One of the most controversial aspects of Internet addiction is the fact that it’s very hard to differentiate causation from correlation. Causation means that x causes y; for example, that spending too much time on the Internet causes depression. (We don’t know that, but that’s an example of what would be causation.) Correlation means we can identify that x and y are linked, but we can’t say that one causes the other; for example, people who spend more time on the Internet have higher rates of depression, but we can’t say for sure that one causes the other. Perhaps having depression makes you more likely to use the Internet, or perhaps there’s some other variable that makes both things more likely. When it comes to Internet addiction, there is a lot of difficulty determining cause and effect.
It goes beyond just the chicken-and-egg problem that we’ve discussed so far. That in and of itself makes understanding Internet addiction a very difficult undertaking. Does the Internet definitely change the brain, or does a preexisting neurological difference make some people’s brains more likely to develop an addiction? More than that, though, we simply can’t account for all of the different variables that are at play. We can study the brains of children who are engaged with technology, but we can’t eliminate all of the other life variables that might be at play in changing their brains.
Life is very different today from two hundred, one hundred, or even twenty years ago. Technology, including the technology at our fingertips daily, plays a huge role in that. But there are many other issues going on for people living in society today. From the chemicals and plastics in the food we eat every day to the regular threats of terrorism and mass shootings, we live with a wide variety of physical and psychological stressors that may differ from those of previous generations. Perhaps the increase in depression is linked more to an increase in awareness, and a decrease in stigma, that allows for more frequent identification. In other words, maybe people aren’t more depressed; maybe they’re just reporting it more and dealing with it more publicly. We don’t know. There are a lot of factors.
Even if we limit the conversation just to the problems of smartphones, can we say with 100 percent certainty that what’s changing our brains is the actual tactile individual use of these objects, or could it be a completely different effect, caused by the electromagnetic energy pulsating in the air all around us? Our brains are electric, after all, and surely that electricity in the air must have some impact on them. Maybe people have more headaches not because of eye strain from facing those screens all day but because of electromagnetic sensitivity. Maybe people’s attention spans are shrinking because of factors that have little or nothing to do with physically being on our devices so often. So even if we blame the phone, it might not be the act of engaging in behavioral addiction causing all of our physical and mental health issues. Or it might be. The fact is, we don’t really know.
Of course, legitimate scientific studies do all that they can to account for all of those other variables. Cal Newport summarizes how psychology professor and author Jean Twenge found that people born after 1995 had significantly higher rates of anxiety, depression, and suicide. She compared data going back decades (in some cases as far back as 1930), and she accounted for myriad variables “from stressful current events to increased academic pressure” but found that despite deep investigation into other causes, the only seeming difference between this generation and the others was the existence, availability, and use of smartphones and social media. This is one example of how established researchers have done deep dives into other possible explanations and continued to find enough support to believe that even though there are other factors at play, the prevalent use of the Internet is responsible for some serious problems facing individuals in our society today, problems that may lead to widespread addiction.
We can see that there are changes in individuals and in society over time. Studies show that there’s a correlation with increased Internet usage. There might even be a case for causation. However, we’re just beginning to understand the impact of the Internet, let alone Internet addiction, so it’s challenging to say for sure exactly what the ramifications are. We can make very educated guesses, and we can keep researching; keeping the conversation open and ongoing can help us learn more about the issue.
As we research Internet addiction, we have to face the fact that we can’t say for sure that the widespread problems in our society are directly linked with increased Internet usage, although they likely do have some link. That’s at the macro level. But what about the micro level? In other words, let’s look at any one individual who develops an Internet addiction. Can we say for sure that the addiction causes the problems (or vice versa, that specific things put that person at risk and caused the addiction)? Or are we unable to parse that out? For example, if a person with an Internet addiction also has social anxiety, can their doctor say for sure that the Internet addiction caused the social anxiety or, conversely, that the social anxiety made them turn to the Internet, and then they became addicted?
