Since the 1980s, the widespread availability of personal computers and advent of the Internet and the World Wide Web have revolutionized society. In addition to channels of communication, the Internet provides a forum for the exchange of cutting-edge health information and resources. However, it has also created many health-related problems. Consider the following scenario:

Charlotte is a 56-year-old, recently unemployed woman. Her husband, Henry, is concerned that she has become irritable and short-tempered, distancing herself from her friends and family. She constantly complains of a stiff neck, sore shoulders, and lower back pain. At other times, she is as radiant and vibrant as a schoolgirl in love. She spends inordinate amounts of time sitting in front of the computer, searching the Internet. Many nights, she doesn’t come to bed until 3 AM or 4 AM. Henry talks with his sister, who is a nurse, and tells her he’s afraid of “losing” his wife. His sister suggests that he take Charlotte to the family clinic to talk with a nurse practitioner.

Background and overview

In 1962, the RAND Corporation began research into communication networks to maintain military command and control that could survive a nuclear war.¹ By 1969, four West Coast universities became involved in developing computerized linkages and networks. Online communication made public headlines in 1976 when Queen Elizabeth sent the first royal e-mail message. In the mid-1980s, loose connections of networks (previously referred to as ARPANET) became known as the Internet; this development corresponded with widespread availability and use of personal computers.² Since its inception more than 30 years ago, the Internet has emerged as a major part of the U.S. infrastructure. Today, the Internet is rapidly proliferating in U.S. households and serves to connect people and businesses around the world.

Information retrieval is probably the most common use of the Internet. One can obtain the latest news, weather reports, and sports scores or use database searches and library connections for research and reports. Other uses of the Internet include communication and correspondence, which have increased through use of e-mail, instant messages, and chat rooms. Social relationships have been vastly transformed through dating services and virtual communities. Economics and trade have also been influenced by the Internet. For example, it is possible to buy and sell stocks, bid on products through online auctions, buy a home, or purchase virtually any commodity or service (although eBay, an online auction house, banned postings for the sale of babies and kidneys).^3,4 The Internet is also a forum for entertainment, including games, music, and virtual travel. Vices, such as gambling, sex, and pornography, readily accessible on the Internet, are causing public controversy and concern.

The growth and expansion of Internet use has also revolutionized health care. A vast array of consumer and provider education is available online. In fact, anyone can now access support groups and independently consult with professionals. Diagnosis and treatment and “trustworthy and timely health info” are available through online services, such as WebMD <www.webmd.com>. Increasingly, individual physicians are hosting their own website offering patient education and in some cases providing interactive consultation. Even pharmaceuticals can be easily obtained at up to an 80% discount with free shipping, often without a prescription from virtual U.S. and Canadian pharmacies at sites such as www.lepharmacy.com and www.mydiscountdrugstore.comuniversaldrugstore.com.

This easy access to medical information and medication online has not been without problems. A recent Consumer Reports article detailed the experience of one of their editors who logged on the Internet, did a simple search for “prescription drugs for sale,” and in seconds was provided with 150 websites. Many of these sites boasted, “No prescription? No doctor? No problem.” Without ever communicating with a doctor, the editor was able to purchase seven different prescriptions for conditions that he did not have.⁵

In essence, people can almost live their entire lives without leaving their homes and screens. With the rise in use of wireless access laptops, Blackberrys, Treos, and iPods, no matter where you are, you can be “online” or “hooked up” to the Internet. The New York Times recently published a series of articles on the rising use of these technologies and the resulting problems.⁶

However, as with any technology, the Internet has both good and bad sides and thus the potential for either benefit or harm.

Is Internet addiction real?

Addictions, defined loosely, can be healthy, unhealthy, or a combination of both. Fascination with a hobby and the desire to spend as much time as possible engaged in an activity can be an outlet for learning, creativity, and self-expression. But in truly pathological addictions, the bad outweighs the good, resulting in an inability to function in the “real” world. Almost any activity can become a pathological addiction — taking drugs, eating, exercising, gambling, smoking, shopping, engaging in sex, working, or using the Internet.^7,8

Ivan Goldberg, MD, first coined the term Internet addiction disorder (IAD) for pathological, compulsive Internet usage. Goldberg also drew parallels between IAD and other addictions that do not involve substances, such as workaholism and pathological gambling.⁹ Maressa Hecht Orzack, PhD, a therapist who established one of the first treatment programs at McLean Hospital in Belmont, Mass., uses a broader term — computer addiction — to include both IAD and nonsocial pathological computer use, such as game playing or life management by software through the use of electronic calendars, address books, and recipe lists <www.computeraddiction.com>.^10,11 In view of the newness of the phenomenon, there is still much controversy and discussion among professionals about whether Internet addiction actually exists and how to differentiate between normal and abnormal use.^12-16 To date, IAD does not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).¹⁷ This problem is currently best classified as an “impulse control disorder not otherwise specified.”¹⁸

Prevalence/demographics

Since IAD is a new phenomenon, little research defines its prevalence. According to the American Psychological Association estimates 6% of the 85 million Web users in the U.S. suffer from IAD.

