlier [Nua Internet Surveys, 2002]. As this electronic
medium continues to expand, it is likely that we may
see an increase in problematic behaviors related to its
application.
Problematic internet use has been described pre-
viously under various pseudonyms as Computer
Addiction, Internet Addiction (Disorder), Interneto-
2001; Beard and Wolf, 2001; Belsare, 1997; Grif fiths,
1996, 1997; O’Reilly, 1996; Shaffer et al., 2000;
Stein, 1997a,b; Shapira et al., 1998, Young, 1998a,b;
Young and Rogers, 1998]. Furthermore, reports of
numerous individuals with problematic internet use
have been published in the mainstream media and
medical literature over the last several years. Overall,
1
Department of Psychiatry, University of Florida, Gainesville,
Florida
2
Mood and Anxiety Disorders Program, National Institute of
Mental Health, Bethesda, Maryland
3
Department of Psychiatry, University of Stellenbosch, Cape
Town, South Africa
n
Correspondence to: Department of Psychiatry, E.F. & W.L.
McKnight Brain Institute, University of Florida, Gainesville, FL
32610-0383. E-mail: shapira@psych.med.ufl.edu
Received for publication 26 June 2002; Accepted 9 December
2002
Published online in Wiley InterScience (www.interscience.wiley.
com). DOI 10.1002/da.10094

& 2003 WILEY-LISS, INC.

208 Shapira et al.
problematic internet use could be characterized by an
individual’s inability to control their internet use, which
in turn leads to feelings of distress and functional
impairment of daily activities [Shapira et al., 2000].
There are many potential dangers associated with
internet use/overuse. In addition to the internet being a
portal for the expression of psychiatric illnesses (i.e.,
pathologic gambling, paraphilias, and compulsive
buying), small systematic face-to-face psychiatric stu-
dies of people with problematic internet use suggest
high rates of psychiatric comorbidity including mood
and anxiety disorders [Black et al., 1999; Shapira et al.,
2000]. In these studies, problematic internet use was
also associated with significant distress and functional
impairment. Thus, it remains unknown whether this
type of behavior represents a distinct disorder or a
substratum of another psychiatric illness. In light of
this, it is imperative to propose provisional diagnostic/
research criteria, as a first step, to enable clinicians to
be able to recognize this maladaptive behavior.
Importantly, given the possible comorbidity of proble-
matic internet use with other psychiatric disorders,
these criteria need to be unique from that of other
disorders in order to evaluate the validity of proble-
matic internet use as a distinct disorder. The criteria
may also need to help the clinician think about internet
use as simply a symptom of other disorders such as
pathological gambling, a paraphilia, or bipolar dis-
order.
BACKGROUND
PROBLEMATIC INTERNET USE:
ADDICTION
Interest in the growing phenomenon of technologi-
cal dependencies or technological addictions has been
reported in the literature since the early 1990s,
although researchers had previously studied the effects
of television and excessive viewing [Kubey and
Csikszentmihalyi, 2002]. Grif fiths [1995, 1996] oper-
ationally defined ‘‘technological addiction’’ as a che-
mical or behavioral addiction that involves nonhuman
interaction. Keepers [1990] reported on a technological
dependency in the form of a young boy who was
‘‘obsessed’’ with playing video games. The child had
become so consumed with playing coin-operated
games in a local arcade that he had resorted to theft
and forgery. By utilizing face-to-face interviews and
mailed questionnaires, Shotton [1991] reported ‘‘com-
puter addiction’’ or ‘‘Dependants’’ made up a small
portion of the British population. These individuals
were found to have a mean age of 29.7 years which was
older than anticipated, had been dependent for an
average of 5.6 years, and overall had done well in
school. Although the majority of the respondents to the
survey were male, Shotton described that although
women had less overall interest in purchasing a
computer, they did not appear to be less likely to
become computer dependent than men when they
became computer owners. Shotton also reported that
‘‘Dependants’’ purchased their computers as soon as
commercially available and had an almost constant
need for positive intellectual stimulation. From an early
age, ‘‘Dependants’’ noted the interaction with others
offered them limited satisfaction; viewed computers in
a more positive light than people; and were more likely
to describe non-nurturing parenting. Interestingly, in
contrast with more recent reports of problematic
internet use, Shotton [1991] observed very few negative
effects of their computer use and only a few
‘‘Dependants’’ had concern over the negative responses
of their spouses.
