Special Report: Be Prepared to Address Technological Addictions in Psychiatric Practice

When conceptualizing technology-related addictions, we limit our scope to the people who exhibit a true medical disorder. Most people can use technologies for extended periods without ill effect. Parents, teachers, and doctors may bemoan that today’s youth are spending too much time online, but in most cases the children do not develop clinical problems. And although there is a growing consensus that social media is decreasing our civility and increasing tribalization, negative online behaviors are not necessarily indicative of an underlying disorder. The question of how online technologies are influencing our wellness, happiness, and creativity is extremely relevant, but let us leave that discussion for another day and invite the sociologists, philosophers, and policymakers to join the conversation.

From a psychiatric perspective, we are primarily concerned with those individuals who continue to be preoccupied with a technology despite experiencing internal preoccupation and external consequences. Just as with substance use disorders, people with a genuine technological addiction can develop tolerance and require greater time or intensity in their behavior to achieve the same effect. People with a technological addiction also think obsessively about their behavior when not online, and they experience withdrawal symptoms if they are shut out from their technology of choice.

Only one technological addiction has been semi-officially recognized by APA as of DSM-5: internet gaming disorder is in Section III of our manual as a condition for further study. However, addiction specialists generally agree on seven major online behaviors of concern: internet gaming, online gambling, online shopping, cybersex, internet surfing, texting/emailing, and social media.

In examining the above list, one can see that these (proposed) disorders have not arisen from the depths of the World Wide Web; most of these online behaviors have addictive reflections in the real world. Our professional great grandparents Emil Kraepelin and Eugene Bleuler, for example, described compulsive shopping disorder more than a century ago, while accounts of compulsive gambling or sex addiction are older still. Even some problematic elements of social media use, such as obsessive following of photos and videos from influencers, resemble the problems seen a generation ago among youth who obsessed over fashion magazines. Given these connections, some might wonder whether we need to establish a class of technological addictions; perhaps it is better to incorporate these problems into existing frameworks of behavioral addictions—for instance, making internet gambling disorder a subtype or specifier of gambling disorder.

But while the base behaviors are similar, conducting these behaviors through a digital intermediary can alter many fundamental aspects of the disorder. In gambling disorder, for instance, individuals are diagnosed who meet a minimum set of criteria over the previous 12-month span, reflecting that gambling episodes are often sporadic and not always financially ruinous. With online gambling, the same at-risk individual now has 24/7 access to casinos, and the symptoms for diagnosis of a disorder might emerge in a couple of months or even weeks. Likewise, many people engage in cybersex specifically to experience “online dissociation,” which makes the psychology of the disorder quite different from that of those who have real-world sexual dysfunction.

Another option floated by some professionals is to develop broad diagnostic criteria based on platforms, such as internet addiction or smartphone addiction. There is certainly a rationale for this. Consider online gaming: While the ability to maintain gamers in a “flow state” contributes to addictive gaming, developers also increasingly entice gamers with elements derived from gambling (loot boxes that offer prizes of varying rarity) and shopping (releasing a game for free but incorporating microtransactions to unlock bonuses or cosmetic upgrades) arenas. Likewise, many online gambling sites have taken to gamifying their experience (for instance, by enabling players to level up their casino avatar the more they play) or adding sexual elements to separate themselves from physical casinos.

However, individuals have different motivations and gratifications when conducting each of these online activities. While gambling can be seen as a thrill of risking something of value, shopping is done for the thrill of acquiring something of value. In addition, data suggest that certain demographics may be at elevated risk of different addictions. Online gaming addiction occurs more frequently in men, while social media addiction is more likely to afflict women; texting addiction is seen more often in young adults, while shopping addiction is more common in older adults. Understanding these differences will help professionals develop more robust screening tools and treatment strategies.

For classic substances of misuse, we can reasonably look at well-validated scales, screening instruments, and diagnostic criteria to identify people who might be experiencing an addiction. But when it comes to digital devices, we mostly are at a loss. One factor we can be confident about is that time spent online is not a reliable indicator of a problem. Being routinely engaged with social media is a requirement for many corporate jobs, while competitive gaming and/or online streaming of games has become a popular pastime and money maker. How can psychiatrists distinguish a healthy, though time-consuming, habit from an unhealthy psychiatric condition?

