By Howard J. Shaffer, Ph.D., C.A.S.
 
Dr. Shaffer is associate professor of psychology and director of the Division on Addictions at Harvard Medical School, as well as editor of the Journal of Gambling Studies.

Ever since the idea emerged that objects have the capacity to influence psychological states, the idea that almost any subjectively rewarding activity (e.g., drug use, shopping, working, running, gambling) can become the object of addiction has become increasingly popular (Shaffer 1999b, 1997).

The UCLA Internet Report (Cole et al., 2000) is one of few studies of randomly selected community samples available to illuminate the epidemiology of computer or Internet usage patterns.

However, one prospective study of Internet use examined its impact on 169 people in 73 different households during their first one to two years online (Kraut et al., 1998).

Used extensively for communication, greater Internet use in this study was associated with declines in participants' communication with family members in the household and in the size of their social circle, as well as increases in their depression and loneliness.

Nevertheless, with the exception of watching less television, new research reveals that Internet users may not be very different from their non-Internet user counterparts on a variety of important dimensions (Cole et al., 2000).

Given this conflicting evidence, more longitudinal research is necessary to understand the impact of computer technology on cognitive and emotional patterns of experience.

The growth of the Internet has been accompanied by a growing concern that excessive use is related to the development of what has been called "Internet addiction," "Internet addiction disorder" and "pathological Internet use."

People struggling with Internet addiction report a compelling need to devote significant amounts of time to checking e-mail, participating in online chat rooms or surfing the Web, even though these activities cause them to neglect family, work or school obligations.

These intemperate problems reflect a user's loss of control over Internet use, increasing involvement with the Internet and an inability to stop this involvement in spite of adverse consequences associated with such use.

Although the rate of this behavior pattern is unknown, proponents of the Internet addiction construct suggest that the problem is growing as more people have access to the Internet and its associated computer technology (Young, 1998, 1996).

Yet it has not been established whether excessive Internet or computer use causes or reflects psychopathology, nor whether it has meaningful adverse impacts on social patterns.
(For a more detailed examination of these issues, please see Shaffer et al., 2000.)

It also remains to be determined whether excessive Internet or computer use represents a source for existing family problems that previously had been attributed to other sources (Oravec, 2000).

A Plea for More Cautious Conceptual Development

Jean Rostand once said, "Nothing leads the scientist so astray as a premature truth."

Young (1996) and Young and Rogers (1998) adapted the American Psychiatric Association's criteria for pathological gambling to develop a measure for Internet addiction.

An understanding of pathological gambling is just emerging, however, and many questions remain regarding its nature relative to a panoply of comorbid psychiatric disorders (Committee on the Social and Economic Impact of Pathological Gambling and Committee on Law and Justice, 1999; Shaffer 1999a, 1999b, 1999c, 1997).

Thus, it is premature to adopt these criteria as the basis for Internet addiction guidelines.

Much remains unknown about the overlap among various mental disorders with excessive computer use.

Even if new research satisfactorily demonstrates that the prevalence of computer addiction is relatively stable and robust, epidemiologists also must establish that this phenomenon represents a unique construct.

We must ask, "When is computer addiction, computer addiction?"

For example, Blaszczynski and Steel (1998) reported that of 82 consecutive treatment seekers for gambling-related problems, 93% met diagnostic criteria for at least one personality disorder, with the average patient experiencing at least four overlapping personality disorders.

As with pathological gambling, questions about comorbid conditions and the need for exclusion criteria also exist with excessive computer use.

Young and Rogers (1998) suggested that there is a link between depression and pathological Internet use but acknowledged that it is unclear whether depression is the cause or the effect of excessive computer use.

Kraut et al. (1998) concluded that the direction of causation is more likely to run from use of the Internet to declines in social involvement and psychological well-being, rather than the reverse.

However, these results might not apply to people experiencing problems with excessive use.
A pilot study of excessive Internet users revealed a high lifetime and current prevalence of comorbid bipolar disorders, anxiety disorders, eating disorders, impulse control disorders and alcohol dependence, suggesting that excessive Internet use might be closely related to and even be an expression of these disorders (Shapira et al., 1998).

M.H. Orzack, M.D., founder and director of the computer addiction service of McLean Hospital in Belmont, Mass., reports that every patient seeking treatment evidenced at least one comorbid psychiatric disorder (personal communication, 2000).