It has been suggested that dependency on the
internet is also similar to the concept of a ‘‘positive
addiction’’ introduced by Glasser [1976; Grif fiths,
1996]. Positive addictions are things that are consid-
ered good for the individual, (e.g., exercise and
meditation) and might be useful as a substitution to
aid in weaning addicts away from more destructive
behaviors [Glasser, 1976]. To be classified as a positive
addiction, Glasser [1976] described that an activity had
to incorporate the following six criteria: it had to be
non-competitive with other daily activities, relatively
easy to complete, could be done alone, had value to the
individual, some improvement would result, and
involved no self-criticism. Although it is relatively easy
to see how Glasser’s criteria could apply to the use of
the internet, it is also been questioned whether positive
addictions are actual addictions as the criteria for
positive addictions do not resemble many of the signs/
components of established addictions such as tolerance
and withdrawal [Grif fiths, 1996]. Also, one might
suggest that positive addictions fit a conditioning
paradigm as described below.
However, it has been suggested that ‘‘technological
addictions’’ and classical models of addictions that
involve the intake of a drug have a number of common
features including salience, euphoria, tolerance, with-
drawal, conflict, and relapse [Griffiths, 1995]. In terms
of becoming ‘‘addicted’’ to the internet, several
researchers have further described a correlation be-
tween the amount of time online and reported negative
consequences [Grif fiths, 2001]. Most of the back-
ground research on ‘‘technological addictions’’ has
been accomplished through evaluations of gamblers
who become ‘‘addicted’’ to fruit-machines (slot-
machines). Fruit-machines operate on principles of
cognitive conditioning by teaching the gambler that
they will be rewarded for their ef forts [Donegan et al.,
1983]. However, not every effort is rewarded and it
becomes a gamble as to which ef fort will result in a
prize [Griffiths, 1993]. Manufacturers strive to make
their machines attractive to gamblers; lights, sound
effects, and the technical difficulty of the game are all
used to peak the participants interest in the game at
hand [Griffiths, 1993]. According to Grif fiths [1995],
there appear to be two types of individuals who become
 Research Article: Problematic Internet Use: Diagnostic Criteria
addicted to the fruit-machine: those who enjoy the
technology itself and find it arousing and those who are
using the technology as a form of escape to avoid
dif ficulties they are experiencing in their daily lives. He
has also postulated that due to technological advances,
the potential ‘‘casualties’’ of the technological revolu-
tion would increase as technology improves [Grif fiths,
1995; Griffiths and Parke, 2002].
Dependency on the internet could also be concep-
tualized as a ‘‘behavioral addiction’’ [Bradley, 1990;
Marks, 1990]. Behavioral addictions operate on a
modified principle of the classic addiction model;
however, the validity and clinical usefulness of classify-
ing certain mental disorders and behaviors such as
compulsive spending, gambling, hypersexuality, klep-
tomania, overeating, etc. under the rubric of addictions
has been questioned [Bradley, 1990; Holden, 2001;
Miele et al., 1990]. Others (Greenberg et al. [1999])
have reported, that there is a tendency for individuals
to be multiply ‘‘addicted’’ and to have overlapping
addictions between common substances such as alcohol
and cigarettes and ‘‘addictions’’ to activities such as
internet use, gambling, exercising, and television. A key
factor to both models of substance and behavioral
addictions is the concept of psychological dependence,
in which no physiological exchange, such as ingestion
of a substance, occurs [Bradley, 1990; Marks, 1990].
For example, in the case of a heroin addict, psycholo-
gical dependence can be observed by craving responses
made to photographs of needles or individuals shooting
up. Thus, the principle of psychological dependence
may lend itself to the pull of the internet for
problematic internet users since no physiological
exchange has taken place, although in the case of the
heroin addict at one time a physiological exchange has
also occurred. Nevertheless, this also arguably de-
scribes a process of conditioning rather than of
‘‘addiction’’.
The types of activities that people use the internet
for is quite varied (chat forums, emailing, file
transferring, ‘‘surfing’’, multi-player games, etc.), and
it is possible that only some of these activities
(particularly highly interactive ones) may facilitate
‘‘addictive’’ or ‘‘compulsive’’ use of the internet in
susceptible individuals [Grif fiths, 1995, 1996, 1997;
Turkle, 1995]. In terms of problematic internet use,
studies have tended to show these individuals have high
use in areas that involve communication and interac-
tion (i.e., chat forums, email, and interactive games)
[Black et al., 1999; Chou 2001; Shapira et al., 2000;
Young, 1998a,b]. In addition, these studies indicate that
usage may also vary by age and sex. For example,
women and older ‘‘addicts’’ are reportedly more drawn
to chat forums that are often of a sexual nature, while
men and younger ‘‘addicts’’ are more often drawn to
games and pornographic web sites [Mitchell, 2000].