As with all types of addiction, the truth is probably somewhat murkier than one or the other. Let’s consider substance addiction, to a very commonly used (and perhaps misused) drug: caffeine. Imagine that you’ve had a very restless night. You couldn’t sleep, you tossed and turned, and when you finally started to dream, the alarm went off. Groggily, you snoozed a few times, but you needed to get up and get going because you had to be at work. With glazed eyes and a slight headache, you reached immediately for a cup of hot coffee. As the coffee kicked in, your headache subsided, the sleepiness went away, and you embarked on your day. During the commute, you were irritable with the other passengers. Maybe this is so normal that you didn’t even notice how grumpy you felt. But if you noticed, could you say for sure why? Were you irritable because you were still tired, because you weren’t feeling great, because the caffeine was kicking in and starting to make you restless, because you hadn’t eaten, or because of some other factor we haven’t even considered? If you’d had three cups of coffee instead of one, would you have felt differently? Once we look at something as seemingly innocuous as coffee, we realize just how hard it is to define addiction and how much harder it is to separate cause and effect.
Consider, first: is this really an addiction to coffee? Arguably, even if you insist on having your daily coffee, find it hard to stop even if you want to, and develop withdrawal symptoms (like headaches) when you don’t have it, it’s still not an addiction if it’s not causing problems in your work, in your financial and social life, or to your health. Most daily coffee drinkers do not consider it to be a problem and wouldn’t consider it an addiction. Plenty of reports indicate that it might even be healthy to have coffee every day. But is it affecting your sleep? Maybe the reason you tossed and turned the night before was because you had too much caffeine in your system that day. Is it affecting your relationships if you’re so irritable every morning? These are subtle things. They certainly don’t rise to the level of harm that we see in most types of drug addiction. But it goes to highlight that it’s hard to define what an addiction is.
And it’s even tougher to determine cause and effect. Were you tired because your system was already off from caffeine the day before, or did you need caffeine because you were tired? Were you grumpy because the caffeine hadn’t kicked in or because it had or because of some unrelated issue? What was the cause and effect? If you removed the drug entirely, would there still be a problem? And that’s where we can get back to the Internet. If someone has an Internet addiction, and you remove all access to the Internet (which, of course, is a challenge in and of itself in today’s society), would there still be a problem? Would society as a whole still have these huge sweeping issues of decreased empathy and increased attention deficits? Would the individual still have those problems, or would they resolve themselves? If the Internet addict had never been exposed to the Internet, would there still be an issue? Does it matter, given that the Internet is a reality of today’s world and there aren’t going to be many people who have never been exposed to it?
We know two things for sure: addictions existed long before the Internet and so did most, if not all, of the problematic symptoms that we associated with Internet addiction. So, the person with an addiction to Internet pornography may be a twenty-first-century character, but people have been addicted to pornography since long before the Internet existed. The person with a pornography addiction may have similar symptoms of depression and feeling numb to interaction with real live humans, whether that addiction is to Internet porn or old-fashioned erotic literature.
The argument on one hand is that these problems have always existed and that the Internet is just one more way to facilitate them. The argument on the other hand is that the speed and expanse of the Internet has exacerbated those existing problems, perhaps creating a new level of addiction if not an entirely new type of addiction.
Consider this: in her book about the benefits of reading aloud, author Meghan Cox Gurdon reports on fascinating research from Dr. John Hutton at Cincinnati Children’s Hospital working to understand how young children’s brains react differently to hearing a story read aloud with no visuals as compared to with still images (e.g., those in a print book) and animated images (e.g., those on a screen). What they found was that in very young children’s brains, there were five key areas that were most engaged when they heard a story read aloud and looked at still images—this perfect combination of auditory and visual stimulation along with the need to employ some imagination had the best effect in growing children’s neural networks. The different parts of the brain all linked together. In comparison, when just hearing a story with no visual images at all, the young children had to work too hard to come up with their own meanings, so while some parts of the brain were well stimulated, others were not. This applies specifically to young children who haven’t necessarily developed a strong bank of images for their imagination yet.
So, what does that have to do with Internet addiction? That’s where the third scenario becomes very important: what happens to children’s brains when they hear a story while also watching animation, as they do on a screen? Their brains stop engaging almost at all. The visual part of the brain is highly stimulated, but it seems completely separated from the rest of the brain. As the children watch the animation, they stop employing any sort of curiosity or imagination. The higher-order parts of the brain just turn off. The brain works better just hearing a story and not seeing anything at all than it does when hearing a story combined with viewing animated images. Watching those images turns the rest of the brain off.
