Human in the web
Internet addiction and its comorbidities
by Julia Weiler
October 1, 2014
Chatting via WhatsApp rather than meeting friends in real life, sharing holiday photos on Facebook rather than showing them in person, playing video games rather than going out. Digital media play an important role in our everyday lives. Some people spend an excessive amount of time online, and they are unable to break free. PD Dr med. Bert te Wildt studies this phenomenon at the Ruhr-Universität’s LWL Clinic for Psychosomatic Medicine and Psychotherapy.
It is estimated that one per cent of all Germans between 14 and 64 years suffer from Pathological Internet Use (PIU) – that is more than half a million people. In the age bracket of 14 to 16, it is as much as four per cent, according to a study commissioned by the Ministry of Health. Most of the affected individuals excessively play video games online, often more than five hours a day; others are addicted to cybersex or spend all day with social media.
PD Dr Bert te Wildt in his office at the LWL clinic for psychosomatic medicine and psychotherapy © RUBIN, photo: Nelle
Dr Bert te Wildt (fig. 1) deals approximately three quarters of his workdays in the clinic with PIU patients. Three to five PIU patients per week seek help at the LWL clinic. “Most patients are young men, who have been excessively exposed to the Internet and video games growing up,” says Dr te Wildt. “The adolescents are overwhelmed by the increasing demands regarding their performance and autonomy that society piles on them. In cyberspace, they are playing the dashing heroes.” Just like in case of substance abuse, PIU patients get caught up in the vicious circle of addiction. “Eventually, the virtual world is the only place where positive experiences are possible,” says te Wildt. One of the aspects he researches at RUB’s LWL university clinic is the way media addiction correlates with other disorders.
For this purpose, he and his team recorded concomitant disorders that affect PIU patients, thus compiling a so-called comorbidity profile. To this end, the researchers invited 25 patients to take part in structured clinical interviews that are specifically designed to diagnose mental disorders. All tested CIU sufferers presented at least one concomitant disorder. Seventy per cent of them suffered from depressive disorders. Other disorders included anxiety, especially social phobias, and attention deficit hyperactivity disorder/hyperkinetic disorder, ADHS for short.
The researchers studied the comorbidity profile of alcohol addicts for comparison. It turned out to be quite similar (fig. 2): depressive disorders, anxiety disorders and ADHS. Unlike CIU patients, however, only every second alcohol addict suffers from a concomitant disorder. “The results highlight the great significance of comorbidity in compulsive Internet use,” concludes Bert te Wildt. The question remains if CIU was there first or if it is a side effect of another disorder. “This is not a one-way street,” says Dr te Wildt. “These two factors interact.”
Internet addicts almost always suffer from a concomitant mental condition; more often than not, the concomitant condition is a depressive disorder. Alcohol addicts present the same concomitant conditions, but only 50 per cent of all patients are affected. © RUBIN, graphics: VISUELL Marketing
There is evidence that certain personality structures encourage a CIU disorder. Using standardised psychological tests, Bert te Wildt and his colleagues determined the personality traits and disorders of 30 adult CIU patients. Thirty-three per cent of the participants presented an avoidant/anxiety personality disorder; they have feelings of inadequacy, are anxious in interaction with others and withdraw from society. Twenty-seven per cent suffered from a depressive personality disorder, 13 per cent from an addictive disorder with separation anxiety. Another 13 per cent presented a negativistic traits, i.e. they offer passive resistance to demands in the social and professional context, they often feel misunderstood and unfairly treated. Accordingly, Internet addiction frequently goes hand in hand with depressive and anxiety symptoms. In a number of patients, CIU can thus be traced back to similar personality disorders, was te Wildt’s conclusion.
Together with his team, he examined if PIU occurs as concomitant disorder in other patient groups. To this end, the researchers interviewed patients suffering from ADHS and depressive disorders. In both groups, 24 per cent of all participants turned out to suffer from Internet addiction; neither the patients nor the therapists who treated them had been aware of this fact. “This evidence indicates that PIU frequently remains undetected,” says te Wildt. Data compiled in a study with individuals who played first-person shooter games at least four hours a day for two years likewise indicate that many cases go unreported. Almost 50 per cent of the young men examined in the course of this study met the criteria of computer game addiction, without ever having been mentally ill before.
Online gaming addiction is the most frequent media addiction. First-person shooters are particularly popular: games in which the user experiences the world through a first-person perspective. © RUBIN, photo: Nelle
Bert te Wildt made the diagnosis using criteria set forth by the “Fachverband für Medienabhängigkeit” (association for media addiction). Today, the “American Psychiatric Association” has included Internet gaming disorder as a condition to be further studied into the standard diagnostic manual “DSM” (Diagnostic and Statistical Manual of Mental Disorders). However, no universal criteria have as yet been established for a general Internet addiction resp. its subtypes. Nor does a specific therapy exist the effectiveness of which has been scientifically substantiated. In practice, the same behavioural-therapy techniques are applied that have proved efficient in the treatment of other addictions.
“However, the treatment of CIU patients does not begin and end with getting rid of addictive behaviour,” points out Bert te Wildt. “Successful escape from addiction in cyberspace in the long run is only possible if patients discover alternative spheres in which they can gain positive experiences and succeed in the real world.”
At the media outpatient clinic run by the LWL University Clinic for Psychosomatic Medicine and Psychotherapy, patients initially take part in group therapy sessions, which focus on reducing or stopping addictive behaviour and to open up new spheres for them to operate in. The first withdrawal phase aims at achieving real behavioural changes. In the long term, patients typically require continuous psychotherapy which focuses on the underlying psychopathology, counteracts addiction displacement and sustainably improves the quality of life. Here, psychodynamic psychotherapy approaches are applied.
The media outpatient clinic will be utilizing computers and the Internet itself in its future therapy programmes. Counterproductive? “Pitting negative and positive effects of new digital media against each other is not very helpful,” says Bert te Wildt. “We want to meet people in the sphere where they spend most of their life, namely on the Internet. Our aim is to apply an integrative approach in order to steer new ground-breaking technologies into a direction where they will be of use to people, and not vice versa.”
Diagnostic criteria for Internet addiction
Pre-occupation. A strong desire for the internet. Thinking about previous online activity or anticipation of the next online session. Internet use is the dominant activity in daily life.
Withdrawal. Manifested by a dysphoric mood, anxiety, irritability and boredom after several days without Internet activity.
Tolerance. A marked increase in Internet use required to achieve satisfaction.
Difficult to control. Persistent desire and/or unsuccessful attempts to control, cut back or discontinue Internet use.
Disregard of harmful consequences. Continued excessive use of Internet despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by Internet use.
Social communications and interests are lost. Loss of interests, previous hobbies, entertainment as a direct result of, and with the exception of, Internet use.
Alleviation of negative emotions. Uses the Internet to escape or relieve a dysphoric mood (e.g. feelings of helplessness, guilt, anxiety).
Hiding from friends and relatives. Deception of family members, therapist and others about the actual cost/time of Internet involvement.
Risk/lose relationships/opportunities. The gamer has risked or lost significant relationships, career opportunities, or jobs, or jeopardised his future in some other way.
(cf. Tao R, Huang X, Wang J, Zhang H, Zhang Y, Li M (2010). Proposed diagnostic criteria for internet addiction. Addiction 105(3): 556-64)