Periscope
Refractions

Totally Wired

By VENKAT SRINIVASAN | 1 November 2013
Patrik Stollarz/AFP/Getty Images

It was around three o’clock in the morning in December 2006, and 13-year-old Willy’s family was asleep, deep in the winter darkness of their small Connecticut town. But Nashaal was wide awake, and ready for the raid. His cohort of warriors—their “guild”, they called it—needed Nashaal’s special powers; if the raid was successful, they could loot armour, maybe even the Royal Crest of Lordaeron shield. For Nashaal, the cold night held promise; everything was perfect.

Except, that is, for the jarring hum from the desktop computer in the otherwise quiet living room. Nashaal, 13-year-old Willy’s alter ego in the online role-playing game World of Warcraft, needed complete focus. Plus, if Willy’s parents found out he was still awake, they would throw a fit. Such interruptions would not do. Willy silently covered the computer with blankets to muffle the internal cooling fan. There, that should do it, he thought. Nashaal and his guild were ready.

Nashaal had transformed family dynamics. Developing his powers and plotting game strategies had become Willy’s main activity, as though he lived for and through Nashaal. His mother, Jane, thought she was looking at Willy when she saw her red-eyed son. But now, that figure appeared to be a medium for Nashaal, the new member of the household. To only know Willy, and not Nashaal, was not to know her son at all.

Jane agonized. Was Willy hooked on something she and his father, Bill, did not understand? Or was it just a game, Willy just a child, and the whole thing just a phase that would fade away? She couldn’t help but worry, though. She could hardly recognize Willy anymore; he was under the game’s spell. Was there such a thing as an addiction to a game, she wondered. Is that what she should call it? Would anyone believe her if she said that Willy was addicted? Should anyone?

"Trapped in the net: Will Internet Addiction become a 21st century epidemic?” was the sensational headline of an editorial in the October 2009 issue of the Archives of Pediatric and Adolescent Medicine (now known as the Journal of the American Medical Association Pediatrics), the oldest continuously published paediatric journal in the United States. Studies on Internet addiction have featured in about 100 scientific journals. Research spans numerous fields—from psychology to sociology, neuroscience to anthropology, and health policy to human-computer interaction. Cyberpsychology and Behaviour (not to be confused with Computers in Human Behaviour) publishes about a quarter of the research. But, despite a massive number of studies, there is no consensus on what to call the phenomenon. Video-game addiction or excessive use? Internet addiction disorder, Internet use disorder, problematic Internet use, pathological Internet use, or—of course—Internet addiction?

Without clear criteria for what constitutes these problems, understanding the scope of Internet addiction has proven to be difficult. Estimates of problematic Internet use vary between less than 1 per cent to over 8 per cent in the United States. In China and South Korea, anywhere from 2 per cent to over 35 per cent of adolescents are considered to have an Internet use problem. South Korea considers excessive Internet use as one of its most serious public health issues, with increasing reports of fatalities. A South Korean gamer collapsed and died in 2005 after playing the game Starcraft for 50 hours at an Internet café, and a 2007 paper estimated that over 210,000 South Korean children—about 2 per cent of those between 6 and 19—were afflicted with Internet addiction. There has been no test across India for excessive Internet use; even if one were attempted, it would be difficult to get credible numbers. For one thing, only 11 per cent of Indians have access to the Internet. Moreover, if a researcher sent a survey to a private school in Delhi, how and when a kid logs on (everyday, at home) might be vastly different from a public school in a smaller city (sporadically, at a cafe).

This year, a group of researchers from the University of Adelaide in Australia and the International Gaming Research Unit at Nottingham Trent University in the UK published an extensive analysis of Internet addiction tests. They looked at 63 studies that sampled 58,415 participants in 11 languages. There were 18 different tests, and no two tests were alike. The researchers found that the tests were broadly incompatible with one another, and that various measurement scales could not adequately measure addiction over time.

One recent study tried to address such testing inconsistencies. In 2012, a European Union project, Saving and Empowering Young Lives in Europe (SEYLE), conducted a coordinated Internet addiction survey across 10 European countries and Israel. They gave 12,000 adolescents aged between 14 and 16 years a questionnaire designed by Kimberly Young, a psychiatrist and professor of management sciences at St Bonaventure University in New York. Pathological Internet use averaged about 4 per cent across the 11 European countries, with boys notching up higher addiction rates than girls. But there was wide and inexplicable variation from country to country. A nation with more Internet access did not necessarily have more Internet addicts. Italy scored the lowest at a little over 1 per cent; Israel tipped the other end, at 12 per cent. Aviv Weinstein, an Israeli psychologist who studies dependence on alcohol, drugs, and, of late, the Internet, said that he was deeply concerned by such trends. (Weinstein was not part of the SEYLE research group.) “It’s like we are creating a whole new generation of zombies,” he told me.

