Internet dependency as a symptom of depressive mood disorders

Abstract

In psychiatric contexts, the quick distribution of virtual techniques in private and professional everyday life gives rise to the question, if these can evoke a psychological addiction. Yet, the diagnostic assessment of internet or computer game dependency remains problematic.
Within a study with 23 internet-dependent patients with significant psychological strain, 18 (77.8%) were diagnosed with a depressive mood disorder by thorough clinical examination and structured interviews. The presented work compares psychometric test results of the depressed subpopulation with healthy controls matched for age, sex and school education.
In the Barrat Impulsiveness Scale patients with internet dependency scored significantly higher than the control group (p < or = 0.05), while there was no significant correlation to the Internet Addiction Scale. Becks Depression Inventory and the Symptom-Checklist subscale for depression revealed significantly higher scores within the patient group as compared to controls (p < or = 0.001). And in the Dissociative Experience Scale, the Sense of Coherence Scale and the Inventory for Interpersonal Problems the internet dependent subjects showed significantly more pathological scores than the healthy subjects (p < or = 0.05).
Since internet dependency can be understood as a novel psychopathology of well known psychiatric conditions, every psychiatrist should be able to detect and treat it adequately, as long as there is a willingness to deal with the contents and impacts of cyberspace. Especially with depressed patients, it seems to be crucial to include questions about media usage in psychiatric examination taking.

Full text

Internet dependency as a Symptom of psychiatric disorders:
A prospective study on psychiatric phenomenology and clinical relevance of Internet dependency
B. T. te Wildt, I. Putzig, M. Post, M. Zedler, Kropp S, H. M. Emrich, M. Ohlmeier
Abstract
Objective
With the rapid growth of the Internet, questions arise about its mental impacts. The presented study
examines the question, whether the dependent use of the Internet can be understood as an impulse control
disorder, an addiction or as a symptom of other psychiatric conditions.
Method
Patients seeking psychiatric assistance and fulfilling the criteria for pathological Internet use (PIU) were
examined with the Structured Clinical Interview according to DSM-IV (SCID), and a variety of
questionnaires including the Barrat-Impulsiveness-Scale (BIS), Becks-Depression-Inventory (BDI) and
the Dissociative-Experience-Scale (DES). The patient group was compared to a matched group of healthy
controls.
Results
The patient-group consisted of 23 subjects, 74 % male, with an average age of 30 years. Average time
spend in Cyberspace was 6,5 h/d, mostly in Internet-roleplays. According to SCID and BDI, 18 patients
(78%) suffered from a depressive syndrome, with 11 cases of major depressive disorder (48%) and 7 cases
of adjustment disorder with depression (30%). Compared to healthy control subjects, the patient group
presented significantly higher levels of depression (BDI), impulsivity (BIS) and dissociation (DES). 8
patients (34.8%) met criteria for a personality disorder, nine patients (39.1 %) an accentuated personality
structure, with personality types from cluster B (dramatic-eccentric) dominating in 11 cases (47.8 %).
Four patients (17,5%) suffered from a comorbid anxiety disorder. Only two patients (9%) reported former
substance abuse.
Conclusions
Rather than a diagnostic entity in itself, an addiction or an impulse control disorder, Internet dependency
appears to be a symptom of other well known psychiatric conditions, especially of depressive syndromes.
However, Cyberspace may not only provide a regressive space for people with depression, but also the
opportunity to transform an underlying neurotic conflict.
Objective
With the arrival of new media techniques, questions about their alleged addictive potential always have
been aroused. In this respect, the book was no exception (te Wildt, 2004)[1]. However, not even the
concept of TV-addiction has stood the test of time, even though some somatic addictive features may hold
valid (Kubey & Csikszentmihalyi, 2002)[2]. With the Internet representing a paradigmatic shift in media
technology, merging all presentational and communicative media and their analogous contents in one

