‘Internet addiction’ is in the news this week, as the authorities in China are threatening to recognize it as a clinical syndrome. It has steadily been accruing column inches of late having received a substantial profile boost in March when Dr Jerald Block suggested in an editorial American Journal of Psychiatry that it is a ‘common disorder’ and deserving of a place in the upcoming DSM-V.

It’s telling that internet addiction disorder (IAD) was originally proposed as a joke. In 1995 New York Psychiatrist Dr Ivan Goldberg decided to parody the complexities of DSM-IV by means of a disorder of his own invention, and was surprised when his bleary-eyed colleagues stepped forward as sufferers and asked him for help. Ironically in response Goldberg set up an online internet addiction support group. This apart, he remains a less than committed advocate. Here he is, talking to the New Yorker:

IAD is a very unfortunate term. It makes it sound as if one were dealing with heroin, a truly addicting substance that can alter almost every cell in the body. To medicalize every behavior by putting it into psychiatric nomenclature is ridiculous. If you expand the concept of addiction to include everything people can overdo, then you must talk about people being addicted to books, addicted to jogging, addicted to other people.

Although the rise and rise of the World Wide Web and its possible misuse is worthy of study and debate, I disagree with the classification of internet overuse as an ‘addiction disorder’. The concept contains so many holes, you could use it to strain pasta.

In a psychiatric sense ‘addiction’ is best applied to the use of psychoactive substances where it is described in terms of dependence syndrome. In brief: in order to keep us alive, the brain has evolved reward pathways which make us feel better about fundamental things that are in our interest, such as eating and sex. The trick that drugs such as heroin pull is to reward us in the same way for an activity that has no intrinsic value. Thus, for an individual, the taking of heroin then takes on a much higher priority than other behaviours, which once had a greater value. The presence of a withdrawal syndrome is also important.

An obsession with the internet shares few characteristics with a dependence syndrome. But this is only a small part of the folly of IAD. Framing overuse of the internet as a psychiatric condition, medicalises it and leads to us thinking about its treatment in terms of psychiatric interventions where more prosaic ones might be more appropriate. Here’s Block again, pen in one hand and in this other his prescription pad and section papers.

South Korea considers Internet addiction one of its most serious public health issues. Using data from 2006, the South Korean government estimates that approximately 210,000 South Korean children (2.1%; ages 6–19) are afflicted and require treatment About 80% of those needing treatment may need psychotropic medications, and perhaps 20% to 24% require hospitalization Am J Psychiatry 165:306-307, March 2008

You can almost hear the ambulance sirens. If something is sufficiently hazardous to require 1.6% of South Korea’s population of 6-19 year olds to take psychotropic medication, surely the authorities should think about banning it? And should we believe these figures? Block cites various symposia and reports, but little in the way of peer reviewed research. Any attempt to understand the natural history of internet overuse goes unmentioned.

Some of the strongest advocates for the IAD model are involved with selling addiction treatments and so cannot be regarded as unbiased. Dr Block owns a patent on technology that can restrict computer access. If we heed their advice mental health services will again recruit mildly dysfunctional people, for whom it can offer little help. More appropriate action would require looking into why some people appear more comfortable convening with a computer screen to the expense of other arguably more wholesome activities. I would not be at all surprised if provision for alternative activities in relentlessly urban Beijing or Seoul are lacking. Or that China’s brave new world requires many families to live apart and where their only communication is via the internet. For the totalitarian minded, It’s also a useful excuse for limiting internet access.

And even if none of the above objections were valid, the internet is not simply one thing to be addicted to, but rather a portal to allow a wide range of activities. As a media it can be no more addictive than a book, or as part of the social milieu it can no more be addictive than the air to breathe. And the question must be asked of how much additional information is convey in an IAD diagnosis, when the behaviour could more usefully be described in terms of more established diagnoses.