By the early 1990s, the Internet, which began as a wired network of academic and government institutions, had expanded to include residential homes. It soon became a global communication medium, and online chatting, games and browsing developed into everyday habits. Usage exploded, from about two million worldwide Internet users in 1990 to 40 million in 1995. The increase in Internet use inspired discussion forums on Internet addiction. That year, a New York psychiatrist named Ivan Goldberg posted a memo detailing the “Seven Symptoms of Internet Addiction” on psycom.net, an online psychiatry bulletin board. One symptom was if someone accessed the Internet “more often or for longer periods of time than was intended.” Chalk up three or more of these listed symptoms, and you could call yourself an Internet addict. People thronged the site to evaluate their behaviour and self-diagnose, and soon many Internet users began to refer to themselves as addicts.

They had fallen for a prank. Goldberg’s post was a parody of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The leading reference for psychiatric research and diagnosis across the world was also the subject of ridicule for being a boundless Bible of disorder symptoms. He was contemptuous of what he considered a growing trend towards over-diagnosis among psychiatrists and the public. (In a 1997 New Yorker article, he said that having an Internet addiction support group was equivalent to having a support group for coughers.) Using the DSM’s criteria for pathological gambling, Goldberg cooked up a diagnostic protocol for Internet addiction.

Around the same time, the psychiatrist and professor of management sciences Kimberly Young began earnestly conducting research into Internet addiction. Adapting the same DSM criteria for pathological gambling that Goldberg had used in his prank, she formulated an eight-item questionnaire to assess Internet addiction among study participants. Cases were positive if they answered yes to five or more questions, including “Do you stay on-line longer than originally intended?” and “Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction?” Over 600 subjects responded after viewing college campus flyers, advertisements in local newspapers and postings on online Internet-addiction support groups.

Young’s findings, presented at the 1996 American Psychological Association meeting in Toronto, in one of the first detailed papers written on the issue, were startling. Based on her questionnaire, Young determined that over half her study participants were “dependent” on the

Internet. The media swarmed her; the research community scorned her, with some critics saying that there was bound to be sampling bias since some of her participants were from online addiction-support groups. Young’s paper acknowledged that, but she said she was nevertheless reporting what was out there; her conversations with patients had shown her that something about the Internet was addictive.

Goldberg’s hoax is history. But the addiction debate lives on, in 18 years of chat-room chatter and research papers, dismissal and advocacy, scepticism and cautious acceptance. Jerald Block, a psychiatrist in Oregon, argued in the March 2008 issue of the American Journal of Psychiatry that the American Psychiatric Association should officially recognize the disorder. “Internet addiction is resistant to treatment, entails significant risks, and has high relapse rates,” he wrote. When the American Psychiatric Association published the fifth edition of the DSM (DSM-V) in May 2013, Internet Use Disorder was included in a section of conditions that needed further research; the manual suggested a set of evaluation criteria including preoccupation, withdrawal symptoms, tolerance for ever higher doses, loss of other interests, attempts to hide the behaviour from others, and negative effects on personal and professional relationships.

The manual also added a section for behavioural addictions, a radical departure from earlier psychiatric dogma. Before, only substances such as drugs and alcohol had been considered medically addictive. For now, the sole behavioural addiction in the manual is excessive gambling, which used to be classified as an impulse-control disorder (a category also used by Internet-addiction advocates in the past). Wherever gambling goes, however, other behavioural traits, including Internet addiction, could easily follow.

What the DSM says matters. A mention in the 992-page tome adds legitimacy to pathologies that might otherwise have been ignored, doubted or considered innocuous. Although it’s not a treatment guide, clinicians—not only psychiatrists, but also general practitioners—often cross-check their patients’ stories with symptoms mentioned in the manual to arrive at diagnoses. These diagnoses help guide treatment, including the prescription of antidepressants. Moreover, in the United States, if you have a ‘DSM-validated’ disease, your health insurance company could subsidize the bill; if not, the burden is likely all yours. Increased awareness could even boost patient visits to mental health clinics. And inclusion in the DSM will unleash psychiatric research funding.

Although the DSM is mainly used in the US, it is the global standard for psychiatric research and thus for the development of new approaches to diagnosis, treatment and disease funding. The new edition was the product of a decade of deliberation among 1500 experts across the globe. “Its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America,” the Indian Psychiatric Society wrote in a review paper earlier this year. “The younger generation of psychiatrists, raised in the DSM tradition, consider the diagnostic system and criteria as authoritative text.”

The DSM’s innovations with regard to behavioural addictions and other conditions sparked an outcry, and many psychiatrists believe that new classifications included in the manual will do more harm than good. “This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry,” Allen Frances, a professor emeritus at Duke University, said in December 2012 on the website of Psychology Today, a popular American mental health magazine. Frances, who chaired the taskforce that drafted the DSM-IV, objected to changes in the fifth edition, such as making excessive grief a Major Depressive Disorder, making excessive eating a Binge Eating Disorder, and adding the section on behavioural addiction. He fears these will create a slippery slope whereby any excessive behaviour will be considered a disorder. “Watch out for careless over-diagnosis of Internet and sex addiction,” he wrote.

Around the time Kimberly Young released her findings in 1996, Willy’s mother, Jane, was using the family computer for her legal work at home in Brooklyn, New York. Willy, then four years old, was immediately drawn to the machine, and Jane appreciated its potential as an educational tool. She bought “Reader Rabbit”, a software programme, to help Willy learn to read.

