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?


I've been listening to the ... (Below threshold)

June 19, 2008 8:17 PM | Posted by Lexi: | Reply

I've been listening to the Procrastination Podcasts, from the procrastination research group in Canada . . . and the guy was talking about how use of the internet is more about inability to self regulate, and that people use the internet to avoid anxiety and they fall into a negative feedback loop-- i.e. anxiety about doing a paper, oh I'll just check my e-mail it will take five minutes, which then turns into another five minutes checking facebook etc., in turn your anxiety goes away when you are not working on that paper (or whatever).
And while he didn't state he didn't believe there was an addiction to the internet overtly, that is the overall message I came away with. That it is not an addiction, but rather the "something elses" some of which you mentioned above. He, of course has a much more detailed and thorough statement about these things than I do.

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I actually LEARN more on th... (Below threshold)

June 19, 2008 8:43 PM | Posted by Chad: | Reply

I actually LEARN more on the internet than I would from reading a book
or watching a video on a subject, then again - I learn about computer
related topics.

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Have you read <a href="http... (Below threshold)

June 19, 2008 9:44 PM | Posted by iwdw: | Reply

Have you read In the Realm of Hungry Ghosts yet by any chance? Great book about addiction and it's nature.

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I covered this here<a href=... (Below threshold)

June 19, 2008 10:49 PM | Posted by Steve : | Reply

I covered this here as well (with a response by Block)

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Sorry, I guess your html ta... (Below threshold)

June 19, 2008 10:52 PM | Posted by Steve : | Reply

Sorry, I guess your html tags don't work:


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Man, the new Monster Manual... (Below threshold)

June 19, 2008 11:58 PM | Posted by V: | Reply

Man, the new Monster Manual sucks. The races are nice, but they got rid of all of the fluff for the monsters- and while the new monster creation rules are significantly better, they're in the DMG.

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You've hit it spot on again... (Below threshold)

June 20, 2008 11:38 AM | Posted by Andrew: | Reply

You've hit it spot on again, great post and great blog. I wish people would start taking responsibility for their own actions instead of citing a disease that makes them do it. Addiction and obsession do seem to share traits, but where do we draw the line between the two? Is the physical dependence that makes an addiction? Is just really liking something and not wanting to be away from it (like I was with a few of my old ex's) considered "abnormal"? I'm not sure what the answer is, I just know that people ultimately need to be held accountable for their own actions, even when the right decisions is really really hard.

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Son everything is incorrect... (Below threshold)

June 20, 2008 2:28 PM | Posted by Diane Abus: | Reply

Son everything is incorrect except humor-

thanks for the visione of the new FSM

From the heart,Dian

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Your last few paragraphs ar... (Below threshold)

June 21, 2008 9:54 AM | Posted by Adjective: | Reply

Your last few paragraphs are the strongest- psychiatry focuses on the symptoms because it can't get at the disease, but then the symptoms soon become the disease.

But, and this is not meant to be funny, your joke about MadLibs is sadly right.

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The objection in note (2) i... (Below threshold)

June 23, 2008 4:06 AM | Posted by Anonymous: | Reply

The objection in note (2) isn't convincing. This behavior would be expected if gambling, sex, etc. light up the same reward mechanism but are simply less efficient or effective than the various chemicals of abuse.

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I read that article back wh... (Below threshold)

June 23, 2008 8:27 AM | Posted by MindDr: | Reply

I read that article back when it was first published and couldnt stop laughing. If internet addiction should be considered a new diagnosis, why not television addiction (as was already pointed out), cell phone addiction, masturbation addiction, or even car driving addiction? Addictions can (and maybe should be) an all or none phenomenon. Either they exist or they dont - you cant claim one thing can be addictive while the plethora of other behaviors are not, especially when the argument for the addictive diagnosis (Block states 1) excessive use, 2) withdrawal 3) tolerance and 4) negative repercussions) are vague and completely generalizable to all sorts of behaviors.

But let's just say, for argument's sake, Block is right in his description and justification of internet addiction as a diagnosis - how do you diagnosis something as a disorder when its an integral part of 21st Century life?

I believe that is a more potent argument against such a diagnosis - if everyone is doing it, can it really be a disorder? Psychiatric disorders, examined from its a basic component, exist outside of the norm - how then can internet addiction be a disorder if the norm is already engaging in the behavior?

The use of computers, cell phones, the internet, etc along with its components, such as email, text messaging, etc etc are a part of life in today's major cultures. We all rely on them to do our jobs, communicate, solve puzzles, etc etc. As a culture, we NEED the internet to get through our days (as sad as that may sound). We have developed into a technological society, reliant on technology to help us get our jobs done. We just cant disconnect from it - it is a part of who we are. For example, if some of society were to withdraw from using the internet, how much of our society would suffer financially? Considering financial market trends are posted online, and stock brokers rely on these trends to make decisions, stock markets around the world could suffer dramatically if the internet were to suddenly go down (or if everyone who used it were to suddently stop using it). Consequently, some people CANT withdraw from the internet - not because they just cant, but because a lot more rests of them staying connected. Its not a selfish act that they stay connected (well, maybe a little selfish if they arent sharing the information that can help make other's very happy). But that doesnt seem to be a part of Block's conception.

The internet is needed as much as air and water. Should we then suggest that air and water addiction be considered for DSM-V?