Links

Wikipedia: Internet addiction disorder

News

The Times 11 November 2008 Internet addiction made an official disorder in China

China Daily 10 November 2008 Internet addiction ‘not just a bad habit’

BBC health 29 September 1999: Internet addicts ‘need help’

In support of IAD

Addiction Inbox: Internet addiction: A novel disease

Centre for internet addiction recovery

Criticism of IAD

PsychCentral 10 November 2008: China declares internet addiction, imprisons addicts

PsychCentral 18 March 2008: What’s that smell? Internet addiction disorder in the news

Beating stress, anxiety and depression by Jane Plant and Janet Stephenson

Previous posting on this book

This is a self help guide for people with anxiety and depression which grandly purports to offer ‘ground-breaking ways to make you feel better’. Its authors Plant, a professor in earth sciences, and Stephenson, a psychologist, have both had problems with their mental health and are keen to share their insights.

It’s a strange journey, with very broad subject matter, so much so that every chapter rightly requires a critique of its own. The book is at once curious display of scientific partisanship - once their personal stories are over, Plant and Stephenson dive into a detailed account of how mood disorders can be localized to particular parts of the brain a contentious assertion – coupled with a paean to alternative therapies. Later on, like two meddling aunts, the authors turn their attentions to UK housing policy and their dislike of ‘so called intellectuals’ who have the gall to suggest that God is a delusion.

In all this, psychiatrists are only worth consulting if they also have a qualification in neurology and are willing make available functional MRI scanning to their patients. Antidepressants are equally acceptable, but only in conjunction with laboratory tests, undertaken in private laboratories, which inform which neurotransmitters are lacking in the brain. If only clinics were so simple, and the research in this area so concrete. There are long sections on ECT and neurosurgery, the latter of which I can only imagine is included in the book specifically to scare people.

Following this mad scientist part of the book, Plant and Stephenson put on their hair shirts. There’s much talk of detoxing, which includes staying away from cut flowers, homeopathy and biofeedback, all presented as if scientific certainties rather than highly contentious and based on questionable studies. Indeed often when flicking to the references the source is not a peer-reviewed paper from a major journal, but a book, or even a newspaper article.

To be fair, there is quite a lot of sensible advice on lifestyle, and a reasonable account of psychological therapies. For a book which is somewhat hostile to conventional medicine, no consideration is given to encouraging a patient to consider their problems using a non-mental health framework. Indeed the orthodox mental health classification system is not just accepted, but expanded with an assertion that post traumatic stress disorder can be caused by a difficult relationship split. Not recommended

Book review full disclosure page

I did swear to myself recently that I wouldn’t write any more posts about celebrities and their mental health problems, but then David Duchovny started saying he’s a sex addict and I have a problem with this.

The word ‘addiction’ hasn’t an exact or agreed definition either within common or medical usage, but is normally applied to the use of psychoactive substances, and, called dependence syndrome; its use in psychiatry implies:

A cluster of psychological, behavioural and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours which once had a greater value.

For the diagnosis to be robust there needs to be accompanying evidence of difficulties in controlling behaviour despite clear evidence of consequences, and increased tolerance to the substance, a withdrawal syndrome and progressive neglect of alternative pleasures. A good example would be someone who is dependent upon alcohol; you can readily observe the effects, a complete deterioration of self control in pursuit of drunkenness, on a street near you.

An obsession with sex shares few of these characteristics, and its classification as a disorder offers a comforting cushion for those whose behaviour has landed them into trouble. With this narrative, wherein greedy behaviour is rebranded as a disorder, the afflicted can neatly sidestep responsibility and jump straight into the sick role.

Regrettably the more this line is trotted out by popular press, supported by some psychiatrist and psychologists, the more the approach is normalized and what develops is a popular narrative and language for describing behaviour in pseudo-medical terms that which would once have been viewed as an issue of self control and personal failing.

Wikipedia page

BBC Magazine - Does sex addiction exist?

Addictions.co.uk (sponsored by the Priory)