In 1995, I noticed that I was spending more and more time playing solitaire on my computer. I was trying to learn a new computer program and was very frustrated by it. My anger and inability to decipher the manuals led me to escape to solitaire. I became aware that I started my game program at an earlier time each evening, and at times I would avoid my primary reasons for using the computer. I was not alone.

Some of my patients told me about their computer use and how they were unable to stop spending time online or arranging electronic files.

I decided that these patterns might indicate a form of dysfunctional behavior associated with a new technology, and was worth investigating. I found support for my idea from colleagues, friends and reports in the media (Murray, 1996). As a trained cognitive behavior therapist, I often treat gamblers, alcoholics and people with obsessive-compulsive disorder, and have also studied mood changes resulting from the recreational use of psychotropic medication. I concluded that this inappropriate and excessive use of the computer might be a distinct disorder (Orzack et al., 1988).

This behavior has variously been called Internet addiction, pathological Internet use, problematic Internet use, and a mere symptom of other disorders. I am often asked why I call it computer addiction. I was not the first to use this term. Shotton (1989) coined the term in her book Computer Addiction. After searching the literature about alcoholism, gambling and other addictive behaviors, Shotton decided that she was witnessing computer addiction in a very specialized group of men who were developing hardware and software for computers. According to Shotton, these men were completely focused on their activities in the laboratory to the point of neglecting both family and friends.

The information superhighway did not exist when Shotton wrote her book. Few ordinary citizens outside of academia, the military and the computer industry had their own PCs, and fewer still had access to the Internet. Since then we have moved into the Information Age. The computer industry is now the fastest growing industry in the world. In 1997, the population of Internet users in the United States was estimated at 50 million to 80 million, and is projected to increase to 150 million to 200 million by the year 2000 (Pohly, 1995).

Any new technology requires a shakedown period in which the flaws and its effects on both society and individuals become evident. This is also true of the computer. As this rapidly evolving technology develops, so do the opportunities for negative consequences from its use. It is for these reasons that we must examine the phenomenon.

No epidemiological studies on computer addiction have been done. There have been online studies (Brenner, 1997; Young, 1998) and targeted group studies (Anderson, 1998; Scherer, 1997; Shotton, 1989), but to my knowledge no one has either interviewed a randomized sample of people about their computer use or recorded usage directly.

We have no idea what levels or kinds of computer usage are “normal.” Therefore, we cannot state which behavior is always pathological. There have been heated and contentious arguments about these issues in an online forum devoted to research on the Internet (see http://www.cmhc.com/mlists). Discussions include topics such as the validity of scales to measure Internet addiction, with exact indicators defining a pathological or addictive behavior.

What is it about using computers that makes some people behave in ways in which they would not ordinarily? Is it the technology itself, or is it the way people interact with that technology? Is the behavior pathological or creative? Why are some people so connected to life on the screen that they have difficulty coming back to reality? Who are the people who act this way, and if they come to your office for help, how do you treat them?

Signs and Symptoms

Based on contact with my own patients, numerous requests for referrals from other therapists, and many online requests for help (see table), I have designed a behavior list based on an impulse control model very similar to one used for gambling. These are the signs and symptoms of computer addiction, or, as I now prefer to call it, impulse-control disorder, not otherwise specified. I make no other claim for the validity of this diagnostic paradigm, since it is based on a highly selected population.

Tolerance, withdrawal and compulsive use are requisites for any diagnosis of dependency (American Psychiatric Association, 1994). Psychological tolerance is indicated by the need to spend increasing amounts of time on computer activities such as playing games, arranging files or participating in online discussion groups. Even though computer users are aware of problem behavior, they continue to use the computer compulsively. They often blame others for the problem. Withdrawal symptoms are indicated by an increase in irritability and anxiety when a person is unable to access a computer. Even though one investigator (Anderson, 1998) used a three-day abstinence as an indicator of problems, at least one patient has said that it is a matter of only hours before he starts to feel irritable, depressed or anxious.

The physical symptoms associated with computer addiction can have serious consequences. For instance, resulting carpal tunnel syndrome often requires months of care and may result in surgery. Eating habits change so that some people eat while at the computer and never exercise. Others may skip meals altogether. One patient has told me that she sometimes does not get to the bathroom in time. Failure to blink can cause migraines. Optometrists and ophthalmologists often prescribe special lenses for computer use because patients spend so much time looking at the screen.

The following cases illustrate the signs and symptoms described above:

Patient A, a recovering substance abuser, stated that she craved participating in an online chat and that she returned to it at earlier and earlier hours each day. She had such an intense relationship with a cyber friend that she lost her sobriety when that person suddenly disappeared from her screen.

Patient B also has a history of substance abuse, and compared his feelings when he was on a chat line to an amphetamine high.

Patient C said he feels an intense power and excitement when he plays interactive power games.

Patient D turned to a computer game for comfort after she wrecked her car.