Then, in 1999, Willy developed an interest in Age of Empires, a computer-based strategy game series spanning time from the Stone Age and the Iron Age to the Spanish conquest of Mexico. Jane used the series as a disciplinary aid, rewarding Willy with game time in return for cleaning his room or doing his homework. “It was the perfect carrot and the perfect stick,” she said. Since the computer was in his parents’ bedroom, Willy couldn’t play the game for long. Living in Brooklyn also gave the family enough to do outside their home. The computer was a comfortable addition to family life—pleasurable in spurts without being overwhelming. “It was sort of like ice cream,” she said.

The family didn’t stay long in Brooklyn. Willy’s grandmother lived with them, and after she died in 1998, Bill wanted to move out of the city and away from cherished but painful memories of his mother. He and Jane were also concerned about school quality and wanted to be closer to their church, in Connecticut. In 2000, they moved with Willy and his siblings to a small town along the New England state’s affluent Gold Coast—a huge change from big and bustling New York City.

There, Willy and his 10-year-old brother, Joe, enrolled in Boy Scouts, but it was no substitute for busy Brooklyn and for the pleasures Willy derived from the computer. On a field trip, Willy struck up a friendship with David, another Boy Scout. Soon, David and Willy began hanging out a lot, often playing computer games together. To his parents, this didn’t raise any red flags. Willy was like any other eight-year-old that gets hooked on an activity.

What started as an ordinary friendship, however, soon became exclusively centred on computer games. Willy and David camped out in front of the computer during sleepovers. They’d game after school, day after day, and through weekends. They would order junk food, wrap themselves up in blankets and burrow all night into the worlds contained in the computer. “They got big bags of candy and bottles of pop and played it till they fell asleep on the floor,” Jane told me. Once, Willy and David played for 18 hours at a stretch. To keep themselves awake and “caffeinated,” they guzzled 20 cans of diet soda. Jane began to wonder about their behaviour, but wasn’t sure that it was anything to worry about. “So many kids game, what’s the problem?” she asked herself. Still, computer games no longer seemed as harmless as ice cream.

Facing high real estate costs, Willy’s family moved again in 2004, this time to a more affordable town about an hour east. Around the same time, Jane, concerned about giving her children a rounded education, decided that they would be better off learning at home. “We could have more freedom,” Jane said. “Learn more stuff.”

The changes seemed to have a significant impact on Willy, who was now 12. “Willy was Mr Social before we moved,” Katie, his younger sister, told me. But with the new distance from a past social life and an increasing pull online, David, his fellow gamer, became his only real-life friend, and their game-based friendship blossomed.

Willy and David’s bond reached a peak when World of Warcraft came out in November 2004. It was a hook unlike anything Willy had encountered before—and nothing like his relatively isolated surroundings in small-town Connecticut. Nobody in his new surroundings knew much of Willy except David and Willy’s family. But in the World of Warcraft, Willy’s avatar, Nashaal, was popular. Nashaal shone. Willy asked his parents to pay for the game’s $15 monthly subscription fee instead of giving him an allowance. “He would talk to us about it all the time,” Joe said. “As an older brother, I thought my younger brother was just being a little pathetic.”

By 2005, when he was 13, Willy’s life revolved around World of Warcraft strategy books, guild meetings at designated times, and the nurturing of Nashaal. Never one to participate in outdoor sports, Willy now stopped going to movies and parties. Vacations were spent at home. Schoolwork ground to a minimum. David and his family weren’t as affected by the game. His mom never saw much of it since David used Willy’s subscription to play, and often at Willy’s place. David also went to a local public school, where he could interact with other kids. But all Willy did was game, Jane said, or fight with her about playing. She remembered the part in Lewis Carroll’s Alice’s Adventures in Wonderland in which the Cheshire Cat fades away to nothingness except for its grin. “I watched him disappear in front of my eyes,” she said.

Addiction entered the English vernacular more than 400 years ago. Back then, the word merely indicated a strong inclination. In Shakespeare’s play Henry V, written around 1599, the Archbishop of Canterbury mentioned the king’s “addiction” to activities of little importance, ‘his hours fill’d up with riots, banquets, sports.’

Through much of the 17th century, to be addicted usually meant that you were in the habit of doing something, and that habit was seen as a product of choice; an individual got drunk on alcohol because he wanted to drink, not because he had some underlying pathology driving him to the bottle. Even when psychiatry started as a clinical field in the 18th century, addiction was still considered a matter of habituation and choice. At the same time, physicians associated individuals’ personality traits with local factors, such as the physical environment. For instance, in his book The English Malady, published in 1734, George Cheyne described England as a country ‘particularly liable to the morbus anglicus (despair and suicide)’ due to climate, diet and the pace of life.

By the latter half of the 18th century, some writers started using the word “addiction” for severe inclinations that didn’t seem like a matter of choice. People began describing alcoholics as individuals who lacked control over irresistible urges. What these addicts needed was not to make different choices, but to be reformed. This new view of addiction coexisted with the choice model, and, in the 19th century, with the rise of the opium trade, became dominant. More and more, it was thought that alcohol and drugs stripped from addicts the willpower to control their habits. At the same time, these external forces were increasingly thought of as being independent of local environment or culture. Addiction was no longer a way to describe behaviours; it became a state—a disease—that needed to be fixed.