Obviously, this has huge implications for the dangers of screen time for young children. Gurdon makes a great case for replacing, or at least supplementing, young children’s screen time with reading aloud with kids. But this also has important implications for Internet addiction for people of any age. It highlights the fact that our brains act differently when engaging with screen technology than they do with other types of media. Can you become addicted to reading books? Sure, possibly; they’re a great escape, but you aren’t going to develop the same kind of addiction to them as you are to online reading with all of its hyperlinked text, moving animation, and other forms of distraction.
If we completely removed the Internet from our society, there would be people who got addicted to the same types of content that addicts them online. But it wouldn’t be as easy. The addiction might not go so deep. And there would likely be mitigating factors that would help keep that addiction in check. People had shopping addictions years ago, but they had to physically go to the store, spend their cash, and face the cashiers (who often knew them and their families personally). This not only meant natural restrictions on the behavior itself (after all, who wants to hit the same store three times in a week when that judgmental clerk is going to be there again?) but also incorporated some protective factors. For example, if you were shopping because you were depressed or lonely, going out to engage with the world was part of what helped.
Then came the Home Shopping Network and catalogs and the ability to order anything you wanted on the phone. It became easier to engage in addictive shopping behavior, because the clerk on the other end of the phone was anonymous and you were anonymous to them. Plus, you didn’t have to leave the house. You could impulsively shop more easily because there were less barriers to making your purchases. And there were less protections; you weren’t engaging directly face-to-face with people anymore to help soothe the underlying issues that made you want to shop. And today, of course, we can easily shop online at any minute of any day without ever engaging in even voice contact with another human being. We can get same-day delivery and, in some instances, don’t even need to be home to deal with the other human delivering the package. If we suddenly removed online shopping from our society, some people would still have a shopping addiction and new people would still develop it, but it wouldn’t happen as easily and therefore would likely be less prevalent. Some of the people who have that addiction might venture out into the face-to-face world to do their shopping and discover that some of those protective benefits of doing so help reduce the addiction itself.
Someone who is prone to addiction in general—because of brain chemistry, life circumstances, or (most likely) the intersection of both—can develop addiction anyway, regardless of access to the Internet. But the Internet sure makes it easier to develop the addiction and perhaps harder to break it. So maybe we can’t say which came first—the problem we’re masking with addiction or the addiction itself—but we can say with fairly strong certainty that the Internet complicates things. It likely makes addiction more prevalent in our society. This correlates with other widespread issues in our society including serious mental health issues. And the individual who has an Internet addiction may benefit from learning which issue came first, but they don’t necessarily need to know that in order to start addressing their own problems.
Many of the problematic effects of Internet addiction are mental health issues. Just like at the societal level, it’s hard to say at the individual level which problem came first. Did your teen develop depression because they were on the Internet too much? Or did they increasingly turn to the Internet because they already had symptoms of depression that they were trying to self-medicate? Does it matter? Even if we can’t tell the cause and the effect, we can talk about comorbidity and dual diagnosis. In other words, we can acknowledge that both things exist for the individual as serious, likely related, problems. The teen has depression and Internet addiction, and it doesn’t necessarily matter if one causes the other because you can treat them both as serious mental health issues, ones that likely reinforce each other, and each requiring attention and treatment.
When I first started writing this chapter, I realized that I wasn’t certain that I knew the difference between comorbidity and dual diagnosis. This surprised me. I have a master’s degree in psychological studies. I read psychology literature regularly. This is a very basic topic of addiction. How could I not know the difference? But then I started digging in, and I realized that it’s because there’s a lot of really confusing, conflicting usage of the two terms (and incidentally, a third term, “co-occurring disorders”). Before I digress for a second, let me clarify that what we’re basically talking about here is the existence of two different diagnosable issues in one person—such as when someone has a diagnosis for both Internet addiction and anxiety. We’re about to read some conflicting definitions (I promise, the reason for even getting into this will reveal itself shortly), so just keep in the back of your mind that more or less, despite these differences, we mean two separate mental health issues in one person.