enormous digital media, named cyberspace, the burning question appears, whether excessive Internet use
is to be viewed as a potentially hazardous addiction as substance abuse or if it represents another complex
life form in a virtual parallel world, enriching and competing with life in the real world.
Some early scientific approaches mostly from psychologist have simply declared this phenomenon as an
addiction, although according to DSM-IV (Wittchen, Zaudig, & Fydrich, 1997)[3] and ICD-10 (Dilling,
Mombour, & Schmidt, 2000)[4] it is to be classified as an impulse control disorder. The conceptualization
of impulse control disorders, however, seems to be a rather invalid conceptualization, since it combines
pathological forms of behavior such as pyromania and cleptomania, psychopathological symptoms behind
one would expect complex neurotic or personality disorders. The most convincing diagnostic entity in this
context is pathological gambling, which can be expected to be related the most to Internet dependency,
which has been originally labeled as pathological Internet use (PIU) according to Young (Young, 1996)[5],
the American pioneer in this field. Stemming from the notion that PIU is an addiction several German
studies have claimed to reveal immensely high levels of Internet dependency among users of the Internet,
ranging from 3 to 7 % (Hahn & Jerusalem, 2000; Niesing, 2000)[6, 7]. However, those studies neither
validated their nosological concept nor the psychometric instruments they were using. So, there remains a
lack in knowledge concerning the question, whether all of those subjects identified as Internet-dependent
actually suffered from a psychiatric condition and were in need for treatment.
The presented study tries to contribute to the process of determining the nature of the phenomenon of
Internet dependency by examining only those affected individuals, who were clinically ill. It tries to prove
the hypothesis, that pathological Internet use is not to be understood as an addiction in the narrow sense,
but rather as an impulse control disorder, which in itself is better explained as a symptom of a known
psychiatric disease.
Methods
To recruit participants the study was made public via the Internet, TV, radio and paper-magazines in
Germany and by posters and flyers in the city of Hanover. Within a preliminary telephone interview with
interested subjects the study’s inclusion criteria were tested. Participants had to meet both Young’s
(Young, 1999)[8] five criteria for ”pathological Internet use” (PIU) and one of Beard’s (Beard & Wolf,
2001)[9] additional criteria for ”Internet Addiction” (see table 1).
Proposed Diagnostic Criteria for Internet Addiction
All the following criteria (1-5) must be present (Young) [8]:
1. Is preoccupied with the Internet (think about previous online activity or anticipate next online session).
2. Needs to use the Internet with increased amounts of time in order to achieve satisfaction.
3. Has made unsuccessful effort to control, cut back, or stop Internet use.
4. Is restless, moody, depressed, or irritable when attempting to cut down or stop Internet use.
5. Has stayed online longer than originally intended.
At least one of the following criteria (6-8) must be present (Beard) [9]:
6. Has jeopardized or risked the loss of a significant relationship, job, educational or career opportunity.
7. Has lied to family members, therapist, or others to conceal the extent of involvement with the Internet
8. Uses the Internet as a way of escaping from the problems or of relieving a dysphoric mood
(e.g., feelings of helplessness, guilt, anxiety, depression).

