Internet Addiction in Psychotherapy

D. Kuss,M. Griffiths

• Verlag: Palgrave Pivot
• Jahr: 2014
• ISBN:
  9781137465078
• Thema: Psychologie
• Thema: Klinische Psychologie

Current knowledge about effective internet addiction treatment is limited. This book explores how 20 international internet addiction therapy experts experience the presenting problem of internet addiction in psychotherapy.

1

Internet Addiction: What Is It?

Abstract: Internet addiction is a behavioural problem that has gained increasing scientific recognition in the last decade, with some researchers claiming it is a “21st Century epidemic”. The classification of Internet addiction has been problematic ever since the term’s conception in the mid-1990s. In an effort to provide consensus and clarity in the area, the American Psychiatric Association (APA) proposed the inclusion of Internet Gaming Disorder in the revised fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), although this has led to greater confusion as Internet Gaming Disorder is arguably a sub-type of Internet addiction and/or a sub-type of video game addiction. This chapter provides a brief overview of the current scientific knowledge on Internet addiction, including diagnosis, risk factors, and neurobiological underpinnings.

Keywords: diagnosis; definition; Internet addiction; research; terminology

Daria J. Kuss and Mark D. Griffiths. Internet Addiction in Psychotherapy. Basingstoke: Palgrave Macmillan, 2015. DOI: 10.1057/9781137465078.0003.

Internet addiction is a behavioural problem that has gained increasing scientific recognition over the last decade, with some researchers claiming it is a “21st Century epidemic” (Christakis, 2010). Internet addiction has been conceptualised as behavioural addiction involving the excessive use of online applications and leading to detrimental impacts on the affected individuals’ lives (Kuss, Griffiths, Karila, & Billieux, 2014). Prevalence rates vary from 0.8 per cent in Italian students aged 14 to 21 years (Poli & Agrimi, 2012) as assessed via the Internet Addiction Test (IAT; Young, 1998) to 18.3 per cent of English university students (Niemz, Griffiths, & Banyard, 2005) using the Pathological Internet Use Scale (Morahan-Martin & Schumacher, 2000). However, comparative studies across countries and age groups indicate potential Internet addiction is present in approximately three per cent of Dutch adolescents (Kuss, van Rooij, Shorter, Griffiths, & van de Mheen, 2013) as well as English university students (Kuss, Griffiths, & Binder, 2013). These discrepancies in reported prevalence rates most likely exist owing to different sample characteristics and assessment instruments. The classification of Internet addiction has been problematic ever since the term’s conception in the mid-1990s (Goldberg, 1996). Classifications have included terms such as compulsive Internet use (Meerkerk, Van Den Eijnden, Vermulst, & Garretsen, 2009), Internet dependence (Dowling & Brown, 2010), pathological Internet use (Morahan-Martin & Schumacher, 2000), and virtual addiction (Greenfield, 1999). With the variety of terminologies, a diagnostic conundrum emerged, impeding scientists’ and practitioners’ efforts to find the appropriate diagnostic category, which is of paramount importance for clinical practice.

In an effort to provide consensus and clarity in the area, the American Psychiatric Association (APA) proposed the inclusion of Internet Gaming Disorder in the revised fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5; American Psychiatric Association, 2013; Herold, Connors, & Moore, 2012), although this has led to greater confusion as Internet Gaming Disorder is arguably a sub-type of internet addiction and/or a sub-type of video game addiction (Griffiths, King, & Demetrovics, 2014). The new DSM-5 classification draws on Internet addiction studies that have mostly focussed on online gaming addiction rather than any other form of pathological cyber behaviour (Kuss & Griffiths, 2012a) and is therefore a condition that requires further scientific investigation.