Now, for the digression. Some legitimate, well-recognized sources say that there is absolutely no difference between these terms. Others say that there’s a subtle difference between comorbidity and dual diagnosis. But they seem to disagree vastly on the difference. For example, some sources say that dual diagnosis refers only to times when a person is diagnosed with both an addiction and a psychiatric illness, whereas others say that a dual diagnosis can be any two diagnosed issues at the same time including physical health issues. So, by those latter standards, someone with both diabetes and depression would have a dual diagnosis, but that same person would not have a dual diagnosis by the first definition.
The confusion deepens when you try to not just understand the nuances of dual diagnosis but also separate it out from comorbidity. Let’s go with the first definition of dual diagnosis given previously: when a person is diagnosed with both an addiction and a psychiatric illness. Some sources say that comorbidity is the exact same thing as that. Others say comorbidity is when a person has both an addiction and a mental health diagnosis but not necessarily at the same time; in other words, someone has an addiction and then resolves it but later develops depression. Still others say that comorbidity means that the person has both an addiction and a mental health issue at the same time but more specifically that the mental health issue is directly linked to the addiction (either causing it or worsened by it).
It took me a little while to parse this out. I dug deeper and deeper to find increasingly legitimate sources for definitions. And then I realized something interesting. Although certainly individual people have had two or more diagnoses at the same time for years upon years, the term “dual diagnosis” is relatively new. It was really only in the late 1980s that people started using the term, and they also used the term “co-occurring disorders” at that time. It was also then that researchers began in-depth study into the relationship between mental health and addiction. They weren’t any exact terms in use as the research developed. It’s not as though there’s a specific regulating body that says, “We’re going to use this term, only this term, and only to mean this.” So different researchers were using different terminologies to mean similar things. And we have to consider that this happened only within the past few decades, which is right around the time we started using the Internet. Just when a lot of the research into dual diagnosis was becoming mainstream, so were computers in the home. As the years went on, the research continued, and so did ever-increasing use of the Internet to access and spread information. So, it’s little wonder that we don’t have a clear-cut definition of comorbidity versus dual diagnosis; there are many different (legitimate and less so) researchers and reporters spreading those words around without ever agreeing on a definition. The Internet itself complicates the matter of agreeing on definitions about problems associated with the Internet.
So, that was the digression into why the terms aren’t so clear-cut and why that matters. But now we’ll get back to the meat of the matter, which is that it is very common for someone with an Internet addiction to also have one or more other mental health issues. As we saw earlier in this book, depression and anxiety are particularly prevalent among people with Internet addiction. We could debate endlessly which one caused, or exacerbated, the other, but when it comes to treatment, it’s not all that important. What’s important is that the individual has two (or more) serious issues that rise to the level of a diagnosis and therefore require intervention and treatment. If your child has violent aggressive outbursts when their phone is taken away and also has such terrible social anxiety that they’ve stopped going to school, it doesn’t really matter much whether the phone addiction caused the anxiety or the anxiety caused them to cling to the phone; what matters is that they have both issues and you must treat them both as serious.
One of the problems that arise, though, is the complexity of trying to treat someone with a dual diagnosis. (Note that for the rest of this book, we’re going to use the terms “dual diagnosis,” “comorbidity,” and “co-occurring disorders” interchangeably to refer to someone who has both an addiction—specifically an Internet addiction since that’s the topic of this book—and another mental health diagnosis.) As we saw in the previous chapter, there are many different treatment options for Internet addiction. Naturally, there are also many different treatment options for each second mental health diagnosis. And so, of course, there are going to be many different ways of approaching treatment for someone who has co-occurring disorders.
The best treatment option for dual diagnosis clients is something that the addiction community has been debating since the community first started using the term. Generally speaking, you can either treat one problem first or treat both problems simultaneously. For example, if someone has both addiction and depression, you might first treat the addiction and then deal with the depression. Alternatively, the individual may work simultaneously with multiple professionals to treat both the addiction and the depression at the same time. There are good arguments to be made for either approach. What works best for one individual may not work well for another.
