Computer Addiction: Implications for Nursing Psychotherapy Practice
Wieland, Diane M
TOPIC. Nurse psychotherapists will encounter the impact of today’s technology on the daily lives of people including computer addiction. Computer addiction may also present with comorbidities such as depression, gambling, substance abuse, and marital infidelity and divorce.
PURPOSE. This overview article presents what is currently documented in the literature regarding the incidence, symptomatology, and nursing psychotherapy interventions relevant to computer addiction and its treatment. Issues presented include computer addiction, virtual relationships, online marital infidelity, and compulsive online sexual behavior.
SOURCES. Review of literature from Medline, Psychoinfo, CINAHL, and current texts.
CONCLUSIONS. Given the increased use of computers in today’s society, there is the potential for overuse of technology and neglect of others and self as a result of computer addiction. Computer disorders also present themselves as marital or couple discord with the potential for online extramarital affairs and compulsive sexual online behavior. A summary and an assessment tool are provided to guide the nurse psychotherapist in practice.
Search terms: Cyber disorders, Internet addiction, pathological Internet use, computer addiction
Computer Addiction: Implications for Nursing Psychotherapy Practice
Since the 1980s, personal computers and Internet access have been proliferating in households across the United States and other countries. Everyday activities at home, work, and school are increasingly dependent upon computers. Computers are used to organize data, word process documents, send e-mails, and search for new information via the Internet. Between 9 and 15 million people use the Internet daily, and it is estimated that every 3 months the rate of use increases by 25% (Cooper, 1999). Although a useful tool for communication, the Internet has properties that for some individuals promote addictive behaviors and pseudo-intimate interpersonal relationships. Such cyberspace contacts may result in cyber disorders such as virtual relationships that evolve into online marital infidelity or online sexually compulsive behaviors. An increasing mental health concern, cyber disorders such as Internet addiction disorder (IAD), also known as pathologic Internet use (PIU) have been identified to diagnose serious issues related to Internet use (Young & Rogers, 1998). Caution is offered by some authors about such terms until more substantial research can be accumulated (Shaffer, Hall, & Vander BiIt, 2000).
The terms Internet addiction and pathological Internet use (PIU) are used interchangeably and are identified based on the Diagnostic and Statistical Manual, IV-TR (American Psychiatric Association, 2000) definition of substance abuse and pathological gambling. Problematic Internet use may be another form of the obsessive-compulsive spectrum disorders, making it responsive to the selective serotonin reuptake inhibitors (SSRIs) (Shapira, Goldsmith, Keck, Khosla & McElroy, 2000). The affected person has an inability to control use of the Internet. This lack of control causes marked distress and/or functional impairment (Shapira et al., 2000). These individuals may have comorbidities such as alcohol and drug addiction, depression, or obsessive-compulsive disorder. Symptoms of Internet addiction include social isolation, family discord, divorce, academic failure, job loss, and debt (Young, Pistner, O’Mara, & Buchanan, 1999).
Internet addiction is an overarching term characterizing five problematic Internet-related issues: cybersexual addiction, cyber relationship addiction, net compulsions, information overload, and addiction to interactive computer games (Young et al., 1999). Table 1 presents an overview of Internet addiction.
Internet addiction is a new term in the psychiatric lexicon; thus, some researchers and practitioners question its validity. However, a growing body of literature on the subject exists. Dr. Ivan Goldberg first coined the term Internet addiction disorder (IAD) for pathological, compulsive Internet use (Brenner, 1997). Goldberg invented the terms webaholic and pathological computer use disorder. Internet addiction disorder is not currently identified in the Diagnostic and Statistical Manual, IV (American Psychiatric Association, 2000) as an addiction. It is, however, described under the category of impulse control disorder, not otherwise specified (Babington, Christensen, & Patsdaughter, 2003). Notably, addictions occur not only to legal and illegal drugs and alcohol, but can be manifested by addictive behaviors such as compulsive gambling, chronic overeating, sexual compulsions, and television watching (Young, 1998). “In behavior-oriented addiction, those who get hooked are addicted to what they do and the feelings they experience when they are doing it” (Young, 1998, p. 17). Prevalence of IAD is difficult to estimate because it is a new phenomenon. Young (1998) claims there were 56 million Internet users in 1997. Extrapolating from prevalence rates of other addictions, 5-10% of users will most likely experience IAD.