Internet Gaming Disorder is situated within the category of Substance Use and Addictive Disorders, and this paves the way to increased recognition alongside the only recognised behavioural addiction so far (i.e., Gambling Disorder). Given the novelty of the term Internet Gaming Disorder and the conventional usage of Internet addiction in major reviews (e.g., Chou, Condron, & Belland, 2005; Kuss, et al., 2014; Widyanto & Griffiths, 2006), the condition here will be referred to as ‘Internet addiction’. As a behavioural addiction, Internet addiction includes the following main components as specified by Griffiths (2005): salience (preoccupation with Internet use), mood modification (using the Internet to change how one feels), tolerance (the need to use the Internet for increasing amounts of time), withdrawal (psychological and physical withdrawal symptoms), conflict (interpersonal – problems with others, and intrapersonal – losing control over one’s behaviours), and relapse (reinstatement of the problematic behaviour following a period of abstinence). When these symptoms are present and significant impairment or distress is experienced, the individual would be classified as experiencing Internet addiction. Recently, the Internet addiction components model has been established, indicating that the above symptoms make up Internet addiction across different samples (Kuss, Shorter, van Rooij, Griffiths, & Schoenmakers, 2014). Moreover, a number of personality traits have been identified as presenting a risk for Internet addiction based on the component’s model, namely low agreeableness and high neuroticism (Kuss, Shorter, van Rooij, van de Mheen, & Griffiths, 2014). This indicates that individuals who lack trust, straightforwardness, altruism, compliance, modesty, and tender-mindedness and/or who experience increased levels of anxiety, angry hostility, depression, self-consciousness, impulsiveness, and vulnerability (Costa & McCrae, 1992) may be more vulnerable to developing Internet addiction (Kuss, Shorter, van Rooij, van de Mheen, & Griffiths, 2014). These personality markers may be targeted directly in prevention campaigns as well as clinical settings. Regarding prevention, children and adolescents who score high or low on the respective personality scales may be targeted directly prior to the onset of any problematic behaviours possibly in school and other youth settings. Regarding treatment, individuals who have the personality markers may benefit from tailored treatment approaches. For instance, those individuals who score low on agreeableness may profit from group therapy, where they can learn social norms and acceptable social behaviours by interacting with individuals who share the same experience of problematic Internet use, potentially facilitating social interaction.

Internet addiction has been found to be similar to substance-related addictions on the neurobiological level in various studies. In an extensive review of neuroimaging studies of Internet and gaming addiction (Kuss & Griffiths, 2012b), 18 empirical peer-reviewed studies were identified. These studies indicated that there are three levels of similarities between Internet addiction and more traditional addictions, namely the molecular, the neural circuitry, and the behavioural level. On the molecular level, individuals suffering from Internet addiction may have decreased dopaminergic activity in their brain, leading to reward deficiency and making them increasingly vulnerable for developing problems with their Internet usage. Accordingly, the Internet is used to alleviate negative moods (Kuss & Griffiths, 2012b). Following several successful pairings of Internet use and mood modification, the individual may habituate to using the Internet, resulting in tolerance and possibly withdrawal symptoms if the Internet cannot be used any longer (Koob & Le Moal, 2008). Therefore, it may not come as a surprise that Internet addiction is often comorbid with affective disorders, including depression (Morrison & Gore, 2010), bipolar disorder (Di Nicola et al., 2010), and borderline personality disorder (Bernardi & Pallanti, 2009).

From the perspective of neural circuitry, excessive and prolonged engagement with the Internet may lead to changes in the structure of the brain. In turn, these changes appear likely to reinforce problematic behavioural patterns and lead to the maintenance of excessive engagement. Excessive and prolonged engagement may lead to desensitisation to the pleasurable effects of Internet usage over time, requiring higher doses (i.e., increased amounts of time investment) to result in similar benefits. However, desensitisation not only occurs in the context of Internet usage but also in relation to more natural reinforcers. More specifically, rather than experiencing natural reinforcers such as food, sleep, and social interactions as pleasurable, individuals who experience Internet addiction symptoms may require reinforcers that are stronger (such as intense online gaming), limiting positive effects experienced in daily life situations. The structural changes involved in these patterns occur in the orbitofrontal cortex and the cingulate gyrus, which are associated with decision making and emotional processes, learning, and memory (Liu et al., 2010; Schoenebaum, Roesch, & Stalnaker, 2006). This may explain why individuals constantly think about the Internet and the next time they can use it (i.e., Internet usage becomes increasingly salient) and why they may lose control over their behaviours, resulting in excessive Internet use (Kuss & Griffiths, 2012b). The brain learns that Internet usage is associated with relieving anticipation and negative moods and remembers these pleasurable effects, leading to the unconscious decision of renewed and compulsive engagement, irrespective of potential psychosocial problems (Volkow, Fowler, & Wang, 2004).