This disease model of addiction was predominant well into the 20th century. In the 1960s, however, an influential antipsychiatry movement evolved in academic and intellectual circles, and issued a compelling set of protests against this approach to addiction, and mental illness in general. The philosopher Michel Foucault in many ways articulated the core position of this movement when he wrote, in his 1961 book The History of Madness in the Classical Age, that psychiatric dogma might be as much a reflection of the moral assumptions of a given generation as the result of independent scientific research.

Today, addiction often refers to debilitating conditions that are seen as largely outside individuals’ control and independent of context. As with many other psychological afflictions, the DSM seems to describe addiction as if it were a universal disorder, detectable across a diversity of human populations. Although the manual has a section on “cultural formulation” that tries to bring environment factors into the picture, this contingent approach is not integral to DSM categories. “Context, history and politics are regarded as non-essential and somehow external” to disease, wrote the Indian Psychiatric Society in its recent critique of the DSM.

Outside the walls of medicine, however, addiction is still frequently used to describe any “compulsive” behaviour, from exercising to updating one’s Facebook status. To ask whether such activities should count as addictions, researchers and theorists are now reconsidering what addiction is in the first place. There have also been new attempts to explore how addiction, and conceptions of addiction, interact with personal history, local environment, and culture.

These new approaches cluster around three broad approaches to understanding the nature of addiction. One, the neuroscience approach,studies how addiction manifests itself in the circuitry and chemistry of the brain. This model generally takes substance abuse as its paradigm, and often sees addiction as the result of drugs that flick certain neurological switches in the brain.

“Addiction is a brain disease,” Alan Leshner, then head of the National Institute on Drug Abuse in the US, wrote unequivocally in a 1997 Science editorial. The focus of most neuroscientific studies of addiction has been the brain’s so-called ‘reward centre’. Located deep in the brain, this region largely drives our feelings of satisfaction and motivation.

In the 1950s, James Olds and Peter Milner, two postdoctoral researchers at Canada’s McGill University, used rats, which have similar reward centres, to demonstrate the importance of this region. They implanted electrodes in a part of the rats’ brains called the nucleus accumbens, the major component of the reward centre. The rats would receive an electric stimulus in the nucleus accumbens whenever they scurried to a specific corner in a cage. Instead of running away from the area that caused the electrical shock, the rats kept returning to that corner. In another test, rats stimulated themselves thousands of times every hour for 24 hours by pressing a lever that caused the electrodes to send similar electrical signals into their brains; they ignored all other activities. There was, Olds and Milner noted, some method to the rats’ impulse; it was as if the rodents were addicted to the stimulus.

This was the first series of experiments that showed it was possible to create pleasure, and behaviour that approximated certain features of addiction, by directly triggering the brain’s reward centre. Other external stimuli, such as food, were known to have similar effects. However, instead of directly activating the reward centre, like the electrodes in the rats’ brains, these other stimuli follow a complex set of message transfers. If the front of the brain, the cortex, receives a stimulus through one of the five senses, it forwards that signal to a part of the reward centre called the ventral tegmental area. Neurons in this area then produce the chemical dopamine, a neurotransmitter that flows into the synapses between brain cells and lodges in the receptors of adjacent neurons, stimulating those cells into certain kinds of response. Dopamine moves from neuron to neuron through the brain along broadly predictable courses known as ‘dopamine pathways’. One of these pathways triggers feelings of pleasure by connecting with the nucleus accumbens, the region where the McGill scientists had plugged their electrodes.

Drugs, too, work to a great extent by altering the chemical balance and stimulating neurological pathways in the brain. The brain has a variety of mechanisms that help it regulate the flow of neurotransmitters. For example, dopamine usually travels from one neuron, across a synapse, to another neuron, where it typically attaches to a structure called a receptor and stimulates the receiving neuron. Once that’s done, the transmitting neuron uses structures called transporters to absorb any excess dopamine that gets stuck in the synapses. This process, called reuptake, ensures that you never get too great a dose of any one neurological stimulus. In addition, the sending neuron has its own receptors that regulate how much dopamine gets out in the first place.

All of these regulatory mechanisms can be inhibited, however, if other molecules block the relevant receptors or transporters. When transporters are affected, reuptake is decreased and more of the stimulating neurochemical, such as dopamine, is free to flow around the brain, thereby increasing dopamine’s effects. Many antidepressants work on the same principle, blocking transporters designed to reuptake serotonin, a neurotransmitter that plays an important role in inducing feelings of well-being. In a similar but more potent way, cocaine inhibits the reuptake of dopamine; the more cocaine a person ingests, the more dopamine stays in the synapses that fire the dopamine pathway and, ultimately, the reward centre.

Over time, however, the brain responds to such dopamine ‘overdoses’ by producing less of the pleasure-generating neurotransmitter. As a result, an addict needs ever greater quantities of of cocaine to release the levels of dopamine needed to get an equivalent high. Activities that aren’t able to artificially flood the brain with dopamine in this way become less and less pleasurable. If you take away the drug, you take away the mechanism that an addict has for stimulating his reward centre, and cravings set in.