Online pornography, cybersex, and ‘‘cyber-relation-
ships’’ are an important part of the internet landscape
[Cooper and Sportolari, 1997; Cooper, 1998]. How-
209
ever, the role they play in problematic internet use is
currently in debate [Mitchell, 2000] and may be better
explained as a symptom of an underlying hypersexual
disorder [Stein, 2001]. Some have proposed that
‘‘internet sex addiction’’ may even constitute a specific
subtype of ‘‘internet addiction’’ [for review, see
Grif fiths, 2001]. Certainly, the amount and usage of
sexually related material online is staggering. For
example, it has been estimated that over half of all
money spent on the internet is sexually related and
some estimates suggest the industry may be worth as
much as $1 billion [Griffiths, 2001].
CURRENT CONCEPTUAL APPROACHES
In terms of trying to conceptualize what diagnostic
framework best represents problematic internet use,
there have been several attempts to classify and
quantify the symptoms of this behavior. For example,
Young in 1996 reported on the impairment of an
individual with ‘‘internet addiction’’ by using a working
model based on the DSM-IV criteria for substance
dependence (considered an internet ‘‘addict’’ if they
answered three of seven adapted criteria) [Young,
1996]. Young [1996] discussed the possibility that
individuals who suffer from problematic internet use
may suffer in a similar manner as individuals that are
addicted to drugs, alcohol, or gambling. However,
Satel [1993] has argued that expansion of the term
addiction to describe any ‘‘compulsive self-destructive
behavior’’ causes several problems. For example, the
meaning of addiction becomes diluted and the risks of
early conclusions, which may prevent fully exploring
other coexisting/underlying illnesses or treatments
other than 12-step based, is often rendered.
More recently Young contends that problematic
internet use more closely resembles an impulse control
disorder [Young, 1998a,b; Young and Rogers, 1998]
and has devised new criteria based on the DSM-IV
criteria for pathological gambling. Young [1998b]
noted that this conceptual approach was adopted
because Pathological Gambling was the most similar
of the DSM-IV diagnoses to the ‘‘pathological nature
of internet use’’. Utilizing the criteria based on
pathological gambling, she constructed and adminis-
tered an eight question Diagnostic Questionnaire in
which ‘‘Dependants’’ answered yes to five or more of
the criteria [Young, 1998b]. Two criteria from Patho-
logical Gambling were not felt applicable and not used.
Surveys were administered by either electronic means
or telephone to 396 individuals classified as dependent
and 100 non-dependent individuals as to the amount of
time spent on-line, activities engaged in while on-line,
problems experienced in their life, and the nature of
these problems. The results indicated that the majority
of the dependent individuals were also experiencing
problems in their daily life (e.g., academic, financial, or
occupational).
210 Shapira et al.
Young and Rogers [1998] have also reported that
similar to disorders such as eating disorders and
pathological gambling, there were increased levels of
depression associated with ‘‘pathological internet use’’
using an online administered Beck Depression Inven-
tory to 259 ‘‘addicted’’ users. Recently, Beard and Wolf
[2001] have taken Young’s diagnostic criteria for
‘‘internet addiction’’ that were based on the DSM-IV
criteria for pathological gambling and made theoretical
modifications in an attempt to strengthen the proposed
criteria. These modifications were in response to
Young’s inclusion of behaviors that may not be entirely
explained by an addiction; Beard and Wolf [2001]
altered the number of criteria necessary for a potential
diagnosis. Supporting the underlying psychiatric pre-
mise of problematic internet use, Praterelli et al. [1999]
described using a factor analysis of a 94-item college
survey to report that individuals with ‘‘computer/
internet addiction’’ have a mixture of obsessive-like
characteristics related to their computer/internet use,
prefer on-line interactions, may use the internet ‘‘to
feel better’’, alleviate feelings of depression, and to
become sexually aroused.