Men and women experience Internet addiction differently. Men are interested in information seeking, games, and cybersex. They seek power, status, and dominance, gravitating to sources of information glut, aggressive interactive games, and sexually explicit chat rooms and cyberporn. Conversely, women use the Internet more for support and friendship, romance, and complaint mechanism about their partners (Young, 1998; Schneider, 2000).
Predisposing factors to IAD include those individuals who are recovering from drugs, alcohol, gambling, and overeating. Young’s (1998) survey participants mostly had past histories of psychological problems, including anxiety, poor self-esteem, and depression. Computers are used to compensate for feelings of loneliness, marital and work problems, poor social life, and financial problems.
Signs and symptoms of IAD are multiple, such as a general disregard for one’s health, resulting in a lack of attention to personal needs for hygiene and nourishment. Sleep deprivation occurs as a result of staying awake and online into the early morning hours. The individual spends many hours alone on the computer, thereby decreasing physical activities and socialization. Obsession with and craving time on the computer results in neglect of real-life personal relationships to the point of divorce. Cyber shakes (psychomotor agitation and typing motions of the fingers), dry eyes, carpal runnel syndrome, repetitive morion injuries in the hands, wrists, neck, back and shoulders, migraine headaches, and numbness and pain in the thumb, index, and middle fingers are physical symptoms. A focus on the computer and lack of attention to daily reality is indicative of poor judgment and results in lowered grades in school, job loss, and indebtedness (Young, 1998; Christensen, Orzack, Babington, & Patsdaughter, 2001).
Fifty-four percent of Internet addicts report a prior history of depression; 34% with anxiety disorder; and 52% with a history of alcohol or drug abuse (Young, 1998). Denial is strong in Internet addicts who claim they cannot be addicted to a machine. Young notes the “one more minute syndrome” (1998, p. 49), a common response by an Internet user who is asked to go offline. The euphoric mood while online is broken when someone else breaks into the individual’s concentration. Family members monitor the amount of time the person spends on the computer. Conflict occurs when a family member or parent attempts to get the Internet user to log off. The computer addict may use the rationalization “one more minute,” in response to being asked to log off. Such rationalization is similar to an alcoholic who justifies his/her drinking by stating that after one more drink, alcohol use will stop. Young (1998) states that denial of IAD is typically shown by stonewalling, minimizing, blaming, excusing, rationalizing, and attacking. Table 2 provides common examples of patients’ rationalizations.
Young’s (1998) survey suggests that too much time on the computer, such as 10 hours during the day during the week and between 10 and 14 hours on weekends, adds up to 40-78 hours per week, time not used to perform mandatory work or home activities. Addictive behaviors emerge such as craving, concealing, and lying. The psychological and social effects of IAD include spending excessive time on the Internet and experiencing a compulsive desire to do this activity. Euphoria is experienced when online as a result of overstimulation and never-ending sources of visual and auditory information. There may be repeated attempts to cut down on the rime spent on the computer; denial of the problem; an inability to control the behavior; escalating issues with family and friends; and feelings of withdrawal, anxiety, and depression when unable to log on to the computer (Young, 1998; Christensen et al., 2001).
Use of computers in the workplace has alerted employers to the issues the Internet may play in decreasing work productivity. Employees prone to Internet addiction spend work time scanning the Internet (including online auctions, shopping, and pornography). Increased time on the computer untowardly affects interpersonal work relationships, promotes loss of family time, and exacerbates psychological issues (Beard, 2002). Beard notes that employers should be alert to excessive Internet users who spend less time with people, resulting in increased arguments, impatience, strains in relationships, and the hindrance of social skills. Table 3 highlights signs and symptoms of IAD. The effects of excessive Internet use can expand beyond the individual to include intimate relationship issues such as online marital infidelity and compulsive online sexual behaviors.