Behaviourally, Internet addiction has been associated with various problems in a number of empirical studies (Kuss & Griffiths, 2012b), including impulse control, behavioural inhibition (Dong, Lu, Zhou, & Zhao, 2010), executive functioning (Han, Lyoo, & Renshaw, 2012), attention (Lin et al., 2012), and cognitive functioning in general (Ge et al., 2011). However, it needs to be borne in mind that frequent gaming has been reported to improve certain cognitive functions, such as perceptual integration of information, and hand-eye coordination. More specifically, gaming has been successfully used in the context of physical and mental rehabilitation and learning (Griffiths, Kuss, & Ortiz de Gortari, 2013), clearly outlining that gaming per se is not harmful but that excessive usage may lead to various negative consequences as evidenced on cognitive, neuronal, molecular, and behavioural levels. In the following chapter, it will be explored how these negative consequences are witnessed and understood by psychotherapists who treat individuals suffering from Internet addiction.

2

Internet Addiction Treatment: The Therapists’ View

Abstract: Literature on Internet addiction treatment is scarce, and there is little consensus among experts as to the most effective treatment intervention. To fill this gap in knowledge, this chapter aims to explore how Internet addiction therapy experts experience the presenting problem of Internet addiction in psychotherapy. A total of 20 psychotherapists from six different countries (i.e., Germany, United Kingdom, United States of America, Canada, Austria, and Switzerland) were interviewed regarding their individual experience of treating patients suffering from Internet addiction. Data were analysed using Interpretative Phenomenological Analysis. Two superordinate themes (“risk” and “addiction”) were identified during the data analysis.

Keywords: expert; Internet addiction; therapist’s view; therapy; treatment

Daria J. Kuss and Mark D. Griffiths. Internet Addiction in Psychotherapy. Basingstoke: Palgrave Macmillan, 2015. DOI: 10.1057/9781137465078.0004.

To date, a number of treatment approaches have been applied to alleviate Internet addiction symptomatology, but the evidence base for treatment of this condition is limited. Three reviews shed some light upon the effectiveness of evidence-based treatment (King, Delfabbro, Griffiths, & Gradisar, 2011; Liu, Liao, & Smith, 2012; Winkler, Dörsing, Rief, Shen, & Glombiewski, 2013). King et al. (2011) assessed the existing literature on Internet addiction treatment using the Consolidated Standards of Reporting Trials (CONSORT) guidelines, which define quality indicators of the reporting of clinical interventions involving psychopharmacology and psychotherapy with the aim of transparency and accountability for study design choices and the reporting of research methods. Important quality indicators include references to sample inclusion criteria, treatment description, and a power analysis of sample size (Schulz, Altman, & Moher, 2010). The eight clinical trials identified by King et al. (2011) varied substantially regarding methods used, diagnosis and classification of Internet addiction, therapy, aftercare, random allocation, blinding, sampling, and recruitment. The therapy components differed and included cognitive behavioural therapy (CBT), motivational interviewing (MI), reality training, as well as novel approaches containing psychological and counselling ingredients. In the included studies, therapy for Internet addiction was delivered by trained professionals or by software that has been developed for this purpose. The length of treatment varied from one session to 19 months (King et al., 2011). They concluded that there was (i) inconsistency in definition and diagnosis of problematic online use, (ii) lack of randomisation and blinding techniques, (iii) lack of adequate controls or other comparison groups, (iv) insufficient information regarding recruitment, sample characteristics, and treatment effect sizes, and (v) small evidence base that suggests CBT has good preliminary support in treating addicted adolescents.