There have been a few other studies that have also
supported the concept that problematic internet use
appears to be associated with features of DSM-IV
impulse control disorders [Shapira et al., 2000; Treuer
et al., 2001]. However, in contrast to previous a priori
diagnostic formulations based on particular DSM-IV
diagnostic criteria, Shapira et al. [2000] defined
problematic internet use broadly to facilitate studying
the spectrum of this phenomenon. Problematic inter-
net use was operationally defined as internet use that
was (1) uncontrollable; (2) markedly distressing, time-
consuming or resulting in social, occupational or
financial dif ficulties; and (3) non-solely present during
hypomanic or manic symptoms. Shapira et al. [2000]
found that 20 out of 20 subjects’ problematic internet
use would meet DSM-IV criteria for an impulse
control disorder, not otherwise specified after system-
atically evaluated subjects by face-to-face interviews. In
contrast, only three of the twenty subjects’ internet use
met criteria for obsessive–compulsive disorder. Treuer
et al. [2001] describe a high prevalence of features of
impulse control disorders among 86 internet users who
completed questionnaires after visiting the authors’
internet homepage.
DISTINCTNESS AND COMORBIDITY
Small studies of face-to-face systematic psychiatric
evaluations have been used to evaluate the co-
occurrence of problematic internet use and other
psychiatric disorders [Black et al., 1999; Shapira
et al., 2000]. Comorbid or primary disorders most
often have included mood disorders, substance use
disorders, anxiety disorders, impulse control disorders,
and personality disorders (see Table 1). Black et al.
[1999] evaluated 21 individuals who presented for
treatment for ‘‘compulsive computer use’’ without
previous psychiatric treatment and noted these dis-
orders were present although not as common. Shapira
et al. [2000] who observed at least one psychiatric
disorder (mean7sd¼5.173.5) in all 20 individuals
evaluated with problematic internet use, particularly
in terms of Axis I DSM-IV disorders. Shapira
(unpublished data, 2000) also found that all 20 subjects
had at least one psychiatric condition that predated the
development of their problematic internet use. Inter-
estingly, both studies found that subjects were in their
low to mid 30s and reported problematic use for
around 3 years. These individuals spent on average
27 to 28 hr online each week in ‘‘nonessential’’
(pleasure/recreational or personal) computer use
and many experienced emotional distress, social,
occupational, or financial difficulties. Shapira et al.
[2000] also reported on the medication management
of 15 individuals with problematic internet use
and the apparent need to treat comorbid/underly-
ing psychiatric illness to effectively manage their
internet use, although the data was gathered retro-
spectively. Furthermore, the treatment of individuals
with problematic internet use is complicated and has
been hypothesized to require a broad approach
including such therapies as cognitive behavioral
therapy targeted to the internet overuse [Orzack,
1999; Orzack and Orzack, 1999; Orzack and
Ross, 2000].
It has been postulated that excessive use of the
internet in the majority of cases appears to be an
expression of rewarding behaviors, whereby the inter-
net is largely being used solely to perform these
behaviors [Grif fiths, 1999, 2000]. Therefore, the
internet would be acting as a media delivery system
and not a causal factor [Shaffer et al., 2000]. Recently,
Pratarelli and Browne have used a factor analysis
approach to try and evaluate this concept by asking
which model (internet addiction is the causal factor
behind its use or vice versa) fits their college survey
data best [Praterelli and Browne, 2002]. They report
that their data support that the ‘‘internet addict’’ has an
‘‘addictive’’ predisposition/susceptibility that then leads
to their excessive use of the internet when evaluated for
sexual and other functional uses.
