Isabel Willemse, a psychologist from Zurich, reported from her practical everyday life on the phenomenon of online addiction. In addition to diagnostic criteria, she presented possible treatment options for this mental illness, which is still quite new compared to other addictions.
“Behavioral addiction is a term for excessive behaviors that exhibit characteristics of psychological dependence and can no longer be fully controlled voluntarily by those affected” [1] with this quote Isabel Willemse, psychologist from the Institute of Applied Psychology, Zurich, introduced her lecture on the topic of online addiction. Such excessive behaviors or substance-unrelated addictions are typically known in mental health care through gambling addiction. In the context of the Internet and online networking, which have become increasingly essential in recent decades, they now also account for a certain proportion of behavioral addiction patients in practice in the form of online addiction.
The socially conveyed feeling of the necessity of constant digital availability could give the impression that the online addiction segment affects an exponentially large proportion of patients. In the statistical analysis, however, it becomes clear that the number is generally rather overestimated, according to speaker Willemse. According to a Europe-wide study, only 1.2% of young people aged 14-17 show pathological Internet addiction behavior. However, an additional 12.7% of these adolescents are at increased risk for Internet addictive behaviors [2].
Diagnosis
The danger of slipping into pathological addictive behavior when using Internet-based applications exists more in the case of offers that have a strongly binding character. The motivation for further engagement with the topic must be great, as with online communication (e.g. chat), Internet pornography, but also online gaming. Currently, there are no well-defined diagnostic criteria regarding online addiction. In the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), only Internet Gaming Disorder is mentioned as an online-based disorder. The diagnostic criteria listed are not about an absolute number of hours spent “gaming,” but about the impact this has on the individual. Five of the following nine criteria must be met over the period of one year to confirm suspicion of computer game addiction: mental capture, withdrawal symptoms, tolerance development, loss of control, continuation despite negative consequences, behavioral capture, dysfunctional stress management, dissimulation/deception, endangerment, and losses. Because adolescents have a greater potential for change in a shorter period of time compared with adults, reducing the diagnostic period for this group to three months is being discussed, Willemse said. Ultimately, Internet Gaming Disorder is not a formal diagnosis in the DSM-5, but is listed as a topic where further research is recommended. In practice, the aforementioned criteria of Internet Gaming Disorder translate well to the more general term of online addiction or pathological Internet use, according to Isabel Willemse, so that a diagnosis can be made that does not yet exist in the official manual. The need for this approach reflects the ongoing divergence on the nosological classification of online addiction in research circles and the need for scientific work in this topic area. Formal diagnostic manuals still seem to lag behind real-world developments here.
Risk factors
Three categories were mentioned in the presentation as risk factors for the development of Internet addiction [4]:
- personal factors
- media-related factors and
- environmental factors.
Using the example of a teenager who formerly played one of the best-known “massively multiplayer online role-playing games” – World of Warcraft (WOW) – excessively for years, Isabel Willemse explains the personal factors. As a teenager, Julia was subjected to enormous psychological stress with a bullying experience. A sense of shame prevented opening up to close people, so loneliness developed, an escape behavior into the WOW reality developed. Often, those affected tend to have anxious personalities with low self-esteem, a low stress tolerance, a tendency to depressive thoughts, but also experiences of loss can promote behavioral addiction. If environmental factors cannot provide good compensation or support, or if there is even further potential for conflict in these areas, these are additional risk factors for the development of an online addiction. This refers to the family environment (including parents as role models), the personal environment (peers) and the educational institution or workplace. Conflict-related environmental factors can be both a trigger and a consequence of the behavioral addiction in this topic and maintain it in the sense of a vicious circle.
Last but not least, media-related factors are also crucial for the development of behavioral addiction. Often a reward system is found that acts as an addiction reinforcer and becomes more and more difficult to “crack” as it progresses. Internet-based functions also exhibit boundlessness in terms of time, they are always accessible; Internet-based games know no night or rest times. Very important and motivational basis for the pathological behavior is the possibility of escaping reality, what is missing in reality can be made up for online. Identities can be played with, there is a potential for development on a safe level, likewise controlled communication can take place and social cohesion can be built. Julia describes this as, “I was missing something that I found in WOW…WOW gave my life meaning, gave me joy, in the game I was respected, I was somebody.”
Intervention/Therapy
As a therapeutic basis Isabel Willemse recommends a systematic approach according to F. Eidenbenz. In this model, the therapy sessions are divided into the initial phase with problem analysis, the motivation phase with filtering out the maintaining structures, the deepening phase with deeper exploration, and the stabilization or final phase. The phases each consist of about three to eight sessions and cover an approximate period of 6-18 months [3]. The goal is to break the vicious cycle of isolation/frustration and escape behavior into a virtual reality that perpetuates real isolation. In terms of behavioral therapy, various intervention models are available for this purpose. In addition to becoming aware of the extent of Internet use through use diaries and psychoeducation, Isabel Willemse points above all to the role of motivation in the treatment regime. In the process, the motivational basis that contributed to the maintenance of the addictive behavior can be taken and transformed into new real-life goals. In addition, social contacts should be consciously reactivated and alternative leisure time activities implemented. Exposure training with ritual goodbyes to the online identity or account can also be helpful.
If caregivers privately suspect the presence of online addiction, questionnaires such as the Compulsive Internet Usage Scale (CIUS) can help to gain a more objective impression. Possible points of contact include schools, the Office for Youth and Vocational Guidance or child and adolescent psychiatry. Going cold turkey is often difficult to do at home, since strong emotional reactions are to be expected and Internet use cannot realistically be completely eliminated from everyday life. The example of Julia, however, makes it clear that with professional help, the topic of Internet/computer game addiction no longer has to dominate one’s life.
Ultimately, the aim is to enable those affected to learn to appreciate the uniqueness of reality again, which cannot be replaced virtually in this way.
Source: FomF Psychiatry and Psychotherapy Update Refresher, May 18-20, Zurich.
Literature:
- Grüsser SM, Thalemann R: Computer game addiction? Advice and help for parents. Verlag Huber 2006, Edition: 1.
- Dreier M, et al: Study on Internet addiction behavior of European adolescents. EU NET ADB Consortium 2013.
- Eidenbenz F: Therapy of online addiction – systemic phase model. Psychotherapy Science 2013; 2: 81-89.
- Willemse I: Onlinesucht – Ein Ratgeber für Eltern, Betroffene und ihr Umfeld. Hogrefe 2016, Bern.
InFo NEUROLOGY & PSYCHIATRY 2017; 15(4): 36-37.