Virtual Relationships and Online Marital Infidelity
The Internet has changed how intimate relationships can be sought and developed. Computer-mediated relating (CMR) (Cooper, McLoughlin, & Campbell, 2000) promotes unique means of developing relationships that can lead to romance and positive interpersonal contacts. CMR presents itself with obstacles, such as lack of physical connection and lustful attraction, things which are deemed important in romantic relationships. Online communication allows each person to present themselves and their personas as they choose, with emphasis on emotional intimacy expressed through text. Age and appearance may be altered in order to remain more attractive to the other person. Superficial and pseudo-intimate erotic contacts may develop in an accelerated fashion (Cooper & Sportolari, 1997). Computer relationships prevent conflict resolution with those in the person’s real-life (face-to-face) relationships. Instead, the Internet contact may be triangulated into the marital or real-life relationship. The Internet contact will be the sympathetic ear to conflicts in the other person’s life. secrecy and shame may develop as deeper involvement occurs between Internet users. Impulsive face-to-face meetings may develop as a result of ongoing pseudo-intimacy through erotic Internet communication. The outcome may develop into Internet marital infidelity. Developing an intimate relationship online violates trust in the monogamous face-to-face relationship.
Beyond the Internet text communication, the partner may desire to engage in online cybersex. A camera attached to one’s computer transmits pictures of sexual stimulation from the sender to the receiver. Cybersex is a symptom of dependency, loneliness, and lack of interpersonal and sexual intimacy in face-to-face contacts. Cybersexual activity further alienates the other partner with whom the person lives, creating feelings of being shut out and ignored (Cooper et al,, 2000). One or both face-to-face partners may seek marital/couple therapy once the virtual relationship and/or cybersex is discovered. Divorce results from cybersex and virtual relationships. In addition to online sexual activity, Internet partners may eventually meet face to face. Meeting sexual partners on the Internet has been cited as one means by which a syphilis outbreak was tracked (Klausner, Wolf, Fischer-Ponce, ZoIt, & Katz, 2000). The conclusions of the McFarlane, Bull, and Reitmeijer study (2000) indicate that individuals who seek sexual partners on the Internet appear to be at higher risk for sexually transmitted diseases than those who do not use the Internet. Beyond the development of outside cyberspace relationships that interfere with real-life couples’ relationships, some individuals further endanger their intimate relationships when they engage in online cybersexual activities that are addictive or compulsive in nature.
Cybersexual Addiction and Compulsive Online Sexual Behavior
The most frequently searched topic on the Internet is sex (Freeman-Longo & Blanchard, 1998). In their study on sexuality and the Internet, Cooper, Scherer, Boies, & Gordon (1999) found that approximately 9 million people, or 15% of Internet users, accessed one of the top adult Web sites in a 1-month period. Cooper (1999) suggests that there are three primary factors that promote online compulsive sexual behavior, which he calls the triple-A-engine. These factors include easy accessibility, affordability, and anonymity. The National Council on Sexual Addiction and Compulsivity (www.ncsac.org) estimates that there are 60 million Internet users, 300 million web pages, and 2 million Americans who are sexually addicted Internet users both in and out of recovery.
Carnes, Delmonico, and Griffin (2001) define a sexual addict as a person in pain who typically believes he or she is bad and unworthy, someone who feels unlovable, whose wants will never be satisfied, and who thinks that sex is his or her most important need. Carnes and his colleagues (2001) further describe the sexual addictive cycle as preoccupation, sexual compulsivity, and despair. Sexual compulsive behavior is “an irresistible urge to perform an irrational sexual act” (Cooper, 1998, p. 1). Cooper (1998) further developed five hallmarks to sexual compulsions, behaviors that must endure for at least 6 months: denial; unsuccessful attempts to discontinue the behavior; excessive amounts of time dedicated to the behavior; the behavior has a negative impact on social, recreational, psychological, and occupational functioning; and repetitious behavior despite negative consequences.
Online sexual behaviors fall on a range between normal/life enhancing to pathological. Profiles of individuals who pursue sex online were identified by Cooper, Putnam, Planchon, & Boies (1999). The three profiles of users include: recreational, compulsive, and at risk. Recreational users satisfy their curiosity about sex online. Compulsive users utilize the Internet to continue to act out their issues through pornography, sex with multiple and anonymous partners, phone sex, and paraphilias (sexual deviations such as pedophilia, exhibitionism, and fetishism). At-risk users are those who have not experienced sexual compulsivity in the past but who now experience difficulties related to the easy access to sexual sites on the Internet. Clients who seek therapy may present with one of the above concerns. What resources and treatment options are available to nurse psychotherapists who desire to assess and treat cyber disorders?