Whether the problem exists at all has also been
called into question. Mitchell [2000] commented in
Lancet that a number of researchers do not believe
‘‘internet addiction’’ deserves its own diagnosis outright
because it is difficult to tease out whether internet
addiction develops on its own or is precipitated by
underlying comorbid psychiatric illness. Without a
clear developmental pattern, particularly in light of
how integrated the internet has become in peoples
lives, it may become even more dif ficult to dif feren-
tiate which developed first [Mitchell, 2000]. Addition-
ally, longitudinal studies of problematic internet
use have not been completed. Behavioral patterns
for internet overuse and misuse are also varied
 Research Article: Problematic Internet Use: Diagnostic Criteria 211

TABLE 1. Comorbid psychiatric disorders: a comparison of the findings in Black et al. [1999] and Shapira et al. [2000a]

Black et al. [1999], N¼21 Shapira et al. [2000a], N¼20

Current Lifetime Current Lifetime

diagnosis, n (%) diagnosis, n (%) diagnosis, n (%) diagnosis, n (%)

Mood disorders Mood disorders

MDD/dysthimia 5 (24) 7 (33) MDD 2 (10) 3 (15)
Mania 1 (5) 2 (10) Bipolar I 11 (55) 12 (60)
Bipolar II 1 (5) 2 (10)
Anxiety disorders Anxiety disorders
Panic disorder 1 (5) 2 (10) Panic disorder w/o agorophobia 2 (10) 5 (25)
Agorophobia 0 (0) 1 (5)
Phobic disorders 3 (14) 3 (14) Specific phobia 4 (20) 7 (35)
Social phobia 8 (40) 9 (45)
GAD 3 (14) 3 (14) GAD 2 (10) 2 (10)
OCD 0 (0) 2 (10) OCD 3 (15) 4 (20)
PTSD 5 (25) 5 (25)
Psychotic disorders Psychotic disorders
2 (10) 3 (14) Schizoaffective disorder, bipolar type 2 (10) 2 (10)
Substance abuse disorders Substance abuse disorders
Alcohol use/dependence 3 (14) 7 (33) Alcohol abuse/dependence 2 (10) 9 (45)
Drug use/dependence 1 (5) 3 (14) Substance abuse/dependence 1 (5) 9 (45)
Eating disorders Eating disorders
Anorexia 0 (0) 0 (0) Anorexia 0 (0) 1 (5)
Bulimia 2 (10) 3 (14) Bulimia 1 (5) 2 (10)
Eating 2 (10) 4 (20)
Disorder NOS
Somatoform disorder 2 (10) 2 (10) Body dysmorphic disorder 2 (10) 2 (10)
Psychosexual disorders 2 (10) 3 (14) Paraphilias
Exhibitionism 1 (5) 1 (5)
Sexual masochism 1 (5) 1 (5)
Sexual sadism 2 (10) 2 (10)
Transvestic fetishism 1 (5) 1 (5)
Voyerism 1 (5) 1 (5)
Impulse control disorders
Intermittent explosive disorder 2 (10) 3 (15)
Kleptomania 1 (5) 2 (10)
Pathologic gambling 1 (5) 1 (5)
ICD NOS 4 (20) 6 (30)
Child conduct disorder 0 (0) 9 (34)
Antisocial personality disorder 1 (5) 3 (14)

and dif ficult to identify; however, there is general
agreement that compulsive/overuse of the internet can
be associated with material and psychological con-
sequences [Mitchell, 2000]. Considering this general
agreement that some individuals do experience proble-
matic use, it will be important for future re-search to
further delineate the problem. For example, individuals
may have problematic use solely while manic, or some
may have problematic use due to the demographics of
choosing to gamble or shop online, or have proble-
matic use worsened due to psychiatric comorbidity.
Once these factors have been taken into account, there
may be individuals left who should be evaluated for a
process of addiction or of impulsivity in terms of their
internet use.
SOCIAL IMPACT AND SOCIETAL DANGERS
OF THE INTERNET
Orzack [1999] has evaluated ‘‘Pathological Compu-
ter Use Disorder’’ in terms of the computer being
utilized as a means to satisfy, induce excitement, and
reduce tension or induce relief. Stein [1997a] has
further addressed the replacement of internet relation-
ships with interactive ones and the dangers this poses
for the individual. Griffiths [1997] commented on the
lack of psychological impact and the ability to hide
behind a cloak of the internet in fantasy games,
allowing the problematic internet user to avoid direct
human interaction. Furthermore, Kraut et al. [1998]
demonstrated in a 2-year prospective study of 169
212 Shapira et al.
people in 73 households in the Pittsburgh area that
there was an association between increasing use of the
internet and withdrawal from family activities, in-
creases in depression, and feelings of loneliness. The
internet can also provide a medium for creating false
senses of interaction [Kraut et al., 1998; Stein, 1997].
Therefore, increased internet use may cause individuals
to become isolated from their peers and from social
interaction. Furthermore, it has also been noted that
some individuals will also increase their use of the
internet as feelings of isolation increases, possibly
leading to a vicious circle of social withdrawal
[Pratarelli et al., 1999].
Among the dangers of the internet, a recent
commentary by Mitka [2001] in JAMA stressed the
importance of policing gambling activities on the
internet, citing the dangers of adolescents gambling
online and an increasing overall use of online
gambling. Additional dangers to youth include un-
wanted online sexual solicitations [Mitchell et al.,
2001]. Furthermore, several groups have described
the dangers of seeking sex through the internet in terms
of fostering high risk sex [Benotsch et al., 2002; Elford
et al., 2001; Kim et al., 2001; McFarlane et al., 2000;
Toomey and Rothenberg, 2000]. As the popularity and
convenience of the internet grows, so do the concerns
for its possible abuse. Feldman [2000] reports on a
series of cases of ‘‘virtual’’ factitious disorder and
Munchausen reports by proxy in which internet group
users gave false personal stories about an illness or
crises and cautions physicians who participate or have
patients that participate in online forums to be aware of
pitfalls of this technology. Although Feldman [2000]
points out the significant benefits that internet groups
can have for patients, he also describes that this new
medium has made it easier for individuals to mask their
true intentions.