Behavioural addictions—shopping, sex addiction, gambling, and Internet-based activities such as compulsive pornography viewing and gaming—are now being understood on the neurophysiological model of drugs. In a widely cited 2010 review paper, four researchers in the US wrote that addictive behaviours, including Internet use, trigger activity in the same dopamine and serotonin pathways as drugs do. In other words, humans get a neurochemical rush, in varying degrees, when having sex, checking email after a long gap, sitting at a slot machine or playing an immersive game; in each of these activities, dopamine surges through the reward centre. Over time, as with substance addictions, the current theory is that the brain tries to respond to the overdose, and people end up having to gamble more, search for more pornography, or play an engrossing online game continuously to get the same effect.

The second paradigm for understanding addiction is to look outwards, at symptoms and consequences. Howard Shaffer, a psychologist at Harvard University, proposed in 2004 that all addictions should be viewed as one single condition, which he termed an “addiction syndrome”, with a set of symptoms and a spectrum of severity. For instance, a patient could go to a doctor and complain of mild withdrawal anxiety the day after a night of drinking. Another could complain of moderate withdrawal anxiety during a break from days of gaming, and another could have the same symptom, but much more intensely, after a week away from his cocaine fix. The symptom—withdrawal anxiety—is the same in each patient, even though it has been produced by a variety of behaviours and is of varying intensity. Now, the doctor could diagnose each patient differently, one with alcohol addiction, another with cocaine addiction, and another with video-game addiction. But they might all be patients with the same manifestation of the addiction syndrome. In such a scenario, what would be the value of pinning a specific substance or behavioural label on the addiction and looking for the neurochemical evidences of say, an Internet addiction?

This second paradigm for addiction brings back elements of the 17th-century view that addiction is just a habituation, not a disease. Drinking five beers every evening, playing 10 straight hours of World of Warcraft or smoking marijuana may be abnormal or excessive in the eyes of some, but sheer quantity isn’t in itself bad. Jim Orford, an emeritus professor of clinical and community psychology at the University of Birmingham, UK, articulated this view in a 2001 paper in the journal Addiction. The focus, he argued, should never be on an the volume of the habit, but on its consequences, including the interpersonal conflict that arises from it. Driving rashly after five beers, stealing money to pay for marijuana, or avoiding family and work to game might be issues that need to be resolved, but there is “no point at which normality ends and abnormality begins,” Orford wrote.

That murky boundary between normal and abnormal is where a third view of addiction shows up. While this view considers both the previous approaches, it attempts a more holistic understanding. An addiction, in this view, always starts as an external event, in which context, not a change in our brain cells, is key. Sure, we are partly defined by our internal wiring. But we define ourselves as much by our external influences, what we do, and why we do what we do. For instance, alcoholism cannot be understood simply as a brain disease: it is something that starts off as a cultural event. Think of family dinners, bars, community gatherings and the possibilities that alcohol offers—business opportunities, relationships, or just a good conversation.

Evenings spent drinking and socializing with friends lodge memories in the brain, and understanding how memory forms is crucial to understanding how addiction shapes our brain. The brain is malleable for as long as we live, tweaked by everything we do, every event we witness. Although alcohol causes chemical changes in the brain that could lead to craving, we are also driven by our desire for a repetition of the memories or the feelings those social events may have invoked.

In a similar way, Daniel Lende, an anthropologist at the University of South Florida, believes that addiction isn’t just about pleasure; it’s also about desire—not just about the chemicals in the brain, but also external reinforcements. In an interview with Scientific American, Lende, who also runs the Public Library of Science blog on neuroanthropology, which studies the bridges between brains and culture, illustrated the role of context and memory in addiction with the following anecdote. A former drug addict in Colombia was just out of treatment, was broke, and needed a free ride on a bus. The bus driver told the addict that he could ride if he stole a watch for him. The addict had led a past life that circled around theft, money and drugs. The driver’s words triggered a series of memories and cravings for that life—and it almost triggered a relapse.

The addict goes in search of the drug, but what he wants is the memories and their effect, not the substance. In other words, the addict wants an alternate or virtual reality built of his memories rather than the reality he is living now, and the drug seems to be the only way to try and reach those memories. Nothing else seems to assemble the dream world, and the addict has no other desires. The philosopher Gilles Deleuze studied this yin-yang nature of the real and the virtual and wrote that the desire for alternate reality starts closing doors on other possibilities. The addict’s body, Deleuze provocatively wrote, is like a body without organs; it exists purely as a medium for that one thing (the drug) that might make it possible for him to reach that one desire (his alternate reality). Over time, the body will undergo chemical changes, and the addictive behaviour may have huge personal costs, but the alternate world is the only world that an addict sees. If alcoholism has pushed an addict into this virtual world and has ravaged his brain chemistry, then it may be as important to focus on opening other doors into this imagined world as it may be to wean the addict off alcohol.

Each of these approaches to addiction can be applied to understanding the influence of the Internet. During the same period that Willy was getting sucked into World of Warcraft, David Greenfield started treating patients for Internet addiction at the Center for Internet and Technology Addiction, in Connecticut. Greenfield, the centre’s founder and a practising psychologist, said the Internet was “the world’s biggest slot machine, with an IV-drip to the brain feeding it dopamine.” Gamblers become hooked on slot machines, he explained, because every once in a while they receive a reward, and that reward drives a dopamine surge in their brains. They don’t know when the coins will pour from the machine, or how many coins there will be. The Internet works in a similar way, and Internet addicts can easily lose their sense of space and time (as gamblers do at slot machines) while they hunt for the dopamine rewards that gaming, social networking and Internet surfing can produce. “We have accidentally discovered the most addictive form of media ever known,” Greenfield said.