A therapist who treats paraphilias tells me that a good proportion of his patients download pornography at their workplaces as well as at home (Kafka, personal communication, 1998). Other technologies have been considered addictive, including the telephone, television, pinball machines and video games. All these activities initially provide positive rewards for their use. Once someone is addicted to a behavior, however, the positive rewards are diminished. Gambling, for example, requires an early win to catch the player. Without a win, the gambler will leave in frustration. If the gambler wins and then loses, he or she will continue to play, taking more risks by raising the ante. The gambler chases losses by expecting to win on the next play.

For the Web surfer, satisfaction must come early, or the user will leave the site. Web pages are aptly named because of the many links attracting the computer user to new experiences, causing him or her to lose track of time. Patient D, who complained about the amount of time she spent online, said she could not leave the Web because the next connection might be just what she was looking for.

Socialization Online

The newest lure is Internet gambling. Shaffer (1996) points out that it is not the addictive quality of the games or program, but rather their capacity to influence the human experience that is the important element to be studied.

Buzzell (1997), who describes the effects in some children who have had seizures watching a TV screen, asks whether the same effect might occur in children who play computer games by the hour. Eastman (1998) goes even further, suggesting that the activity of watching a screen may be hypnotic, and may therefore contribute to the addictive process by maintaining the exposure for longer time periods.

What is it that makes participation in activities like MUD (multi-user domains), Internet relay chat groups, Internet support groups and surfing the Web so compelling? It is a combination of factors which are balanced in nondependent individuals who can surf the Net, enter data, play games or engage in an online forum without it interfering with their other real life obligations. Those who cannot do this can be classified as dependent or addicted.

In the online world, people can become anyone they wish to be. Furthermore, they believe that they are part of a group. Being part of a MUD allows a participant to play a prescribed role that would be impossible in real life. As an example, a young patient fell asleep in class from staying up at night for hours directing a power game.

In addition to the actual activity there is a social connection with other players, which is highly reinforcing. Another patient, in recovery from several problems, described the sense of belonging he feels at a poker table. It is this same sense of belonging that I have heard expressed by people who belong to chat groups. A depressed patient continues to participate in chat groups even though she has had several traumatic experiences with men she arranged to meet offline.

One of the dormitory counselors at a major university reported that sports gambling on the Internet is a very popular group activity. Although gambling on the Internet is illegal in the United States, it thrives because it is hosted on offshore sites over which the U.S. has no regulatory authority. The other highly controversial topic is the number of sex and pornography sites that exist directly on the Internet and on CD-ROMs. How to regulate this is a subject of concern to many people.

Another view of computer addiction suggests that excessive and inappropriate computer use is a new symptom of other psychiatric problems. Shapira (1998) found that 14 self-selected Internet users who had problematic Internet use fit the DSM-IV criteria for a mean of five different psychiatric disorders. This data may suggest that this technology presents a new way to express affect.

One final consideration is treatment of this addiction. Whether or not this addiction is similar to substance dependency, impulse control disorder or a symptom of other disorders, its treatment cannot require abstinence. Computers are present in workplaces, schools, universities and households. Treatment must be similar to that given for an eating disorder where the aim is to help the patient normalize their behavior in order to survive. A combination of cognitive behavior therapy and motivational interviewing are the most helpful to the patient. Treating the depression and anxiety with antidepressants is also recommended. Shapira (1998) has had excellent results in prescribing serotonin reuptake inhibitors or other antidepressants for his patients.

Computer addiction is a combination of signs and symptoms that fit a dependency model, an impulse control disorder model, and are often comorbid with other psychiatric diagnoses. The treatment, therefore, must be for all three classifications. My hope is that an epidemiological study can be done which will define the limits of normal computer usage. Then we can decide what is pathological.

References

American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association, pp 175-181.

Anderson K (1998), Internet dependency among college students: should we be concerned? Presented at Amer College Personnel Association. March; St Louis, Mo.

Brenner V (1997), Psychology of computer use: XLVII. Parameters of Internet use, abuse, and addiction: The first 90 days of the Internet Usage Survey. Psychological Reports 80(3 Pt 1):879-882.

Buzzell KA (1997), The Human Brain and The Influences of Television Viewing. An Inquiry Into Meaning in the Post-Quantum World. Denmark, Maine: Cardinal Printing Company.

Eastman G (1998), The effect of electronic imaging on our experience of reality. Unpublished paper presented at Eastern Psychology Association meeting. February; Boston.

Murray JB (1996), Computer addictions entangle students. APA Monitor 27(6):38-39.

Orzack MH, Friedman L, Dessain E et al. (1998), Comparative study of the abuse liability of alprazolam, lorazepam, diazepam, methaqualone, and placebo. Int J Addict 23(5):449-467.

Maressa Hecht Orzack, Ph.D
Dr. Orzack is the founder and coordinator of computer addiction services at McLean Hospital where she is a senior attending psychologist. She is also a lecturer in psychology at Harvard Medical School.