It is possible that some cases of computer addiction will reflect a discrete and primary disorder. However, clinicians, theorists and investigators must clarify the construct validity of technology-related addictions if this idea is to survive and contribute to the field.

Failing such an advance, it is possible that scientists and clinicians will investigate and treat behavior patterns associated with depression, alcoholism, antisocial personality disorder or other disorders while thinking that they have discovered something new.

"Labeling [computer addiction] as if it were a new diagnostic entity may lead to the misdiagnosis of primary psychiatric disorders for which we have proven therapeutic interventions" (Huang and Alessi, 1997).

Reducing Human Suffering While Doing No Harm

Whether we view disordered computer use as a primary or secondary problem, this syndrome can inflict human suffering.

When clinical guidelines for treating people struggling with an addiction rest on immature and uncertain science, however, there is potential to violate the most basic principle of medical ethics: do no harm.

Without a solid empirical foundation, addiction workers -- in spite of their benevolent motivations and the need to respond to patients struggling with computer-related problems -- cannot know with certainty that they are not making matters worse.

Even in the more established field of substance abuse treatment, practice guidelines are relatively new and equivocal (Nathan, 1998). Because of these complex conceptual conditions and the absence of rigorous empirical research, practice guidelines in the area of computer addiction are premature.

Clinicians also must avoid the possibility of inadvertently doing harm because they have not established empirically supported treatments for a problem with little construct validity.

For example, if clinicians cannot distinguish primary clinical depression from the more transient depression that can follow excessive computer use that costs someone a relationship or financial gain, they might employ clinical strategies that over- or under-treat.

A myopic paradigm can encourage clinicians to miss important signs and symptoms associated with more serious disorders (Shaffer, 1994, 1987, 1986). Faced with computer addiction patients, clinicians must perform thorough diagnostic evaluations and determine the extent of comorbid conditions.

To date, most computer addiction clinicians have adopted strategies from traditional drug and alcohol addiction treatments. However, many of these approaches have little empirical evidence to support their clinical utility (Miller et al., 1995). Consequently, I encourage clinical workers to proceed cautiously.

Conclusions: Considering Treatment

There is no simple solution to the matter of what constitutes an addiction. For computer addiction to find a legitimate home in the psychiatric nomenclature, clinicians will need to view it as the consequence of overwhelming and uncontrollable impulses, compromised bio-behavioral regulatory mechanisms or a combination of both.

Anything less leaves observers to think that it is simply the result of an unwillingness of certain people to control their "habits" for uncertain reasons.

Despite this critical view, people who believe they are suffering from an uncontrollable impulse to use their computers are beginning to seek treatment.

Human suffering deserves our attention and response. Therefore, the clinical issue -- as opposed to the scientific and conceptual debate -- is not whether computer addiction is real or primary.

Rather, it involves establishing a working formulation that clinicians and patients can share (Perry et al., 1987; Shaffer, 1986). Such devices permit clinicians to select treatment methods that offer patients a favorable prognosis given knowledge of the problem and the patient.

For science, the value of improving our understanding of computer addiction rests in the development of better theory. Improved theory can guide better research, which in turn will improve our understanding.

As our understanding of addiction improves, then the vehicle for more effective social policy emerges. From the treatment side, there is little or no value to understanding any individual as addicted or mentally disordered unless it permits clinicians to choose a treatment plan that will maximize the well-being of the patient.

The value of the concept of computer addiction or the classification of any addictive behavior, then, is dependent upon the extent to which an individual sufferer benefits from its application.

While the art and science of diagnosis is dependent upon comparisons among groups, clinicians should apply their choice of treatments prescriptively.

Prescriptive or differential treatment requires consideration of three interactive domains: 1) the physician (e.g., medical management strategy); 2) the patient (e.g., compliance rules and expectations of care and concern); and 3) society (e.g., social mores and attributions of responsibility).

Together these domains define the "sickness" that is to be treated (Kleinman, 1988). The relationship between computer use and addiction ultimately rests upon sociocultural acceptability.

After all, "It is best to think of any affliction -- a disease, a disability -- as a text and of 'society' as its author" (Blum, 1985).

Acknowledgements and References -
see original article: Psychiatric Times April 01, 2002