Kimberly Young, PhD, a leading researcher on Internet addiction, has broadened her research to include the impact of IAD on marriage and families.¹⁹ Young hosts several self-help websites and has available for purchase audio and videotapes for families on a variety of topics ranging from understanding the impact of IAD on marriage and families to protecting your children from cyberspace predators and other dangers. For counselors, Young has several books and tapes available to assist therapists in understanding and treating IAD <www.netaddiction.com>. Young also offers therapy for IAD (telephone counseling or chat room sessions — 60 minutes for $95).

Researchers are just beginning to document the habits and traits of Internet addicts. Anecdotal evidence gathered from the popular press suggests that IAD touches those from all walks of life and all age groups. Young and middle-age people are more likely to be affected because they are most likely to use the Internet.⁹ Many online surveys have queried Internet users who admit to having a problem with usage. Results from these surveys vary with reported demographics. For example, one survey of 400 Internet addicts found that 61% of the respondents were women. In another study of 563 addicts, 27% were women (respondents averaged 34 years of age with 15 years of education).⁹ Reported problems experienced from IAD are similar for men and women, but there appear to be differences in the types of Internet activities in which men and women engage. Men tend to become involved with information seeking, games, and sites focused on sex, while women go to Internet sites that offer support and friendship.^9,19 A recent public radio program identified women as being the major consumers of simple Web-based games, often available on cell phones, while men tended to prefer web-based games that were interactive, more complicated, and were played over a long period of time.²⁰ A very popular website, askmen.com outlines the problems of men and addiction to the Internet. It features an online survey and tips for overcoming the addiction. Anonymity is a particularly attractive feature of the Web; the user can take on a completely new personality. For instance, a recent advertisement for a sporty automobile tries to appeal to the audience by using the comparison that purchasing the automobile is like “becoming the person you are in the chat room,” thus supporting the notion that you can form your own identity on the Internet.

Increasing evidence indicates that IAD is a growing problem in adolescents and young adults, particularly college students. Freshman orientation sessions at most major universities now address the potential for students spending too much time playing Web-based games and gambling online. A recent literature search in the Psychology and Health subject guides resulted in 29 papers in six different languages addressing IAD in adolescents and college students.

Predisposing factors

Computers are everywhere. People are encouraged to “go online” to catch the news, order books, and bid in auctions; www.com has become as common a part of any address line as a zip code. Children are expected to become computer literate at all levels of education, starting in kindergarten. Only those without financial means to own a computer and some members of the over-70 age groups seem to be able to escape the call. On the other hand, computers for public use along with wireless access are becoming more and more available. They can be found in most libraries, hospitals, community centers, and many cafés. Additionally, entire communities are becoming wireless. You can now sit in a park or at the beach and “surf the net.” Community adult-education courses often include computer and Internet use as offerings.

As with other addictions, IAD can exist as an isolated preoccupation or can coexist with other addictions. Young found that half of her survey respondents were in recovery programs for drugs, alcohol, gambling, or overeating. Many had past or current psychological problems, such as low self-esteem, depression, or anxiety. Reasons for becoming a chronic computer user included loneliness, marital discontent, work problems, financial difficulties, or a poor social life. However, in spite of these factors, 80% of those taking the survey described themselves as outgoing or assertive.¹⁹

Symptoms and consequences

Signs and symptoms of IAD include a general disregard for one’s health, reduction in physical activity, sleep deprivation, not eating regularly, craving more time on the computer, neglecting family and friends, and a general decrease in socializing that disrupts relationships.¹⁴ Signs of more severe addiction include voluntary or involuntary typing movements of the fingers, psychomotor agitation (“cybershakes”), fantasy and dreams about the Internet, trouble with employers or school from deteriorating performance, financial difficulties, and excessive indebtedness.^21-25

Physical effects of IAD can be categorized as those resulting from: (a) a lack of attention to personal needs and health habits, (b) neuromuscular problems from excessive computer use, and (c) other maladies. Whenever people focus on one activity at the expense of their personal health, problems are likely to occur. It is difficult to maintain a balanced life when the day is filled with long hours of computer time. For those with a physical illness, such as a chronic disease that requires medication and diet restrictions, computer addiction could lead to dire complications. For example, someone with diabetes could become very ill while captivated online, if she or he ignored the requirements for balancing blood sugar and missed a dose of insulin or a meal.