Stein [1997a] has touched on the growing use of the
internet as a tool for therapy, especially in the form of
self-help [Stein, 1997b], and Bai et al. [2001] have
described setting up of a non-commercial virtual
psychiatric health clinic. However, as the internet
expands so does its influence on psychiatry and
psychiatric patients, as evidenced by reports of patients
enmeshed with the technology. Bai et al. [2002] have
reported that 15 % of visitors to their mental health
clinic met criteria for ‘‘internet addiction disorder’’.
Catalano et al. [1999] reported on two individuals
whose delusions revolved around the internet and the
world wide web. These individuals believed the
internet was controlling their bodies and minds even
though they had limited experience and access to the
technology itself. Gabbard [2001] reported on a case of
erotic transference largely developed through email.
Stein et al. [2002] report on a 42-year-old married man
(a composite of two patients) whose hypersexual
disorder centered around his problematic internet
use. Podoll et al. [2002] reported on a female patient
with post-traumatic stress and multiple personality
disorders. Of her 48 identified identities, two fre-
quently visited chat rooms in a way that could be
considered excessive. From this case report, Podoll et
al. concluded that the patient’s excessive use of the
internet was a symptom of her mental illness and not a
distinct disease entity.
PREVALENCE AND SCOPE OF
PROBLEMATIC INTERNET USE
In terms of the worldwide scope of this problem,
there has been an online interview study of Taiwanese
college students conducted by Chou [2001] and a
survey administered by Tsai and Lin [2001] to 753
Taiwanese high school adolescent students of whom 90
were found to be possible ‘‘internet addicts’’. These
reports, reports described above from the United
Kingdom and United States, and a report by Treuer
et al. [2001] of problematic internet users in Hungary,
further indicate that problematic internet use is likely
worldwide. Just how widespread the problem is has yet
to be determined. The Saratoga Institute conducted a
survey of inappropriate use of the internet while at
work in the year 2000 [Greenfield, 2000]. According to
the report 60% of companies surveyed have disciplined
employees for inappropriate practices online, including
using chat rooms, email, and pornography on company
computers, and 30% have terminated employees for
such practices.
Overall there has been a scarcity of published studies
on problematic internet use with most of them being
(online) surveys often using self-selected samples
without control groups while the rest of the publica-
tions have been theoretical papers [DeAngelis, 2000].
Nonetheless, the studies that have been carried out
indicate that approximately 6 to 14% of individuals
who use the internet may have problematic internet use
[DeAngelis, 2000].
DISCUSSION AND
DIAGNOSTIC CRITERIA
As initially indicated, there is a need for specific
diagnostic criteria for identifying problematic internet
use in clinical settings and to further encourage
carefully designed research initiatives. Based on the
current limited empirical evidence, we propose that
problematic internet use be conceptualized as an
impulse control disorder, a disorder in which indivi-
duals usually experience rising tension or arousal
before an action(s) and subsequently experience a sense
of relief or pleasure after completion of the behavior(s).
The category of impulse control disorders is admit-
tedly already a heterogeneous one that could con-
ceivably be extended even further in multiple directions
to such behaviors as watching TV or driving a vehicle;
nevertheless over time specific syndromes have been
indicated as clinically useful; these include pathological
gambling, and given their prevalence, in the future, we
 Research Article: Problematic Internet Use: Diagnostic Criteria
speculate the will come to include internet related
behaviors. We believe it is important to propose
criteria that are both broad enough to capture
problematic internet users for systematic study but
not so broad as to ignore other known psychiatric
disorders that may account for the patient’s sympto-
matology. We do not feel these goals are currently
being met by the diagnostic schemas that are based
solely on substance use disorders or pathological
gambling as predefined diagnoses, for such a new
entity likely encourages premature conclusions and
prevents a fuller exploration of other treatable diag-
noses. Therefore, in the general style of impulse
control disorders per the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text
Revised (DSM-IV-TR) in addition to the proposed
impulse control disorder of compulsive buying [McEl-
roy, 1994], we propose the following broad diagnostic
criteria for problematic internet use.