Table 1: Diagnostic criteria for Internet addiction according to Beard [9] as modified from Young’s original
criteria [8]
Moreover, they had to suffer from a significant level of distress and an insight to be in need of psychiatric
assistance for their Internet dependency, to grant a clinically relevant level of psychopathology. Only adult
and physically healthy patients were accepted to be enrolled in the study. The study’s participants did not
receive any financial incentive but could expect thorough diagnostic examination taking and both a
concept and a referral for further psychiatric treatment. Additionally, 23 of healthy control subjects,
matched for sex, age and school education, were tested with the same psychometrical paradigm.
The study was performed in the outpatient department of the Department of Clinical Psychiatry and
Psychotherapy of the Medical School Hanover. First, a freelance general psychiatric history and
examination was taken by an experienced medical specialist for psychiatry and psychotherapy. Second,
the clinical diagnosis was confirmed or adjusted by the Statistical Clinical Interview according to DSM-IV
(Steinberg, Buchanan, Cichetti, & Hall, 1993)[10], involving pre- and comorbidity. Third, a test battery of
psychometric tests were performed as self reports to further investigate the patients’ media use and their
psychopathological profile.
The German Internet Dependency Scale (IDS) (Hahn & Jerusalem, 2001)[11] was performed to measure
the level of Internet dependency. The Barrat Impulsiveness Scale (BIS) (Preuss et al., 2003)[12] served to
examine the conceptualization of Internet addiction as an impulse control disorder. Derogatis’ Symptom
Checklist (SCL-90R) was applied to screen patients for other psychopathological syndromes. Becks
Depression Inventory (BDI) (Hautzinger, Bailer, Worall, & Keller, 1995)[13] was used to test for
depressive symptomatology. And the Dissociative Experience Scale (DES) (Freyberger et al., 1998)[14],
the Sense of Coherence Scale (SOC) (Schumacher, Gunzelmann, & Brähler, 2000)[15] and the Inventory
of Interpersonal Problems (IIP) (Brähler, Horowitz, Kordy, Schumacher, & Strauß, 1999)[16] was meant
to detect identity and interpersonality pathology.
The case load estimate of 23 participants per group, calculated with nQuery Adcisor 5.0 (2007)[17] was
based on the core psychometric instrument, the BIS. Data was assimilated and processed by the means of
SPSS 12.115 (2007)[18]. T-tests for unrelated populations were performed between patient and control
group. Correlational calculations were done according to Pearson. A p-value ≤ 0.05 was considered to
be significant.
Results
Mean age of the patient group was 29.7 years. 17 patients (73.9 %) were male. Since study and control
group were matched for age, sex and school education, which also manifests in an equivalent level of
intelligence (107.4 in patients and 103.3 in controls), there was no significant difference in these aspects.
However, 8 patients (34.8 %) were without apprenticeship and occupation, as opposed to the control
group, in which everybody was in training or a professional position.
There was a significant difference (p≤ 0.01) in average days and hours of private use of computers
between patients (6.5 hours, 6.95 d/w) and controls (2.3 hours, 4.00 d/w). Qualitatively, the patient groups’
predominant occupation was playing online games (60.9 %). The majority of these patients were involved
in massively multiplayer online role-playing games (MMORPGs) such as ”World of Warcraft” (50.0 %)
and to a lesser degree in multiplayer first person shooters (35.7 %). None of the subjects reported to be
dependent on console games only.

Expectantly, in the Internet dependency scale (IDS) the patient group scored significantly higher (p≤0.01)
than the control group (see table 2). The BIS also revealed a significant difference (p≤0.01) in the level of
impulsivity between patients and controls, however, there was no significant correlation within the patient
group between IDS and BIS, indicating a rather weak relation between level of Internet addiction and
impulsivity. In all three psychometric tests measuring identity (DES, SOC) and interpersonality variables
(IIP-D) patients scored significantly more pathological (p≤0.01) than controls.
Patient group (n= 23) Conrol group (n=23) Significance
mean SD mean SD P
Internet Addiction Scale (IAS) 54.19 13.18 24.52 6.78 p ≤ .001
Barrat Impulsiveness Scale (BIS) 38,60 6.25 32.91 4.89 p ≤ .01
Global Severity Index (GSI) 0.87 0.46 0.26 0.37 p ≤ .001
Positive Symptom Distress Index (PSDI) 1.80 0.43 1.27 0.32 p ≤ .001
Positive Symptom Total (PST) 42.18 18.43 15.52 17.04 p ≤ .001
Somatization (SCL-90R) 6.95 6.16 3.39 4.05 p ≤ .05
Compulsivity (SCL-90R) 11.00 6.309 4.04 5.16 p ≤ .001
Insecurity (SCL-90R) 9.91 5.68 2.74 4.96 p ≤ .001
Depression (SCL-90R) 14.82 6.21 3.39 6.62 p ≤ .001
Anxiety (SCL-90R) 7.55 7.16 2.78 4.18 p ≤ .01
Aggression (SCL-90R) 4.27 3.73 1.22 2.04 p ≤ .001
Phobia (SCL-90R) 4.45 5.56 0.65 1.19 p ≤ .01
Paranoid Ideation (SCL-90R) 5.32 4.70 1.74 3.16 p ≤ .01
Psychoticism (SCL-90R) 6.73 5.24 1.48 2.91 p ≤ .001
Becks Depression Inventory (BDI) 17.41 7.80 2.91 3.45 p ≤ .001
Dissociative Experience Scale (DES) 14.77 12.69 5.95 8.02 p ≤ .001
Sense of Coherence Scale (SOC) 52.05 6.10 60.43 5.95 p ≤ .001
Inventory for Interpersonal Problems
(IIP-D)
1.46 0.58 0.63 0.48 p ≤ .001
Table 2: Results of psychometric testing between pathological Internet users and controls
In all global parameters of the SCL-90R indicating a general level of psychopathological strain, patients
scored significantly higher (p≤0.01) than controls, confirming that the study subjects really had a
clinically relevant psychopathology. Patients scored significantly higher (p≤0.01) in 7 of the 9 Subcales
subscales of the SCL-90R, i.e. compulsivity, insecurity, depression, aggression, phobia, paranoia and
psychosis, with the subscale for depression revealing the highest score in the patient group and the most
significant difference to the control group. According to the BDI 18 of 23 patients (78,3 %) exhibited a
depressive syndrome. In the Examination and SCID I those 18 patients revealed a depressive disorder in
the narrow sense, as highlighted in dark blue (table 3).
Table 3: Diagnostic psychiatric assessment and Structured Clinical Interview (DSM-IV)
Four patients (17.5 %) suffered from a comorbid anxiety disorder. Two patients (8.7 %) had a history of
substance abuse, but none of the patients were acutely ill in that respect. According to clinical examination
and SCID II eight patients (34.8 %) had a comorbid personality disorder, nine patients (39,1 %) an
accentuated personality structure, with personality types from cluster B (dramatic-eccentric) dominating in
11 cases (47,8 %).