A 2011 neuroscience study from South Korea confirmed this view by showing that Internet addicts—defined using a version of the Young questionnaire—had reduced levels of certain dopamine receptors as compared to a control group. With fewer receptors, dopamine stays in the synapses and fires the dopamine pathway, through other available receptors, for longer periods of time. Critics, however, maintain that the Internet is merely a medium that facilitates addiction. If the Internet itself is just a conduit—for news, work, education, communication, friends and entertainment—how can one get addicted to it? “Gambling addiction, shopping addiction, game playing addiction—all of these are plausible,” Sara Kiesler, a human–computer interaction researcher at Carnegie Mellon University, told me. “But not Internet addiction.”

This is where approaching addiction as a syndrome is useful, where it could manifest in various ways, depending on circumstance—as a gambling urge, a hunt for cocaine, or immersion into a game. In fact, the form that a person’s addiction syndrome takes may even change over the course of her life. Research by Mark Griffiths, a chartered psychologist and the director of the International Gaming Research Unit, has suggested that adolescents addicted to games are prone to gambling later in life.

As with other manifestations of the addiction syndrome, it’s important to focus on the consequences, and not the quantity, of online behaviours. A 2011 paper from Griffiths’ institute reviewed 58 studies on gaming addiction and determined that how much one plays a game is not in and of itself indicative of an addiction. A big appetite for a game does not necessarily make it harmful, and there is much that gamers gain from their online experiences. Alexander Voiskounsky, a psychologist at the Moscow Lomonosov State University in Russia, pointed out that people game for the social network it provides, to experience certain kinds of imagination, and to be part of a team. “Online gamers are not on an island,” he insisted.

If the popularity of online games is any indication, Voiskounsky is right. Massively multiplayer online role-playing games (MMORPGs)—“massive” because they have millions of subscribers, “multiplayer online” because people play against each other on the Internet, and “role-playing” because players create avatars—are one of the fastest growing entertainment markets on the planet. World of Warcraft is the most popular of these worlds in the history of the Internet. It has over nine million monthly subscribers (although competition from other games has driven this figure down from 12 million in 2010). It dominates 45 per cent of the MMORPG market, and makes $1.4 billion in annual revenues for Blizzard Entertainment, the company that owns the brand. Television and YouTube commercials for the game have starred the actor Jean-Claude Van Damme, and the rock-and-roll legend Ozzy Osbourne. South Park, the popular cartoon, even satirised the game in an episode titled, “Make Love, Not Warcraft”.

Successful multiplayer online games are like page-turning novels: they are tale-driven. World of Warcraft plays out in the fantasy world of Azeroth and its numerous continents. There is a delicate balance between two large factions—the Alliance, humans, gnomes and the like, and the Horde, made up of species like orcs. Gamers create an online avatar, the way Willy created Nashaal, based on a variety of races and classes. However, instead of having a single storyline, like traditional computer games, the characters act out a multitude of stories. Breathtaking landscapes, detailed worlds and intricate plot twists unfold throughout game play. A player scours the land, builds alliances, completes missions and strategically beefs up his character’s strength. Players slowly develop their avatars, all while chatting online, mostly in character, with others. The game plays out like an alternate reality for the player—a parallel universe, like the one Deleuze conceived of, that triggers positive feelings.

Griffiths has explored how structural characteristics of a game give it an addictive quality. Sound effects and colourful displays heighten player arousal, as do immersive life-like scenes that bring about a reality seemingly better than the real world. “The blurring of the boundaries between the real and the virtual appears particularly relevant,” Griffiths wrote in the 2011 paper.

In her book Life on the Screen, Sherry Turkle, a professor of social studies and technology at the Massachusetts Institute of Technology, writes that players of these Internet-based games “suspend disbelief and become absorbed in what is happening on the screen”. They start to see the world differently and have a different paradigm for reality. For example, SecondLife, another virtual-reality game, provides players with an alter ego that inhabits an alter world where members are not restricted by real-world geography. Its immersive and communal environment starts to have more value than the “real” world. Like Deleuze’s view of alcoholics, an addictive gamer may search for the effect—friendships, memories of bravado, high self-esteem—that an immersive game offers nearly every time they play. The second life very easily becomes the first.

Jane found it nearly impossible to stop Willy from playing World of Warcraft. In her desperation, she resorted to weak attempts at controlling Willy’s game time. “Two hours a day,” she would tell him. He would agree—but then two hours would become three, and three became six, eight, twelve. Jane tried her old carrot-and-stick tactics. If he’d game less than two hours a day, she promised to take him out to dinner, or he could get new shoes. But World of Warcraft was far stronger than any of his mother’s inducements. The rewards of Nashaal’s world were the only ones Willy wanted.