As noted above, the seven proposed technological addictions are largely unique entities with distinct risk factors and motivations, but at times they share some thematic elements such as thrill seeking, escapism, and financial ramifications. Therefore, the work carried out to define online gaming disorder can provide a framework for diagnosing other technological addictions. Under the current DSM-5 entry, online gaming disorder is likely present if someone meets five of the following nine symptom criteria over a 12-month period:

When considering whether patients might have a technological addiction, consider whether their online activities may be related to another psychiatric diagnosis. As Robert Glick, M.D., director of the Center for Psychoanalytic Training and Research at Columbia University from 1997 to 2007 taught us, “the chief complaint is often nothing more than a dysfunctional solution to a yet unidentified problem.” The problematic engagement with technology may be a coping mechanism, maladaptive behavior, or a self-medication for an underlying psychiatric condition. Since online gaming disorder became recognized, many families have jumped on it to explain problems in their children, when emergent depression, bipolar disorder, or schizophrenia is the true diagnosis. Having an external culprit like video games or social media is a less stigmatizing—and thus more easily accepted—problem than a psychiatric illness for many.

Just as the diagnostic criteria for the seven proposed technological addictions remain a work in progress, the guidance on how to treat patients with such a disorder remains so as well. The best advice currently is to rely on what works well across the broad addiction sphere: providing patients an integrated treatment that incorporates addiction psychotherapy, pharmacological treatment of other psychiatric disorders, and possibly mutual-help (otherwise known as 12-step) facilitation.

The first approach should be professional assessment and counseling, which many general psychiatrists should be prepared to take on themselves. As with substance use disorders and other behavioral addictions, educating and counseling patients about their technological addiction is based on empathy, curiosity, and nonjudgmental support. That a proposed disorder is not yet codified in text does not disqualify someone from having a legitimate psychiatric concern.

After initial assessment and counseling, motivational interviewing and cognitive-behavioral therapy that includes mindfulness techniques may be an effective strategy in the management of many technological addictions. Furthermore, peer support groups are now available for all the technological addictions listed.

Some psychiatrists may wonder whether patients with a technological addiction should be discouraged from using technology-based treatment such as internet-based cognitive-behavioral therapy or online 12-step programs, since this may potentially keep their problem front and center. To that, one could argue that our field uses opioids to treat opioid use disorder and nicotine patches for smoking cessation, so we have successfully gone down this road before. The rise of online peer support and recovery groups has been extremely helpful in addiction treatment (even more so during the pandemic), as individuals now can connect with others in a comforting and, if desired, truly anonymous manner.

When it comes to medications, things get tricky, as no medications are approved for any behavioral addiction, technology based or otherwise. The optimal use of medications for most patients is in the management of common psychiatric comorbidities like depression or anxiety, which have been shown to worsen the problematic behavior. If you think a patient might need some medication assistance, there are a few options to consider, but caution is warranted as the evidence is very limited. Patients with internet gambling or internet shopping disorder, who have an impulsivity-driven technological addiction, might respond to naltrexone, which has moderate evidence of efficacy in non-internet gambling disorder. Patients with a compulsive technological addiction like cybersex may benefit from selective serotonin reuptake inhibitors (SSRIs), which are first-line medications for obsessive-compulsive spectrum disorders; SSRIs also decrease libido as a side effect, which may be an additional benefit for treating cybersex addiction. Finally, methylphenidate might help manage problematic internet surfing, based on some limited evidence in studies among people with attention-deficit/hyperactivity disorder.

Though data on the prevalence of technological addictions are sparse, most people use computers, tablets, and smartphones regularly with great benefits and no serious adverse consequences. Research on the phenomenology and nosology of these illnesses will help us further elucidate the distinction between problematic and nonproblematic use of technology, especially in children and young adults. Another area of new research will involve emerging technologies. By the time clinicians get a firmer grasp of today’s ailments, the technology of tomorrow—such as virtual reality and smart devices powered by artificial intelligence—will be commonplace enough to bring about a host of new problems. Finally, we will need to be ready to guide our patients, our colleagues, and the general public on how to best handle technology with an eye on maximizing its enormous potential for fulfillment, gratification, and happiness while minimizing its significant risks for dissatisfaction, misery, and despair. ■