Conclusions
In the study, every patient with dependent Internet use presented with a psychiatric disorder other than an
impulse control disorder, suggesting that Internet addiction might be rather a symptom of well known
psychiatric diseases than a diagnostic entity in itself. This result has been confirmed by a similar German
study by Kratzer in 2006 (Kratzer, 2006)[19]. Taking into account that the group of impulse control
disorders seems to be a diagnostic construct, anyway, the fact that Internet dependency did not show a
significant correlation with the Barrat Impulsiveness Scale supports the hypothesis that the classification
as an impulse control disorder may not be valid. Since there is a distinct pattern of mostly neurotic
pathology in theses patients, the classification of Internet dependency in simple analogy to substance
abuse does not appear to be adequate, either, because it reduces the psychopathological phenomenon to
mostly quantitative aspects.
It rather seems important to ask, what Internet dependent patients are doing in Cyberspace and why. Since
almost 80 % of patients presented with clinical depression with neurotic features, Internet dependency
represents rather both an attempt to virtually solve a neurotic conflict and a symptom shift of this very
conflict. The average patient presenting with Internet addiction was a young male with slightly higher than
average level of intelligence and school education, who did not succeed in becoming a mature man with a
completed professional education, a financially independent existence and a healthy relationship. By
withdrewing withdrawing himself from his real life into a virtual parallel world, mostly within role play
games, he would try to reimburst his self-confidence by playing the hero he could not be in his real life.
Since there is well known psychiatric pathology behind PIU, therapeutic advice is easy to give. Any
psychiatrist is able to diagnose and treat Internet Addiction addiction as long as he or she is willing to
explore the underlying psychopathology and to engage in the parallel existence of their patients’ virtual
life. Some patients may need an antidepressant against depression and/or anxiety, but in the longer run,
only psychotherapeutic approaches, which identify the psychodynamics of the virtual regression will help
to reimburst real life as an attractive and fulfilling form of existence.
Concerning the nosological phenomenology of Internet dependency, the virtual performance in the
Internet, especially in Internet role play games, is far too complex to function as a clear cut addictive
stimulus, such as alcohol in alcohol abuse addiction or money in pathological gambling. Within the
Internet and its playful interactive modes, users are looking for very different kinds of experiences with
social, friendly, romantic, sexual, aggressive and many other features. To label these as addictive in the
narrow sense would almost equal to declare life itself as addictive. To assess the parallel world of the
interactive Cyberspace as a fascinating or dangerous alternative to the real world is rather a sociological
issue. Hopefully, soon mankind will be able to deal with the new digital media as with its analogous
predecessors without generating individual psychopathology. And we mustn’t forget, that human life to a
certain extent characteristically has always been virtual in some respect, anyhow.
References
[1] te Wildt, B. T. (2004). Psychische Wirkungen der neuen digitalen Medien. Fortschritte Neurologie
Psychiatrie, 72, 574-585.
[2] Kubey, R. & Csikszentmihalyi, M. (2002). Television Addiction is no mere metaphor. Scientific

