In 1995, Ivan Goldberg, a New York psychiatrist, published one of the first diagnostic tests for Internet Addiction Disorder. The criteria appeared on psycom.net, a psychiatry bulletin board, and began with an air of earnest authenticity: “A maladaptive pattern of Internet use, leading to clinically significant impairment or distress as manifested by three (or more) of the following.”
The test listed seven symptoms. You might have a problem if you were online “for longer periods of time than was intended,” or if you made “unsuccessful efforts to cut down or control Internet use.”
Hundreds of people heard of the diagnostic test, logged on, clicked through and diagnosed themselves as being Internet addicts.
Goldberg’s test, however, was a parody of the rigid language in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the American Psychiatric Association (APA)’s psychiatric research manual. In a New Yorker story in January 1997, Goldberg said having an Internet addiction support group made “about as much sense as having a support group for coughers.”
I’ve been researching the science and controversy over the last five years and wrote a long story about it last year for The Caravan. Since Goldberg’s prank, about one hundred scientific journals in psychology, sociology, neuroscience, anthropology, healthy policy and computer science have taken up the addiction question in some form. And after two decades of ridicule, research, advocacy and pushbacks, the debate is still about four basic questions. What do you call it? Does the ‘it’ exist? How do we size up such an addiction? Does it matter?
First, what do you call it? Addictive, maladaptive, pathological or excessive use? Internet addiction disorder, problematic Internet use or perhaps the title suggested in the DSM-5 in a new section of conditions that need further research: Internet Gaming Disorder. And for that matter, must the condition involve certain types of software, such as video games or social media, or certain types hardware, such as mobile phones or laptops?
Then, does the ‘it’ exist? Trying to find how many people have any medical condition is hard. Behavior is worse, and there’s no diagnostic standard. Researchers have used at least 18 different Internet addiction tests across the world. Sampling bias also complicates any measure. For instance, the accuracy of sampling depends on how much of a population actually has access to the web, and how often. That’s one reason why prevalence varies between less than 1 percent to over 8 percent in the United States. Norway clocks in at 2 percent; Poland at 5.8 percent; England at 18.3 percent; Italy at 5.4 percent; and in China and Korea, anywhere from 2 percent to over 35 percent among adolescents.
Then, how do we size up such an addiction? One way is to look at chemistry and the brain’s wiring. Drugs and behaviors are viewed as triggers for the same chemical changes in the brain. Researchers are also testing substance-abuse treatment drugs in experimental trials for Internet addiction and gambling. And the DSM-5 has a new behavioral addictions category, of which gambling is now a part, moved from its past classification as an “impulse-control disorder.” The APA has thus hinted that behaviors can be addictive in medical-speak.
Another way to look at addictions, however, is to look at the symptoms and consequences. You could diagnose addictions differently—alcohol, Internet gaming, etc.—or you could call them patients of a single condition: an addiction syndrome. Each overdose is viewed as a manifestation of this syndrome, driven by circumstance and inherent traits. The syndrome model buckets addictions into one category with a set of symptoms and a spectrum of severity. More than a habit, it’s the consequence that defines the addiction.
A third way is to rethink an addiction like Internet gaming as the development of a new worldview. An addiction often starts off as an innocuous experience. The experience triggers a series of pleasurable feelings but it also plants a series of memories. Taken to an extreme, what an addict wants is the recreation of the memory, an alternate reality. To simply abstain from whatever it is that is addictive is to deny a worldview. The body serves as a medium for the known route (the drug or behavior) that is the ticket to the desired world (the alternate reality). Of course, there are very real chemical changes that happen in an addict’s brain. But this alternate way of looking at addiction illustrates that it is a process, not a condition, and that circumstance influences chemistry.
And thus, the final question: Who decides what matters?
Over 400 years ago to be addicted was to simply have a strong inclination toward substances or behaviors. It was a choice. But over time, addictions started to mean inclinations that were less about choice and more about lack of control. Deviance then became a problem that could be fixed through religious discourse, medicine and social pressures. Today, there’s a psychiatric manual.
The DSM wields power. It’s gone from a 130-page manual in 1952 to a 900-page bestseller that competed with J. K. Rowling and Dan Brown on Amazon’s top-selling of 2013 before settling in at #12. The book is used as a treatment guide for picking out the right mental condition, providing the basis for insurance claims. A line item on the DSM offers legitimacy and support for future research on conditions like behavioral addictions. It makes it okay to talk about in public. But that legitimacy also gives the diagnosis a disease-like quality, a one-size-fits-all way to explain away a patient’s symptoms. As some researchers remarked in a critique of the DSM , “Context, history and politics are regarded as non-essential and somehow external to the disease.”
The despair among families going through a perceived addiction to technology is palpable. But what’s to be done with an agony you’re not sure you should feel? The agonies of an established illness like alcohol addiction are well known – the looming grief or helplessness, a steady sinking into a deep and widening chasm. Those feelings are acknowledged and shared. But what about those who seem to have an unlisted addiction, like excessive gaming? Is that even a thing? To make any headway, the task is not only one of specifics, like finding a name and methodology everyone can agree on, but of a broader, more important need to revisit the very idea of an addiction.