One Mother's Story

Looking at my last post, asking for your opinions on Internet addiction, I heard from one mother today. She worked in Public Health and had gone to three different psychologists to get her son help for his addiction to World of Warcraft. Known to players as WoW, she compared his addiction to heroin and described her son's state when he came home from college in vivid detail. “He came home from his first year of college. He was thin, emaciated, like a stick, like he hadn’t eaten in months. His skin was pasty and white. He was hairy, hadn’t had a hair cut in forever. His eyes were blood shot from lack of sleep. Our son was a good-looking, muscular guy who used to like being active. Now he is this zombie doing nothing else by staring at the computer. Now he wants to quit school. His father and I just don’t know what to do.”

Parents are looking for help for online gaming addiction. The Online Gamers Anonymous site was started by a mother whose son became addicted to EverQuest, subsequently committing suicide in front of the computer.

Managing online gaming for a son or daughter is difficult. Parents need to watch for signs. Much of my posting focuses on the person dealing with the addiction but we see that not only do the addicts suffer but so do family members.

Is Internet addiction real? Your Opinion

I enclosed an article published in 2000 entitled, "Is Internet Addiction Real?" Some of the point is that it shows where we as a mental health field were at that point in time. We were asking the question as this concept was so new and still evolving. Today, we do have more research, more findings, and more clinical treatment settings devoted to Internet addiction recovery. I thought it would be interesting to ask the same question today to see what online users thought.

One of the true signs of addiction is that a person experiences negative consequences as a result of something, whatever it may be - alcohol, drugs, or sex. With alcohol and drugs, a few common consequences are DUIs, jail time, and the loss of a job and/or relationship. A natural consequence for sex addicts is catching STDs. What are the consequences of Internet addiction?

In August 2005, a 28-year-old South Korean man died – not by committing suicide, but after playing the game Starcraft at an Internet café for 50 hours straight. By all reports, the man had not slept properly and had eaten very little in that time. While no autopsy was performed, he was believed to have died from heart failure stemming from exhaustion. A 13-year-old Chinese boy died falling from a building. His parents are suing Blizzard Entertainment, makers of World of Warcraft. The boy was allegedly re-enacting a scene from the game. In the Nevada, a couple ignored their two toddlers to the point of neglect due to their gaming addiction.

The children of Michael and Iana Straw, a boy age 22 months and a girl age 11 months, were severely malnourished and near death last month when doctors saw them after social workers took them to a hospital, authorities said. Both children are doing well and gaining weight in foster care.

Police said hospital staff had to shave the head of the girl because her hair was matted with cat urine. The 10-pound girl also had a mouth infection, dry skin and severe dehydration. Her brother had to be treated for starvation and a genital infection. His lack of muscle development caused him difficulty in walking, investigators said. The prosecutor said, “They had food; they just chose not to give it to their kids because they were too busy playing video games.”

Attorneys said the Reno couple was too distracted by online video games, mainly the fantasy role-playing “Dungeons & Dragons” series, to give their children proper care.

Studies from China, Germany, Italy, Iran, Pakistan, and India have also documented cases of Internet addiction. Given the dramatic effects reported and studies on the consequences of compulsive use of the Internet, the question is "Do you think Internet addiction should be given the same status as other addictions?"

Internet addiction an epidemic in Korea

Compulsive Internet use has been identified as a mental health issue in other countries, including the United States. However, it has reached epidemic levels in South Korea because of the country’s nearly universal Internet access.

According to an article that appeared in the New York Times, itt has become a national issue in recent years, as users started dropping dead from exhaustion after playing online games for days on end. A growing number of students have skipped school to stay online, shockingly self-destructive behavior in this intensely competitive society.

Up to 30 percent of South Koreans under 18, or about 2.4 million people, are at risk of Internet addiction, said Ahn Dong-hyun, a child psychiatrist at Hanyang University in Seoul who just completed a three-year government-financed survey of the problem.

They spend at least two hours a day online, usually playing games or chatting. Of those, up to a quarter million probably show signs of actual addiction, like an inability to stop themselves from using computers, rising levels of tolerance that drive them to seek ever longer sessions online, and withdrawal symptoms like anger and craving when prevented from logging on.