Consider, for example, someone who is so far immersed in active addiction that all they can think about is their next fix. Every single thing that they do all day long is geared toward getting that fix. They also have a history of an eating disorder. But the doctor can’t tell right now if they’re not eating because of the eating disorder or if they’re not eating because their priority is getting the drug. In such a case, it might make sense to treat the addiction first, in order to alleviate the symptoms related to just that issue so as to make the best determination about what treatment, if any, is necessary to help with the eating disorder. Removing the complicating factors of the addiction helps the doctor better see what the real issue is as far as the eating disorder. On the other hand, if the person’s eating disorder is so bad that they are on the verge of death because of lack of nutrients, then it would make sense to treat both issues at the same time, encouraging healthier eating habits while also dealing with the addiction.
People with a dual diagnosis who go to inpatient rehab often deal with both issues simultaneously, although there may first be a short period of detox that focuses on getting the person unhooked from their addictive substance. People who go to outpatient therapy may first deal with their addiction and then their other issue or may deal with both at the same time, depending greatly on which professionals they’re working with, what they’ve told those professionals, and how serious each of the issues is.
Treatment may also change over time as one or both of the conditions start to resolve. For example, think about someone who has both an Internet addiction and an anxiety disorder. Working to quit the addictive behavior may temporarily cause the person to be even more anxious than usual. In the long term, the Internet use may be making the anxiety worse, but in the immediate moment, it can feel like it helps reduce anxiety. Trying to quit, and going through withdrawal, may worsen the anxiety in the moment, even though quitting in the long term could help resolve anxiety issues. Therefore, in the short term, when withdrawal symptoms from the Internet are at their worst and anxiety is at its peak, the individual may benefit from antianxiety medications. They take the medication to deal with the anxiety while working through the Internet addiction. When the addiction is resolved, they may choose to address their anxiety in new ways, such as through cognitive behavioral therapy, and opt to wean off their medication. They may, or may not, find that this causes a relapse in Internet addiction. When dealing with a dual diagnosis, treatment is complicated, but it isn’t impossible.
In fact, treating one issue often goes a long way toward helping resolve the other. For example, someone who treats their Internet addiction with wilderness therapy may find that the treatment helps reduce their symptoms of depression. Maybe getting off of the Internet helps, maybe it’s being in nature, maybe it’s being with all of the people in the group, and likely it’s a combination of all of these things. In any case, even if the depression existed prior to the Internet addiction, treating the addiction may help treat the depression. The most important thing with dual diagnosis is recognizing both issues as serious and working with professionals who understand both conditions.
People can have a dual diagnosis of Internet addiction and just about any other mental health issue. Anyone with a mental health issue could potentially develop an Internet addiction. Each individual is unique, and what they may or may not fall prey to is unique. That said, research indicates that anxiety and depression are the two most common types of disorders that are dual-diagnosed with Internet addiction. Of course, they’re also the two most common disorders diagnosed in general, so it makes sense that their numbers are also high for dual diagnosis. Studies indicate that there’s also a correlation, and a high likelihood of dual diagnosis, for people with Internet addiction and the following issues:
People with an Internet addiction are also more likely to receive a diagnosis of another substance use disorder. They are more likely to develop addiction to nicotine and alcohol, as well as to other substances. A 2010 study by Case Western Reserve University School of Medicine found that teens sending more than 120 texts per day were twice as likely to have tried drinking and 40 percent more likely to have used illegal drugs. Teens engaging in three or more hours of social media per day were 84 percent more likely to have used illegal drugs.
There is some debate about whether or not having an Internet addiction and a substance addiction is truly dual diagnosis. If Internet addiction looks the same in the brain as cocaine addiction, then does a person addicted to both the Internet and cocaine have one diagnosis or two? Regardless of which side of that debate you land on, the research indicates that Internet addiction correlates with higher likelihood of other addictions.
Of course, if you have one type of Internet addiction, you’re also more likely to develop a second type. For example, if you have an addiction to surfing the web generally, you might also develop a specific addiction to a particular type of content such as online auctions or catfishing. If you have a gaming addiction, then you’re more likely than someone who doesn’t to develop an addiction to social media or Internet pornography. In fact, Kevin Roberts reports that 90 percent of the people who come to him and receive a diagnosis of online gaming addiction also have a second diagnosis, most commonly autism spectrum disorders, ADHD, or depression.