Some computer addicts lose track of time and continue their online activities far into the night. Lack of sleep due to excessive computer use can have major effects on health. Problems from sleeplessness include inability to concentrate, fatigue, and even psychotic behavior. The stress of insomnia can alter immune function, disrupt hormone secretion patterns, and have adverse effects on cardiovascular and digestive systems.²⁴

Most computers today come with a bright tag warning users of possible hand, wrist, neck, shoulder, back, and leg injuries due to poor posture and repetitive movements. Proper placement of the keyboard and screen can help prevent neuromuscular strain, but when computer time becomes excessive, little can be done to prevent these problems. The Internet addict is also at risk for myofacial syndromes, leading to chronic pain. Poor posture or repetitive movements cause injury to the muscle and fascia. Spasm, tenderness, and stiffness cause guarding and limited muscle movement. Guarding makes the situation worse by increasing muscle stiffness and spasm. Carpal tunnel syndrome, due to median nerve compression in the wrist, is a common injury among computer users. Repetitive motion of the wrist as it is held in a flexed position causes the injury. Sensory changes can include numbness and pain in the thumb, index, and middle fingers and motor changes, such as muscle atrophy and weakness.

Constant staring at a computer screen can cause dry eyes, eye strain, and blurred vision. Migraine headaches may also occur. A website specifically devoted to understanding and alleviating physical problems associated with IAD includes problems with eyestrain, muscle tension, posture, and sensory processing functions such as vision, hearing, and sleep.

Psychological and social effects of IAD are multifaceted, related to the psychological makeup of the person involved. As with other addictions, the number and severity of symptoms will vary. Some people will have all of the symptoms of addiction, and others will have a few. Common emotional symptoms of addiction include: (a) excessive time spent doing the activity or a compulsive desire to do it; (b) euphoria when online; (c) inability to control the behavior, such as not being able to sign off the computer once online; (d) repeated attempts to cut down or stop, only to return to the behavior; (e) denial that the problem exists; (f) feelings of withdrawal, such as anxiety or depression when away from the computer for a prolonged period; (g) problems with family, work, and friends; and (h) continuing the behavior, in spite of the other problems resulting from its excessive use.^24,26

Family relationships may suffer when a parent or child is obsessed with the Internet. Parents who spend more time on the computer than with their children or spouse may become neglectful, thus creating stress and an unloving atmosphere at home. Stories of mothers or fathers who practically live online describe parents who may be physically at home but “not really there,” unavailable to their children and spouse. These situations can constitute “abandonment” if the parents with IAD are too immersed in their addiction to adequately care for their children.

For some children, excessive computer use can interfere with normal social development. Children obsessed with the Internet report excessive tiredness for usual activities, such as school performance, sports participation, and involvement with friends. There may be a growing separation from family and friends, as well as acting out and moodiness.¹⁸

The Lights of Tenth Street, a popular fiction book for young adults, deals with Internet addiction and its consequences for children.²⁷

Emerging treatment options

Multiple treatment options are currently used for IAD. The most common is cognitive behavior therapy, which teaches patients to identify and solve the problem and learn coping skills to prevent relapse.¹² Other therapists use aversion therapy, such as flooding the patient with many hours of computer exposure. Behavioral therapies are frequently combined with insight-oriented psychotherapy and pharmacological therapy, with such selective serotonin reuptake inhibitors as fluvoxamine (Luvox), fluoxetine (Prozac), and sertraline (Zoloft).¹⁷

Oddly enough, treatment and support are available online for IAD. Websites that diagnose and treat IAD proliferated over the past few years and a recent Web search found 42 IAD online help sites including www.virtual-addiction.com and www.addiction recov.org. Young provides two types of online services for clients: e-mail counseling and chat room counseling <www.netaddiction.com>.¹⁸ Self-diagnosis and treatment are possible on websites such as www.stresscure.com, or by using the online 12-step program available at http://alcoholism.about.com/library/weekly/aa990830.htm.

However, there is controversy within the mental health community about the online treatment of IAD, comparing it to treating an alcoholic in a bar or a gambling addict in a casino. The supporters of a 12-step approach to addictions treatment indicate that in Web addiction, the goal is not total abstinence, but usage control.

Nursing the net needy

Compulsive Internet use is an area many nurses know little about. As more and more people access computers, the potential for developing problems related to overuse rises. To better serve patients, nurses need to keep abreast of health effects related to emerging technologies.

Nurses need to be able to recognize warning signs of potential Internet addiction. If patients present with depression, changes in daily living habits, disrupted social relationships, or psychomotor agitation during nursing assessments, nurses should explore excess computer use as a potential problem and ask appropriate questions about the personal computer habits of these patients. This is particularly important for nurses working with high school and college students. Screening tools can help identify persons with a potential for developing an Internet addiction.^18,20 Nurses can find examples of questions to ask or tests to administer by logging on to www.netaddiction.com. Once a person with a potential or actual Internet addiction is identified, an appropriate referral must be made. Patients can be referred to a mental health professional specializing in addictions or to an online service as an initial step toward problem recognition and treatment. Through appropriate assessment, education, and referral, nurses can help ensure that their clients enjoy using the Web without being caught in it.