American, 286, 62-68.
[3] Wittchen, H.-U., Zaudig, M., & Fydrich, T. (1997). SCID Strukturiertes Klinisches Interview für DSM-
IV Achse I und II, Handanweisung. (2. Auflage ed.) (vols. 2. Auflage) Weinheim: Hogrefe Verlag.
[4] Dilling, H., Mombour, W., & Schmidt, M. H. (2000). Internationale Klassifikation psychischer
Störungen, ICD-10 Kapitel F (V), Klinish-diagnostische Leitlinien. (4. Auflage ed.) Bern, Göttingen,
Toronto: Verlag Hans Huber.
[5] Young, K. S. (1996). Internet addiction: The emerge of a new clinical disorder. CyberPsychology and
Behavior, 1, 237-244.
[6] Hahn, A. & Jerusalem, M. (2000). Stress und Sucht im Internet (SSI-Studie). www.internetsucht.de/
publikationen/internetsucht_kurzpräsentation.pdf [On-line].
[7] Niesing, A. (2000). Zusammenhang des Persönlichkeitsmerkmals Impulsivität und Internetsucht.
Humboldt-Universität Berlin.
[8] Young, K. S. (1999). Internet Addiction: Symptoms , Evaluation and Treatment. In L.VandeCreek & T.
L. Jackson (Eds.), Innovations in Clinical Practice: A Source Book (17 ed., pp. 19-31). Sarasota:
Professional Resource Press.
[9] Beard, K. W. & Wolf, E. M. (2001). Modification in the Proposed Diagnostic Criteria for Internet
Addiction. CyberPsychology and Behavior, 4, 377-383.
[10] Steinberg, M., Buchanan, D. J., Cicchetti, D., & Hall, P. (1993). Clinical assessment of dissociative
symptoms and disorders: The Structured Clinical Interview for DSM-IV Dissociative Disorders
(SCID-D). Dissociation, 6, 3-15.
[11] Hahn, A. & Jerusalem, M. (2001). Internetsucht: Reliabilität und Validität der Online-Forschung. In
A.Theobald, M. Dreyer, & T. Starsetzki (Eds.), Online-Marktforschung. Beiträge aus Wissenschaft
und Praxis ( Wiesbaden: Gabler.
[12] Preuss, U., Rujescu, D., Giegling, I., Koller, G., Bottlender, M., Engel, R. et al. (2003). Evaluation
der deutschen Version der Barrat Impulsiveness Scale (BIS 5). Fortschritte Neurologie Psychiatrie,
71, 527-534.
[13] Hautzinger, M., Bailer, M., Worall, H., & Keller, F. (1995). Becks Depression Inventar Testhandbuch.
(2 ed.) .
[14] Freyberger, H. J., Spitzer, C., Stieglitz, R. D., Kuhn, G., Magdeburg, N., & Bernstein-Carlson, E.
(1998). Fragebogen zu dissoziativen Symptomen (FDS), Deutsche Adaptotion, Reliabilität und
Validität der amerikanischen Dissociative Experience Scale (DES). Psychotherapie, Psychosomatik
und medizinische Psychologie, 48, 223-229.
[15] Schumacher, J., Gunzelmann, T., & Brähler, E. (2000). Deutsche Normierung der Sense of Coherence
Scale von Antonovsky. Diagnostica, 46, 208-213.
[16] Brähler, E., Horowitz, L. M., Kordy, H., Schumacher, J., & Strauß, B. (1999). Zur Validierung des
Inventars zur Erfassung Interpersonaler Probleme (IIP), Ergebnisse einer Repräsntativbefragung in
Ost- und Westdeutschland. Psychotherapie, Psychosomatik, Medizinische Psychiatrie, 49, 422-431.

[17] What is nQuery Advisor® ? (2007). http://www.statsol.ie/html/nquery/nquery_home.html [On-line].
[18] SPSS® for Windows® (2007). http://www.spss.com/spss/ [On-line].
[19] Kratzer, S. (2006). Pathologische Internetnutzung - eine Pilotstudie zum Störungsbild. Pabst Science
Publishers.