The more time that you spend online, the more likely you are to engage in more than one addictive behavior online. That’s not a dual diagnosis, per se, but it’s worth being aware of. If you have a gaming addiction, don’t think that you’re safe just because you stop gaming; you likely have to monitor all of your other online uses as well. When reSTART launched as a treatment center for Internet addiction, it attempted to include both women and men in the program together. However, they quickly found that people in recovery for Internet addiction were at great risk of developing sex addiction, made more problematic by coed programs.
This brings us to one final aspect of this exploration into the underlying problem of Internet addiction, which is the question of whether this addiction might sometimes be used as a “healthier” addiction to replace something that’s more damaging. If someone has a drug addiction that’s ruining their lives because of the financial and legal consequences of that addiction, and they replace that addiction with an Internet addiction, then is the Internet addiction truly a problem? The underlying issue, whatever is causing the tendency to addiction in the first place, might still be there. But if the person’s Internet addiction is comparatively harmless, then is it really so bad? Of course, in order to qualify as an addiction, it has to do some harm to the individual. But if their work performance suffers slightly, yet is so much better than it was when the person had a drug addiction, then is it truly a problem?
The answer is highly individual. It goes back to the concept of harm reduction. Someone who has another addiction, including one to substances, is more at risk of developing an Internet addiction. People who are in recovery may find themselves staying away from their usual drug of choice and turning to the Internet instead. Complete abstinence from all addictive substances and behaviors may be ideal, but it may not be possible. Some people might argue that for them it’s not even ideal. They don’t mind having an addiction; they just want to mitigate the harm. If so, then turning to the Internet, even if that behavior becomes addictive, might not be so bad. But do consider the risks. Someone with an addiction who replaces their substance with the Internet but doesn’t resolve the underlying issues related to addiction more generally may find themselves slipping further and further into their new addiction. It may become more harmful. It may lead to a relapse of the initial drug of choice. It may even become a channel to access that drug, through addiction to the Dark Net, for example. So, on the one hand, harm reduction certainly says that the Internet addiction may be healthier than the substance addiction, but it still recognizes that there are potential risks involved. The individual should be aware of those risks as they work toward recovery and mitigating harm. Once again, it doesn’t really matter if the drug addiction or the Internet addiction came first if one or both of them start to ruin your life.
We saw early on in this book that there are many ways to define Internet addiction. We’ve worked out a basic definition that clinicians can use or that we can look at to self-diagnose if there’s a problem. More or less, that works. However, it’s worth noting that one of the major reasons that it’s difficult to diagnose an Internet addiction is because we as a society have no scale for what “normal” use might be. If we can’t figure out what’s relatively normal or “okay,” then we can’t easily discern what’s abnormal or troubling. Is it normal or okay to spend an hour per day on social media? What about five hours? The technology is so insidious and the changes are happening so rapidly that we as a society haven’t figured out what’s normal. Do you think it would be normal for a person to lose eleven years of their life to handheld devices alone, not even including their computers, televisions, and gaming consoles? That probably (hopefully) doesn’t sound normal to you, and yet, Meghan Cox Gurdon cites research from technology writer Adam Alter that shows that based on current average usage rates, that’s exactly what the average, “normal” person is doing. They’re spending eleven years on their cell phones and tablets, years that could be spent on something else. Is that addiction?
Are we all becoming a little bit addicted? In his book iDisorder, Larry Rosen makes a detailed argument about how the average person in society is manifesting many of the symptoms of various mental health issues as a direct result of the relationship they have with their phone. In other words, even if your Internet use doesn’t rise to the level of addiction, and even if you don’t meet all the criteria of a second diagnosis, you may find that increasing Internet use has caused you to develop many of the symptoms of a second diagnosis, such as depression or a personality disorder. For example, you might not be truly addicted to the Internet or have a narcissistic personality, but with increasing Internet use, you may develop some of the less-than-pleasant symptoms of narcissism. One of the symptoms is lack of empathy; the more you use Tinder for instant gratification hookups or tweet angry, thoughtless responses to people’s comments, the more you may start to exhibit signs of lacking empathy. Are you diagnosable? No. But is it of concern? Perhaps.