Assessment of Internet Addiction
Intervention with individuals who experience cyber disorders begins with an assessment of the individual’s behaviors. In her book, Caught in the Net, Young (1998) developed a self-administered assessment tool. This instrument can assist an individual in identifying Internet addiction and also assist a family member who suspects that an Internet addiction is affecting a loved one (Table 4). Nurse psychotherapists can add this scale to the intake information gathered at the first session.
Cognitive-Behavioral Therapy. Based on Beck’s (1976) theory that thoughts determine feelings, cognitive-behavioral therapy can assist the individual with Internet addiction disorder to recognize thoughts and feelings causing the person to inappropriately use the computer to meet personal needs (Orzack, 1999). Christensen et al. (2001) use the behavioral change stages as described by Prochaska and DiClemente (1998) to assist the patient to change behavior over time. The stages are precontemplation, contemplation, preparation, maintenance, and termination. The therapist must meet the client’s readiness for change in each of the stages with support, educational materials, and other treatments. In the precontemplation stage, the person is not ready to change and does not recognize that there is a problem with computer use and abuse. The focus in this stage is to break the denial that a serious problem with computer use exists. In the contemplation stage, the individual recognizes the need for change; however the desire to change may not be substantial and feelings of being overwhelmed may exist. In the preparation stage, the individual is ready to establish a plan to address the problem. As computer addiction is currently defined as an impulse control disorder, individuals cannot totally avoid computers but they will need to control computer use by setting time limits online. The person will need to assess what other activities could be done when the urge to use the computer exists. The maintenance stage begins when the individual feels he or she has control over computer use and is putting less energy into the behavioral change. The goal of this phase is to prevent relapse. The final stage, termination, occurs when the individual has no more urge to overindulge in use of the computer.
Psychopharmacology. Behavioral therapies are often combined with insight-oriented psychotherapy and medications. Selective serotonin reuptake inhibitors such as fluvoxamine (Luvox), fluoxetine (Prozac) and sertraline (Zoloft) are prescribed to treat depression, obsessive-compulsive disorder, and other anxiety disorders (Lamberg, 1997). As with other addictions, depression is a comorbidity for those with Internet addiction; clinical depression is associated with increased levels of Internet use (Young & Rogers, 1998).
Addictions Treatment and Self-Help Groups. Treatment for Internet addiction disorder is treated by those who specialize in addiction services. Controversy exists on the fact that online treatment and support groups exist. Readers are referred to the Center for Online Addiction at its web site at http:// www.netaddiction.com (Young, 1998). Other resources include the Institute for Addiction Recovery at Proctor Hospital in Peoria, at http://www.addictionrecov.org and the Computer Addiction Services at McLean Hospital in Belmont, MA at http://www.computeraddiction.com. The National Council on Sexual Addiction and Compulsivity can be accessed at http:// www.ncsac.org. This organization has yearly conferences, memberships, a newsletter, a journal, Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention, and professional and patient resources including a reference list of national 12 step programs.
Computers and the Internet are integral parts of daily personal and work life. Although the Internet is an excellent source of data and means of communication, individuals may seek services from nurse psychotherapists to help them or a family member with mental health issues that are intertwined with Internet use and abuse. Cyber disorders such as Internet addiction disorder (IAD) (also known as pathological Internet use, PIU, by other authors), and cybersexual disorders such as online marital infidelity and compulsive online sexual behavior are examples of clinical cases that will soon be commonplace in psychiatric nursing practice. Cognitive behavioral and insight-oriented therapies, SSRI, specialized addiction programs, and support groups are currently used for individuals who show addictive responses to the use of the Internet. Family and marital therapy are also warranted when online marital infidelity is the issue. Nurse therapists who see employee-assistance clients will need to be aware of Internet addiction, the resulting reduced worker productivity, and deteriorating coworkers’ interpersonal relationships that occur. More research in this area will be required for the diagnosis of IAD to be added to the formal compendium of psychiatric diagnoses in the DSM IV-TR (American Psychiatric Association, 2000). Until that time, the diagnosis to identify Internet addiction disorder is impulse control disorder, not otherwise specified.
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Diane M. Wieland, PhD, RN, CS
Diane M. Wieland, PhD, RN, CS, is an associate professor and director of the Undergraduate Nursing Program at the La Salle University, School of Nursing, Philadelphia, PA and Private Practice, Lansdale, PA.
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