Liu et al. (2012) included 24 Internet addiction treatment outcome studies conducted in China that comprised patients aged between 9 and 23 years in their systematic review. Similar to King et al. (2011), they used the CONSORT statement to evaluate the quality of evidence for treatment, including indicators such as objectivity, sample size, power, outcome, random allocation, an active comparison group, baseline measure, manualised treatment, treatment adherence rating, collateral reports, objective assessments, intention to treat (ITT) analysis, and blinding. The particular strengths of the studies were sequence generation and ITT assessment, whereas weaknesses were present in the other criteria. More than half of the studies included treatment that combined various elements, such as physical engagement, CBT, electroacupuncture, family therapy, group therapy, MI, and psychopharmacology. CBT in combination with pharmacological treatment appeared most efficacious with an effect size (Cohen’s d) of 3.93. Overall, the treatment of Internet addiction as based on its outcome was considered to be efficacious with a mean effect size of 1.89. Nevertheless, the quality of the studies was modest (Liu et al., 2012).

Most recently, Winkler et al. (2013) used Internet addiction status (measured via dedicated questionnaires), time spent online, depression, and anxiety as outcome variables. Studies were included if they assessed pharmacological or psychological Internet addiction treatment and were not case studies. Internal, external, and construct validity of the included studies were measured via a quality scale (Glombiewski et al., 2010). A total of 16 studies conducted in China, the United States of America, and Korea were included. Treatments used to alleviate Internet addiction symptomatology varied, including CBT, Multilevel Counselling Programmes (MCT), reality therapy (RT), acceptance and commitment therapy (ACT), and psychopharmacology. Overall, the results indicated that the effect sizes for changes in Internet addiction status were large and changes from pre-treatment to post-treatment were significant, suggesting that treatment was efficacious in reducing Internet addiction symptoms. The analyses revealed that there were no significant differences between psychological and pharmacological treatments in improving Internet addiction status, whereas psychological therapies were more effective in reducing depression symptoms associated with Internet addiction. There was no difference in effectiveness between CBT and other psychological interventions (Winkler et al., 2013).

The recent reviews of Internet addiction treatment effectiveness offer some insights into the state-of-art of evidence-based treatment for Internet addiction. Different types of interventions are applied, and studies use a variety of assessment methods, diagnostic and evaluation criteria, and outcomes, which impedes the possibility of cross-comparisons. Taken together, the reviews suggest that there is not a single most effective treatment approach available to date. Instead, psychopharmacological and psychological therapies are found to be similarly efficacious, a combination of CBT and pharmacotherapy had the strongest effect sizes, and there was no difference between CBT and other psychological interventions in improving Internet addiction symptomatology.

To date, research on Internet addiction treatment has focused on the efficacy of treatment and the alleviation of symptoms as measured via patient self-reports. Research has not paid adequate attention to assessing the core ingredient of therapy: the therapist. Researchers have long called for the examination of the therapists’ experience of treatment (Goldberg, 1986; Jarman, Smith, & Walsh, 1997). Qualitative studies on Internet addiction have focused on how those affected understand, explain, and experience Internet addiction (Douglas et al., 2008), leaving out the position of the clinician. Understanding the experience of the therapist is vital for a number of reasons. First, psychometric assessment does not suffice for the classification of a patient as being addicted to using the Internet. Researchers have emphasised the necessity of professional evaluation in order to gauge the severity of the presenting problem and the need for expert help (e.g., Beard, 2005). Second, professionally trained psychotherapists profit from a large pool of clinical knowledge, including the experience of different treatment settings and therapy approaches and have ex...

Inhaltsverzeichnis

• Cover
• Title
• 1  Internet Addiction: What Is It?
• 2  Internet Addiction Treatment: The Therapists View
• 3  Internet Addiction: Risk
• 4  Internet Addiction: A Real Addiction?
• 5  Internet Addiction: Real-Life Implications
• References
• Index