To address the problem, the government has built a network of 140 Internet-addiction counseling centers, in addition to treatment programs at almost 100 hospitals and, most recently, the Internet Rescue camp, which started this summer. Researchers have developed a checklist for diagnosing the addiction and determining its severity, the K-Scale. (The K is for Korea.)

In the US, the prevalence of Internet addiction appears less than Korea with estimates of 5 to 10 percent of the population who suffer from the problem. The issue of Internet addiction continues to raise significant concern as more therapists see clients who suffer from Internet-related problems, including online gaming, online affairs, Internet pornography and Internet gambling addictions.

Treating Internet Addiction

The October issue of the CyberPsychology & Behavior Journal published the first study to examine treatment outcomes with Internet addicts. The study conducted by the Center for Internt Addiction Recovery examined 114 patients over 12-weekly sessions and upon six-month follow-up after termination. Results showed that clients gained symptom management by the 3rd session and were able to maintain complete recovery after 12 sessions and at six months after treatment ended. The main and most successful treatment with Internet addicts is cognitive-behavioral therapy and the study supports that CBT is the primary therapy to use in treating Internet addiction. This is the first study to examine specific treatment variables with Internet-addicted patients and shows long-term potential in treatment recovery.

To learn more please read the full article published by Mary Anne Liebert entitled, "Cognitive-Behavioral Therapy with Internet Addicts: Treatment Outcomes and Implications" is published by CyberPsychology & Behavior, Vol. 10, No. 5, pages 671-679 (October 2007).

AMA considering Video Game Addiction a disorder

In today's headlines, the American Medical Association is considering video game overuse an addiction. While they say a final diagnostic classification for the behavior is a ways off, studies have been conducted and clinical evidence is mounting to support the validity of this new syndrome.

Dr. Martin Wasserman, executive director of MedChi, the Maryland State Medical Society, helped spearhead the new proposal, which has resulted in a 10-page report submitted to the AMA by the group's Council on Science and Public Health.

"The concern came up because one of our psychiatrists here in Maryland was seeing older people who were losing their social contacts," specifically because of their overuse of video games, Wasserman said. "It was ruining their family life. So, it was not unlike gambling addictions or alcohol, where it was having a profound impact on the lives of individuals."

According to the AMA report, one soon-to-be-released British study polled 7,000 "gamers" and found that 12 percent of them met World Health Organization criteria for addictive behaviors.

Statistics released in 2005 by the Entertainment Software Association (ESA), an industry group, estimated that 70 percent to 90 percent of American children play video games. The typical gamer is a 30-year-old male who spends about seven or eight hours a week gaming.

The ESA survey also found that video game overuse was most prevalent among the approximately 9 percent of video game users who play against others online in Internet-based "massive multiplayer online role playing games."

The new AMA report defines "heavy game use" as two or more hours a day, but Wasserman, a pediatrician, said addictions are best defined by their impact on an individual's life and psyche.

We have already discussed in prior blog posts that online gaming has become problematic for many. These new studies bring to light the issues and continue to add to the growing dialogue of how new technologies can clinically impact individuals and families.

Are you an obsessive online gamer?

As a follow-up to my discussion on online gaming addiction, I received this email from a recovered gaming addict that I wanted to share. I wanted to hear from other gamers to see if physical numbing or problems also result from intensive playing.