A. Maladaptive preoccupation with internet use, as
indicated by at least one of the following.
1. Preoccupations with use of the internet that are
experienced as irresistible.
2. Excessive use of the internet for periods of time
longer than planned.
B. The use of the internet or the preoccupation with its
use causes clinically significant distress or impair-
ment in social, occupational, or other important
areas of functioning.
C. The excessive internet use does not occur exclusively
during periods of hypomania or mania and is not
better accounted for by other Axis I disorders.
CLINICAL EXAMPLES
To help further illustrate using the proposed
diagnostic criteria and some of the complexities
involved in differentiating this ‘‘disorder’’, we describe
three brief clinical vignettes of college students who
were all heavier than average users [above 45 hr/month
across at least 2 months with average students using the
internet around 15 hr/month as tracked by Florida’s
Northeast Regional Data Center (NERDC)]. These
three students all took part in research approved by the
Institutional Review Board of the University of Florida
Health Science Center and signed written informed
consent to allow a face-to-face psychiatric evaluations
(by previously described methods [Shapira, 2000])
performed without knowledge of the students’ internet
use patterns.
CASE 1
Mr. A. is a 32-year-old Caucasian man in his 4th year
of college. Psychiatric evaluation revealed bipolar
disorder, most recently depressed in partial remission,
obsessive–compulsive disorder (OCD), and a history of
paraphilia, not otherwise specified (From 16 to 18
years old, the subject reports masturbating frequently
213
in public and described a ‘‘rush’’ from this type of
masturbation but would cover what he was doing and
did not want other people to see him. He reports
clinically significant distress with these behaviors.). He
is not on any medications and has only been on lithium
briefly approximately 10 years earlier after his first and
only manic episode. Mr. A. describes his father as
having OCD but not clinically diagnosed or treated.
Mr. A. stated that in high school he played various
computer games to the point where it severely af fected
his grades. He began using the internet at age 28 soon
before starting college and his major use at that time
was multi-player video/strategy games. Since starting
college, he also spends significant time in chat forums
mostly to stay in touch with his gaming partners (about
10) with whom he has never met face-to-face. Mr. A.
estimated that he spends about 21 hr/week in ‘‘non-
essential’’ (pleasure/recreation or personal) use of the
internet and 3 hr/week in ‘‘essential’’ (required job/
school functions) use. He describes his ‘‘nonessential’’
use occurs in the following domains: chat forums
(35%), multi-player video/strategy games (25%), email
(15%), WWW ‘‘surfing’’ (5%), file transfers (5%),
pornography (5%), shopping/buying (5%), music
(3%), and selling (2%). He acknowledges that his
internet use throughout college has been associated
with significant academic problems due to the amount
of time he spends online but he has been unable to
decrease or stop his usage. He endorses a rising sense
of tension before using the internet/logging, onto the
internet, and a relief of this tension when he does use
the internet. Furthermore, he is more likely to use the
internet when ‘‘stressed’’ and will often find himself
using the internet for longer periods of time than
planned. According to NERDC his actual use of the
internet averaged 35.9 hr/week.
Although Mr. A.’s clinical presentation is complex
(active untreated psychiatric illness and problems from
his internet use), his usage would fit the proposed
diagnostic criteria for problematic internet use. Mr. A.
has a 4-year history of maladaptive preoccupation with
internet use with both frequent preoccupations and
using the internet for longer periods of time than
intended. He significantly underestimates the amount
of time he spends online and his internet use has led to
impairment in school functioning. Although Mr. A. has
bipolar disorder and OCD and describes using the
internet more when ‘‘stressed’’, his internet use has not
occurred exclusively during any mood state and is not
better accounted for by another Axis I disorder. As
previously suggested in other individuals with proble-
matic internet use, his behavior would currently best be
described as an ICD, NOS.
CASE 2
Mr. B is a 22-year-old male in his 5th year of college.
Psychiatric evaluation reveals major depression, re-
current, currently moderate, alcohol dependence,
214 Shapira et al.
marijuana dependence, generalized anxiety disorder
(GAD), and symptoms of exhibitionism and voyerism
which were subthreshold for the diagnoses. He is
currently on sustained release buproprion. Mr. B.
describes his father as having GAD medicated with
buspirone and two maternal aunts and grandmother
with depression.