World of Warcraft was more than just a game for Willy. It was a social network, and in his case, his only network. He and his “guildees,” he said, would usually plot out strategies for the game. They’d also chat about real life events—wishing each other a happy new year, for instance, like the rest of the world did. “I was sometimes only chatting, not playing,” Willy told me. “That’s part of the pull.”

Willy felt his family didn’t understand him or the game. He and Nashaal led a normal teenage life with friends, exciting conquests, and the associated challenge, camaraderie, secrets and banter. Why did his family find that so disappointing? He had a life. Just not the one they wanted. To Jane and the family, though, there seemed no way to reach Willy, and they felt his alarming behaviour kept getting worse.

In November 2006, his 13-year-old sister, Katie, received an award in recognition of her work as a youth volunteer in the Girl Scouts. The women’s club at their local church invited her to give a speech. The whole family excitedly gathered at the church that afternoon—except for Willy.

Willy, then 14, was supposed to leave from home later and meet the rest of the family at 1 p.m. Instead, he spent the whole day being Nashaal. Nashaal didn’t know Katie, and never showed up to hear her speak. “Everybody else from the church knew he wasn’t there,” Katie recalled. When the family returned home, Jane went up to Willy’s room and yelled at him. Willy wasn’t sure what the fuss was about.

The game had a powerful hold over him. He later compared his experience of World of Warcraft to the movie, The Matrix, in which humans spent their lives plugged into a virtual world. “I felt like the game had a hand on one side, and my mom had a hand on the other,” he said. As long as he was in the game, he felt calm. But whenever his mom came around with that hand, he felt “it was a tussle, a thing to be avoided”.

By the time he was 15, Willy’s behaviour started to resemble that of a six-year-old. He refused to accede to any bargains, and resorted to crying and fidgeting. Jane cried, too, and set timers to monitor his game playing. Willy became irritable. “The game released you from the concept of time,” he said. “So it was very irritating to be brought back to a world that actually did have that.” He didn’t want to be Willy anymore. “Outside life became a means to an end,” he said.

By 2007, Willy was averaging 2,000 hours a year on World of Warcraft, and was now one of the best players in the game. Over the years, he’d also become increasingly adept with gadgets. In 2005, for instance, 13-year-old Willy and his father put together a desktop computer from old computer parts. He would easily make model rockets and fighter planes, and was the designated engineer in the family. But mostly he did anything he could to play the game. He lied about Boy Scouts meetings, saying they had been cancelled, so that he could sit in front of the computer. One weekday afternoon in May 2007, when Jane was away, he was scheduled to take the train to a Boy Scouts outing, his first in many months. Willy’s dad, Bill, was working in New York City and offered to drive to New Haven on his way back so that he could pick Willy up after the trip. Willy was to wait at the New Haven train station. On the way back from work, Bill got stuck in a long and tiring traffic jam. He finally reached New Haven late at night. Willy, though, was nowhere at the station. He had never gone to the Boy Scouts meeting, opting instead to be Nashaal. His parents were furious. “It was the straw that broke the camel’s back,” Jane told me.

Jane began to search online to see if there was such a thing as gaming addiction. Discussion forums and support groups like Online Gamers Anonymous popped up. Much of what these sites said fit well with Jane’s experience of Willy. Until then, his life had felt to her like a jigsaw puzzle without the picture clue. Now, things started to make sense, as she began to see her son through this lens of addiction. She herself had been a chain smoker growing up, often smoking more than a pack a day. “I understood why he was acting the way he was,” she said. “He was part of something that was beyond himself.” She’d stopped in her late 20s, using a 12-step program that guided her out of it. “I saw myself in him,” she said. “If you’re really addicted, there’s no such thing as controlling it.”

The addiction treatment market isn’t well defined. Richard Friedman, a psychiatry professor at New York City’s Weill Cornell Medical College, remembered a patient he treated after she complained to him in 2006 of excessive Scrabble and Risk playing on the Internet. The roots of her problem, Friedman diagnosed, lay in procrastination and her history of depression. In technical terms, she had what clinicians call comorbidity—the presence of multiple interacting conditions in the same patient. Friedman prescribed an anti-depressant, her husband password protected the computer to prevent her access, she started a job, and lost her interest in playing online Scrabble soon after.

Although there are no medicines specifically approved to treat behavioural addictions, researchers have tried to use substance-abuse medications to treat behaviours. Naltrexone is the most prominent cross-platform drug. It is typically used for blocking the feeling of pleasure from substances like alcohol and cocaine. It has now been used to treat gambling, Internet addiction, and kleptomania with some success. Another drug that has been used in attempts to control addiction is escitalopram, an anti-depressant that regulates serotonin levels. Neither medicine has had extensive trials for Internet addiction treatment though.

David Greenfield, at the Center for Internet and Technology Addiction, who uses both behavioural therapy and medication, is pained that the debate in psychiatry is still about diagnosis. Greenfield feels diagnoses are a non-issue since doctors term a behavioural addiction with whatever gets reimbursement. “Every doctor has been doing it since they got out of school,” he says. The DSM-IV had a catch-all category, “Impulsive-Compulsive Disorder, Not Otherwise Specified,” that could be used for Internet-use-disorder patients. But that’s hardly the point, he felt. To him, excessive gaming is an issue, whether or not it is an addiction.