"Hello: I play World of Warcraft which I'm sure must be responsible for a great deal of online addiction. I have gone through periods of playing somewhat intensively which I may do for up to 4 hours 4 evenings in a week but then I am suddenly so bored with it that I don't touch it for a month or two then repeat the cycle. So maybe a binge addiction! Anyway, the purpose of this message is to comment on your online survey: Are you an obsessive online gamer? I am a nurse and one thing I have noticed is that frequently people are playing to a point of physical harm. I am in a guild that actually meets every once in a while in San Francisco (so real face time with fellow guildies which I think is unusual) and often they have what seem to me to be tendonitis and other repetitive stress/overuse injuries such as Carpal Tunnel (although as a nurse naturally I would leave diagnosis up to the physicians!). Also I often hear (on Ventrillo which many gamers use for audio) or see (in online comments) remarks that people have tingling or numbness in the nerves of their hands, wrists, forearms, shoulders, or necks, any of which could be the onset of more serious conditions. People seem to accept all this as part of gaming, especially heavy gamers who go on "raids" (something I'd never do) which take hours and hours maybe three times a week to complete. Therefore I think you need to add a question to your online gaming questionnaire: HAVE YOU EVER PLAYED/CONTINUED TO PLAY AN ONLINE GAME AFTER YOUR HANDS OR AMRS BEGIN TO HURT? In this case I am not even addressing lower back pain and possible damage to spine/cartilage, or damage to vision, both of which I suspect as a result of computer use. I think it would be good to see something on your questionnaire about this."

The Rise in Teen Online Gambling

While doing some research on Internet gambling, I came across some amazing statistics. Two days after Congress cracked down on online gambling, new data released from the Annenberg Public Policy Center at the University of Pennsylvania show that more than one million young people currently are using Internet gambling sites on a monthly basis. Among males 18 to 22, Internet gambling doubled in the past year.

The new data are being released by the National Annenberg Risk Survey of Youth, which has tracked gambling among young people ages 14 to 22 since 2002. Based on the survey's most recent estimates, approximately 850,000 males ages 18 to 22 gamble online at least one a month. The corresponding number for males between 14 and 17 is 357,000.

Among the 18- to 22-year-old age group, weekly use of Internet gambling sites increased from 2.3% in 2005 to 5.8% this year, a statistically significant increase.

With a rise in online gambling comes a greater danger of addiction, according to Nancy Petry, a professor of psychiatry at the University of Connecticut’s Center for Gambling Research and Treatment.

In a recent study, Petry found that Internet gamblers were more likely to have a serious gambling than other gamblers. Furthermore, Internet gamblers were more likely to suffer from health and emotional problems such as substance abuse, circulatory disease, depression, and risky sexual behaviors.

As teens and pre-teens go online with greater frequency, the risk for addiction and the form it takes becomes greater. Old favorites such as sports betting and casino games still dominate the Internet but in the future there will be more opportunities that could draw new gamblers into the fold. People can go online and bet about whether Brad Pitt and Angelina Jolie will get married or if Tom Cruise and Katie Holmes’s marriage will last. They can bet on the outcome of the Oscars or who will win on Survivor. These are the new kind of bets that are done by people who might not normally visit a gambling site.

What is Internet misuse and what is addiction?

After my last blog entry, I received several emails from therapists, many whom are EAPs who have seen cases like IBM in their practice. They would treat an employee who did something wrong using the computer and was fired, or on the brink of being fired.

They asked me how they could diagnose Internet addiction and differentiate that from general misuse of the computer. This is a very relevant question to ask in our technology-rich society. The symptoms are based upon DSM criteria as follows:

1. Do you feel preoccupied with the Internet (think about previous online activity or anticipate next online session)?
2. Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction?
3. Have you repeatedly made unsuccessful efforts to control, cut back, or stop Internet use?
4. Do you feel restless, moody, depressed, or irritable when attempting to cut down or stop Internet use?
5. Do you stay online longer than originally intended?
6. Have you jeopardized or risked the loss of significant relationship, job, educational or career opportunity because of the Internet?
7. Have you lied to family members, therapist, or others to conceal the extent of involvement with the Internet?
8. Do you use the Internet as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)?

Answers should evaluate non-essential computer/Internet usage (i.e., non-business or academically related use). Clients are considered addicted when answering “yes” to five (or more) of the questions over a six-month period, when not better accounted for by a manic episode. Associated features among addicted individuals include: (1) ordinarily excessive Internet use, (2) a neglect of routine duties, (3) social isolation from family members and friends, (4) being secretive about online activities or a sudden demand for privacy when online, and (5) significant changes in normal sleep patterns (depravation). While many people may spend too much time online that in itself is not the only criteria to diagnose addiction. Therapists must also evaluate how the Internet is impacting a client’s life and look beyond diagnosis as purely a function of time.