Mr. B. describes first using the internet at age 15 and
until college used the internet at home mostly for
downloading and staying in touch with friends. Since
starting college, he also spends significant time at
pornography sites, listening to music online, and
‘‘surfing’’. Mr. B. estimated that he spends about 12
hours a week in ‘‘nonessential’’ use and 2.5 hours a
week in ‘‘essential’’ use. He describes his ‘‘nonessential’’
use occurs in the following domains: pornography
(30%), music (23%), email (20%), WWW ‘‘surfing’’
(10%), file transfers (10%), newsgroups (1%), and
shopping/buying (1%). He describes that his internet
use has been associated with school problems (stating
that he was going to improve in his following semester)
but was otherwise ambiguous about the effect his
internet use has had on his academic performance. He
endorses a ‘‘slight’’ rising sense of tension before using
the internet/logging onto the internet and a relief of
this tension when he does use the internet. He is mild
to moderately distressed by the amount of time he uses
the internet but denied that this caused any significant
interference. He denies using the internet for longer
periods of time than intended; however he describes
that to cope with his use, he has instructed his
roommate to come into his room at 2:00 a.m. and
unplug the computer regardless of whether he is
online. Mr. B. describes that this ‘‘coping strategy’’
did cause him significant and disturbing increase in
tension when he was forced to log off. Mr. B. denies
that there are any stressors/triggers to using the
internet and states that it does not vary with his mood
state or drug use. According to NERDC his actual use
of the internet averaged 16.1 hr/week.
Mr. B’s clinical presentation suggests the diagnosis of
problematic internet use although collateral informa-
tion (actual academic performance, roommates experi-
ence with subjects response to having his usage
stopped, and more complete psychiatric treatment
history) would be necessary. Mr. B. has a fairly accurate
estimation of the amount of time he spends online.
Criteria A is supported by subject’s desire to use the
internet less, asking his roommate to stop his usage,
and then becoming significantly upset when forced to
log off. Criteria B is supported by subject describing
that the internet use has caused academic problems
although the exact nature of these problems is largely
unknown. Criteria C is supported by the subject
denying that his internet use varies with his mood
state or drug use but a complete treatment history
would be necessary to ascertain this criterion. Another
factor making Criteria C complex is that Mr. B.
estimates that he spends 30% of his ‘‘nonessential’’
time online viewing pornography and that he has
subthreshold exhibitionism and voyerism. With the
available data, we would provisionally diagnose Mr. B.
with problematic internet use.
CASE 3
Ms. C. is a 20-year-old female in her 4th year of
college. Psychiatric evaluation reveals alcohol abuse
with sustained partial remission. She has never taken
any psychotropic medications or received any previous
mental health treatment. She denies any family
psychiatric history.
Ms. C. began using the internet when about 10 years
old and her usage until college was always school
related. Since starting college, she has used the internet
for emailing, instant messaging, and school related
research. Ms. C estimated that she spends about 7 hr
a week in ‘‘nonessential’’ use and 1.5 hr/week in
‘‘essential’’ use. She describes her ‘‘nonessential’’ use
occurs in the following domains: email/instant messa-
ging (85%), music (10%), and games (5%). She
described that the internet was not associated with
any problems in her life. She denied any distress with
her internet use, any rising sense of tension before
using the internet/logging onto the internet, or any
stressors/triggers to use the internet. According to
NERDC her actual use of the internet averaged 24.1
hr/week.
Although Ms. C. significantly underestimates the
amount of time she spends online (suggesting using the
internet for longer periods of time than planned), she
would not meet the criteria of problematic internet use
as her internet use is not associated with distress or
impairment. It is peculiar that there is such a large
discrepancy between Ms. C.’s estimate of time online
and her actual use; however she did describe living with
two roommates who had access to her computer and
this may help account for the difference.
CONCLUSION
It is currently unknown whether problematic inter-
net use, commonly and probably erroneously called
‘‘internet addiction’’, represents symptoms of pre-
existing psychiatric illnesses. However there is some
evidence that problematic internet use cannot always
be explained by other conditions, and that like other
impulsive disorders, it can be distressing, disabling, and
quite prevalent. What the most effective treatment or
treatment strategies for this proposed entity is also
unclear. Owing to the internet’s rapidly expanding
availability, we recommend more systematic research of
the interactions between the internet and psychiatric
illness. The criteria proposed here go beyond previous
ones and should encourage diagnosis and research.
Acknowledgments. We acknowledge Richard A.
Elnicki, D.B.A. for technical assistance.
 Research Article: Problematic Internet Use: Diagnostic Criteria
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