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Just personal opinion here.... (Below threshold)

June 23, 2008 9:54 AM | Posted by Jen: | Reply

Just personal opinion here...but I do suggest re-naming the DSM to The Book of Fantastikal Magickal Pixies. Until we can create a brain on our own, trust me - we know nothing of its bounds. The DSM is merely a curious collection of all things brain-related that plague mankind today. Something neat for future society to read in their downtime.

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OTOH many of the monsters h... (Below threshold)

June 23, 2008 11:56 AM | Posted, in reply to V's comment, by tanj: | Reply

OTOH many of the monsters have appeared previously and by not including extensive fluff there is more room mechanics and monsters to be covered. Considering that this new edition follows decades of previous material it is perhaps not unreasonable to assume that many players will already have fluff for certain monsters from prior Monster Manuals, Fiend Folios, Campaign Settings, etc.

While it is true that the monster creation rules are in the DMG it is also possible to view the Monster Manual as an example of monsters and abilities that can be customized to better suit your campaign.

Also, WotC has started their Creature Incarnations series that seems dedicated towards further fleshing out monsters. If their online support continues in this manner I suggest that that the new Monster Manuals would probably be best viewed as presenting ready made monsters that are best used when something quick is needed and the other materials be viewed as a better source of more fleshed out creatures more suitable to campaign building.

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I could not find this "DSM"... (Below threshold)

June 23, 2008 11:56 AM | Posted by tanj: | Reply

I could not find this "DSM" in any published materials from either WotC or TSR. Was this from a third party publisher, possibly under the D20 or OGL licenses?

This "The Book of Fantastikal Magickal Pixies" would probably make a better web supplement rather than being incorporated into the next Monster Manual. With the latest naming scheme though it would probably be a part of the Creature Incarnations series.

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Ask a 20 year crack addi... (Below threshold)

June 23, 2008 1:00 PM | Posted by Dean: | Reply

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?

When you have a cookie, and love cookies, do you move over to just eating sugar straight outta the bag?

There's also something to be said about the enormous stigma against crack that's pretty much drilled into our culture; if you're the type of person who started with cocaine, you were pretty much trained to always prefer cocaine to crack. And vice versa.

Or, long story short, your quote above seems to monstrously trivialize something that's not as one dimensional as you've made it out to be.

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This is an excellent post! ... (Below threshold)

June 27, 2008 2:52 PM | Posted by Sonya Lazarevic MD: | Reply

This is an excellent post! I love it, great writing~

there was an article several months back in the NYTimes about this very problem in Korea, how kids could not be dragged away from their computers and were sent to bootcamps to 'detox'...check out the link:


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Oh my god, it's true: I'M A... (Below threshold)

June 28, 2008 12:10 AM | Posted, in reply to MindDr's comment, by Jade: | Reply

Oh my god, it's true: I'M ADDICTED TO WATER.

I suppose an atypical antipsychotic is the first line treatment?

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When we talk about the addi... (Below threshold)

September 1, 2008 2:21 AM | Posted by Heroin Addiction: | Reply

When we talk about the additional effects of the drug itself, street heroin may have addictives that do not readily dissolve and result in clogging the blood vessels that leads to the lungs, liver, kidneys or brain. Short term Heroin Rehabilitation can also be advantageous for this addiction.


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Just saw this: <a href="... (Below threshold)

November 26, 2008 5:17 PM | Posted by Alone: | Reply

Just saw this: 90% of gaming addicts not addicted. The owner of a clinic specifically for gaming addicts says he's changing his "treatment" model, because he believes gaming addiction is not actually an addiction, but a social problem. The gaming world allows a person a whole level of acceptance, even importance, that he doesn't have in his real life. Therefore, he concludes, no "addicted" kid would ever want to stop playing games because rather than being disruptive to his life, it is his life. The only way to fix it is for is "stepping in and sometimes literally taking a child away from a computer, removing them from the game for a period of time until they become aware of their habits and begin to see there are other choices. "

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Carl Jung, a Swiss psychiat... (Below threshold)

January 22, 2009 8:26 AM | Posted by Justin: | Reply

Carl Jung, a Swiss psychiatrist, once said “every form of addiction is bad, no matter whether the narcotic is be alcohol or morphine or idealism”. I absolutely agree to that point of view. Some time ago my son played games a lot and I felt that I had to do something. Under my friend's recommendation I tried parental control software Ez Internet Timer. It allows me to limit the amount of time my kid spends on the Internet and my problem is solved. Parents should always keep their eyes wide open to prevent kids from any addiction.

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“Internet addiction” are ve... (Below threshold)

February 5, 2009 9:28 PM | Posted by Trisha: | Reply

“Internet addiction” are very similar to alcoholism and other substance abuse but there has been no comprehensive quantitative or qualitative research on this addiction. This survey is the first attempt of the researchers to identify this addiction as a distinct condition and draw attention towards this widespread problem.

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Addiction can't just blame ... (Below threshold)

February 26, 2009 10:37 AM | Posted by Bloody Ogre: | Reply

Addiction can't just blame it to games, there are several media that can be addictive, there's TV, music and real drugs (which the society hasn't eliminated successfully). There are several factors why some prefer living in the virtual world, they don't feel secure nor enjoy the reality around them. It maybe the household, friends or even the society. Sad thing the game is played the other way around. I play WoW and grind wow gold
and raid for endless hours but time to time, I make sure reality should strike my head that I have a real life to live. It was supposed to entertain you during your free time but it turned out it's becoming a problem for some. Keep enjoying the game, but live a real life

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For people who suffer with ... (Below threshold)

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July 23, 2015 5:12 PM | Posted by Oedepism: | Reply

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