Internet Addiction and Wrongful Termination

In a story dated 11/20/06, InformationWeek published the article, “IBM Worker Says He Was Fired For Chat Room Addiction”. A former worker for IBM was suing the firm for wrongful termination because he claimed he was addicted to online chat rooms.

James Pacenza admits that he spent time in chat rooms during work hours, but claims his behavior is the result of an addiction and that IBM should have offered him counseling instead of firing him. Mr. Pacenza is seeking more that $5 million in punitive and compensatory damages.

IBM is expected to file a motion to dismiss the case, but this raises a significant concern for other firms who may be at legal risk and liability because of the Internet. As Internet addiction gains legitimacy as a clinical syndrome or addictive disorder, companies who provide access to the Internet may be at risk for similar wrongful termination claims.

Whether you agree that Internet addiction is protected mental disability or not, the case opens the door for potential liability. It is foreseeable that other similar cases could be launched creating new problems and costs for employers.

While the research in the employment field has focused on misuse or abuse of the Internet in the workplace, little has specifically looked at the potential for addiction and how this impacts employers. Questions such as, “How do firms protect themselves from similar wrongful termination claims?” “How do firms define employee Internet abuse?” and “What are the best practices to implement policies and procedures regarding employee Internet addiction?” arise.

It would be prudent for firms to examine the option of rehabilitation, if warranted, rather than termination for workers, not only because of the legal ramifications, but for the practical benefits. Workers who are terminated create poor employee morale and increase other costs for firms such as job turnover, recruitment of new workers, production delays, and training costs.

Beyond offering counseling for Internet-addicted employees, best practices for businesses should also be applied such as job redesign, sensitivity training for employees on responsible Internet use, and collaborative sessions with managers, predominantly from IT and HR to work together on appropriate policies, monitoring strategies, violation procedures, and training.
Linking these issues together, companies will be in a better place to protect themselves and address the practical employment issues that surface from such wrongful termination claims. Employers can also work with EAPs to help develop appropriate referral systems for employees suspected of being addicted to the Internet and examine how to monitor employees who may be at risk for developing such problems.

Is MMORPG Addiction Real?

I have received a tremendous amount of interest on the general question - are role-playing games addictive? From campus newspapers to national television news, stories about online gaming addiction are rapidly becoming a new hot issue. Within this context, you have to ask – does the behavior meet the standard definition for compulsive behavior? Using the DSM, the reference guide for psychiatric practice, many of our clients do fit the criteria. Certainly not everyone who plays games becomes addicted. However, over the last decade, more research has come out citing symptoms, risk factors, and treatment for video game addiction – and addiction to Massive Multi-user Online Role Playing Games.

Signs of online gaming addiction include a preoccupation with gaming, loss of interest in other activities, academic problems for students, social withdrawal from family and friends, using gaming as an escape, and continuing to game despite its consequences. We have seen a dramatic increase in the number of calls from parents concerned about a child’s online gaming habits in the last year. Gaming has become a particular problem in Korea and China where new clinics addressing the problem have opened and a new Detox Center for Video Game Addiction opened in Amsterdam this past summer for intensive inpatient treatment.

Given the growing number of treatment centers and documented cases of gaming addicts, I think we have moved beyond the question on whether gaming addiction exists but rather we need to focus on understanding the dynamics associated with the problem. Some researchers have identified specific personality types who are most vulnerable to develop an addiction to role-playing games. Other research has investigated cognitive or brain changes among gamers and yet other research have looked at the social dynamics of computer-mediated communication in multi-user gaming. This is all helpful to gain the type of academic and clinical understanding essential to dealing with problem use.

I think one way to deal with the issue is to educate parents on the potential harm that can come from online gaming. As with other addictions, education and awareness are perhaps the greatest ways to deal with prevention. From the cases we have seen, children with low self-esteem, who are highly intelligent, socially withdrawn, and who have a family history of addiction appear the most vulnerable to developing an addiction problem. If parents, as the ones most likely to first notice the signs of addiction, could be alerted to them, then they would be better able to act more swiftly to reduce the potential for problems to develop.

