June 19, 2008

Internet Addiction Belongs In The DSM-V

Agreed.  And then let's rename the DSM The Book of Fantastikal Magickal Pixies and incorporate it into the Monster Manual.   And let Mad Libs publish the assessment tools.

Jerald Block has an editorial in the American Journal of Psychiatry, in which he explains why he believes Internet Addiction should be considered a psychiatric disorder.

His reasons include the usual: excessive use, withdrawal (anger, irritability), tolerance (need for more or better), and negative impact on life.

The debate as to whether or not this belongs in the DSM or not entirely misses the most obvious point:  no one is addicted to the internet.  Ever.

Don't scoff.  Let's log on together.

Let's say you are "addicted" to World of Warcraft.  A new game comes out, called Universe of Ninja Piratesses, and you move over to that.  Guess what?  You weren't addicted to WoW or UoNP, but to multiplayer role playing games.  You can follow this logic all the way out to: it wasn't the internet you were addicted to, but something else.

I don't have the data in front of me, but in a study I just made up 0% of porn website "abusers" were at least partially satiated when offered Marthastewart.com.  Withdrawal symptoms were actually worsened.  Three people punched their computers (two in the monitor, one in the graphics card.) 

Ask a 20 year crack addict when was the last time they used powder cocaine.  Do they miss it?  Are they in withdrawal?  "But crack is cocaine."  No, it isn't, or else they would be using both, wouldn't they?  "But crack is more potent and addictive."  Then why don't cocaine adicts move over to crack? 

Do you know how many Xanax addicts I've had throw back at me a prescription for Klonopin? It wasn't availability, I was giving it to them, they had it in their hands, and they refused it.  In theory it should have been "good enough."  It wasn't. 

By age 25, every guy has been with a girl that-- sorry, let me start over--

By age 25, every guy that has been with a girl has been with a girl that they couldn't get enough of, couldn't live without, called all the time, left school work undone, called into work sick, code-named "Freebird" in a journal entry,  etc, etc-- but the relationship sucked, this girl was so evil that all his friends wanted to hit him with a sack of doorknobs.  Was he addicted to her?  Technically, yes-- but really, no.  More to the point: she wasn't actually evil, and he wasn't addicted to her, at all.  (I mean, now that you're 40, you see that, right?)

"Yes, but there's a common addiction pathway..."  Oh, I don't know.  If this was true, chemical addicts would have generally substitutable addictions, and they don't.  Experiments with mice strongly support the idea of substitution  (e.g. cocaine addicted mice will thirstily self-administer amphetamine)  but humans don't really do this.  (1)  And chemical addicts should also have very high rates of other (non-chemical) addictions as well, and they don't. (2)

These non-chemical, behavioral addictions are more properly labeled obsessions but-- and this is the point-- an obsession is not a disorder.  Obsessions can cause harm, we can try to help people with them, but they are not themselves the problem, they are symptoms of something else.

That something else may not be a disorder, either: fragile self; guilt or shame; low or high self esteem; flawed but automatic assumptions, whatever-- but trying to "treat" internet addiction without addressing the underlying problem is like treating cancer with Tylenol.  Not only does it not help, it actually makes the situation worse.

Dr. Block's intention was to describe a series of behaviors, not to create a new disease.  He's already established believer in the positive power of the net, online games, etc.  Unfortunately, psychiatrists will only see this editorial, and come to the wrong conclusions.

In the article he cites research from South Korea, where the average kid (supposedly) uses the internet 23 hours a week, and thus is at risk for addiction.  Compare that to the U.S. 20 years ago, where the concern was 20+ hours of TV a week.  I do not recall discussion about kids becoming addicted to TV; we worried they were becoming stupid.  What's changed isn't the medium or the amount of time on it, or the harm to the intellect or society; what's changed is the social movement to pathologize, rather than condemn, behaviors.

I'm not saying let's go back to condemnation, but to put "Internet Addiction" into the DSM legitimizes the symptom-is-disease approach that has caused such great difficulty for patients, and nearly irreparable harm to humanity.


(1) Please do not say the words "dopamine" and "nucleus accumbens" anywhere near me, I still have my old sack of doorknobs.  These explanations could not be more general and useless.  Using those two in support of a common addiction pathway is like involving "gasoline" and "spoons" in the diathesis for serial rapes.  Even though these are involved in various "addictions"-- cocaine, alcohol, internet, sex-- these "addictions" and their associated behaviors are so disparate that the pathway serves no useful clinical target.  Haldol blocks dopamine in the nucleus accumbens, but you can't cure alcoholism with it, can you? 

I'm not denying that such a pathway exists, I'm doubting the utility of this information, even if true.  Call me when science catches up to your lies.

(2) Here's an example: why do so "sex addicts" or gamblers have such high rates of drug abuse, but the converse is not true?