Finally, as part of the dialogue in the field, I have published a new article "Addiction to MMORPG: Symptoms and Treatment" that gives a basic summary of the problem, signs of addiction, and treatment issues involved. You can link to http://www.netaddiction.com/articles/addiction_to_mmorpgs.pdf to view the article.

Stanford Study on Internet Addiction

I was interested in this new study conducted by Stanford School of Medicine Researchers on Internet addiction. In the past, studies conducted on problem Internet use utilized adopted DSM criteria that suggested that people suffered from impulse control disorders. In a first-of-its-kind, telephone-based study, the researchers found that more than one out of eight Americans exhibited at least one possible sign of problematic Internet use. The findings follow results from previous, less rigorous studies that found a significant number of the population could be suffering from some form of Internet addiction.

"Our telephone survey suggests that potential markers of problematic Internet use are present in a sizeable portion of the population," the researchers noted in their paper, which appears in the October issue of CNS Spectrums: The International Journal of Neuropsychiatric Medicine. "We often focus on how wonderful the Internet is - how simple and efficient it can make things," elaborated lead author Elias Aboujaoude, MD. "But we need to consider the fact that it creates real problems for a subset of people."

Aboujaoude, clinical assistant professor in psychiatry and behavioral sciences and director of Stanford's Impulse Control Disorders Clinic, said that a small but growing number of Internet users are starting to visit their doctors for help with unhealthy attachments to cyberspace. He said these patients' strong drive to compulsively use the Internet to check e-mail, make blog entries or visit Web sites or chat rooms, is not unlike what sufferers of substance abuse or impulse-control disorders experience: a repetitive, intrusive and irresistible urge to perform an act that may be pleasurable in the moment but that can lead to significant problems on the personal and professional levels.

According to preliminary research, the typical affected individual is a single, college-educated, white male in his 30s, who spends approximately 30 hours a week on non-essential computer use. While some may hear this profile and assume that a person's Internet "addiction" might actually be an extreme fondness for pornography, Aboujaoude stressed that pornography sites are just one part of the problem.

"Not surprisingly, online pornography and, to some degree, online gambling, have received the most attention - but users are as likely to use other sites, including chat rooms, shopping venues and special-interest Web sites," he said. In the Stanford study-which Aboujaoude said is the first large-scale, random-sample epidemiological one ever done-the researchers conducted a nationwide household survey and interviewed 2,513 adults. This study confirms past findings on Internet addiction and further validates the existence of the disorder and its potential for widespread misuse. Further empirical evidence on the disorder helps researchers and clinicians understand the effects of the Internet when misused or abused and I think provides a greater understanding of its prevalence.

Online Gaming Addiction

Over the past year, we have received a growing number of phone calls from parents who are increasingly concerned about their child's online gaming habits. They are sure that there is a problem but counselors unfamiliar with online gaming addiction don’t understand how seductive they can be. One parent that I had worked with told me she had gone to talked to her son’s guidance counselors, the school psychologist, and two local addiction rehabilitation centers. "No one had ever heard of someone getting addicted to X-Box. They all told me it was a phase and that I should try to limit my son’s game playing. They didn’t understand that I couldn’t. He had lost touch with reality. My son lost interest in everything. He didn’t want to eat, sleep, or go to school, the game was the only thing that mattered to him. When I told him to get offline, he yelled, screamed, and once, he pushed me. This isn’t my son. He’s a quiet and loving boy. Now, I don’t know who is."

While many people play online games without developing any addictive or compulsive type of behavior, it seems that some users do go beyond normal limits. In trying to understand the behavior better, what are your thoughts on the potential of online gaming addiction? Do you believe it can become addictive? Do you believe that certain personality traits place some users at greater risk to develop an addiction to online games?

Are you an Internet addict?

Thank you for visiting our blog. I would like to welcome you and invite you to share your story about recovery. So many search for help and by sharing your story you can help others realize that they are not alone.