Having an official disorder is a double-edged sword. It makes it okay to talk about it in public. But it also gives the diagnosis a disease-like quality, used to explain away a patient’s symptoms.

Over the last decade, a number of centres like Greenfield’s have sprung up around the world, specializing in treating behavioural, Internet-related and other addictions using a range of methods. The Institute of Mind Control and Personal Transformation at Bangalore uses alternate techniques like Reiki, a Japanese spiritual practice that uses the palm of the hand for transferring energy. (They have seen about a dozen technology addiction cases in total.) The Muktangan Rehabilitation Center in Pune favours a regimented timetable for all its “inmates” who have had excesses of drugs or habits. The centre follows a five-week course, a timed schedule of yoga, physical exercise, group and individual discussion sessions, prayer and medicines. Another US Internet addiction rehabilitation clinic, reSTART, offers a 45-day in-patient program—a therapeutic “detoxification” retreat.

The General Hospital of Beijing Military Region has an Internet Addiction Treatment Center that has treated more than 3,500 people, predominantly male teenagers. The centre does it all: medicine, bringing in the family, military drills, and cognitive behavioural therapy—a combination of time management strategies, self-awareness and resolving conflict.

New avenues for treatment are also opening up through recent research in brain training. Working memory, the system in the brain that is used to plan and recall quickly, is also the place that tells an individual whether she should do what gives her pleasure in the moment, or delay and plan for a future and better reward. By training the working memory, some researchers believe they can help addicts forego their substance cravings in favour of longer-term benefits, but the field is still young and the method largely unproven.

The most common way to combat an addiction is to, of course, simply stop doing whatever it is that is addictive. But abstinence is also easier prescribed than practised. Stopping a drug that opened a new worldview is to deny the worldview. An addict will invariably do whatever it takes to find that world again. “Abstinence is a failed policy,” wrote Howard Kushner, in a 2010 cultural review of addiction. “It denies the historical evidence that humans in all societies and cultures have and continue to rely on substances to alter their consciousness.”

In May 2007, after browsing addiction support-groups like Online Gamers Anonymous, Jane started to see Willy as a gaming addict. Her family couldn’t risk losing Willy to Nashaal. Abstinence seemed to them to be the right way forward: Nashaal had to go. Willy was forced to sell his alter ego on eBay for US$350 in June 2007. He bid farewell to his guild. His friend, David, who used to hang out with him, called within 24 hours of learning that Willy was leaving the game. He hasn’t been in touch since.

The first week without Nashaal was the most dramatic for the family. A change would do their 15-year-old some good, they hoped. Selecting a clear summer day in June 2007, the family decided to set out to the Hammonasset Beach State Park on the Connecticut shores. But Willy stayed in the car throughout the family’s time at the beach and cried.

“I don’t think life’s worth living without it,” he would often plead with his mom. “I’ll do anything you want if you let me play for 15 minutes.” Jane paused as she recounted what he said. “It’s a lot to ask of somebody of that age, especially when everybody else is doing it,” said Jane. “I think he was relieved to get off the merry-go-round. But it was sad to see him begging.”

Willy stopped eating regularly. He had three “relapses” in the next two years, including one that got him back on World of Warcraft. He set up a PayPal account with money from his parents and bid for a character on eBay. Maybe someone else out there was selling their character like he had done. He wanted his world back.

Willy’s desire to game gradually began to subside with constant intervention from his parents. “You see this as us against you,” Jane would say, trying to reason with him. “But really, it’s you against you.” To her, the game was preventing Willy from realizing his potential.

Willy entered high school in the fall of 2007. Jane could not keep up with the higher education load and also feared the consequences of him staying at home. For the most part, the family pushed this self-devised rehab, which involved a strict routine, abstinence, and talking Willy through the withdrawal phase. He went to 12-step meetings, doctors and counsellors. One psychiatrist who thought he had attention-deficit disorder (ADD) prescribed Adderall. (The doctor felt afterward that he did not have the disorder, and stopped the medication.)

The transition back to a school was hard for Willy. At home, “there were no due dates” for assignments. “It was hard to be organized,” he said. He reflected back on his time gaming, thinking of its hook, how he cracked complex game plays, climbing up the levels. “It’s an icon of your accomplishments,” he told me in 2009. “And it’s an icon of what you’ve not accomplished.”

Willy was in 11th grade then. It was more than a year after Willy first quit World of Warcraft. He said he hung out with more people and started dating. He spent more time in Boy Scouts, eagerly preparing for an Eagle Scouts Award. He also started participating in FIRST Robotics, a NASA-initiated program at his school. “It’s sort of a team sport for those who do science and math,” Jane explained. Willy worked on a game that involved moving robots across a slippery surface. He coded for the project.

“I feel really good because it is not gaming,” Jane said.

“It’s just something I am interested in,” Willy replied.

“You’re not so much thinking now that you want do that for a career?” Jane asked.

“No.”

There was an awkward pause.

“I don’t think it will be a good environment to be in,” Jane said.

“No, you’ll be around computers the whole day,” said Willy.

He wanted to become a doctor. Jane liked that.

"It got worse before it got better,” Jane told me earlier this year. Willy had hacked into his school’s computer network. “They were particularly angry with him,” Jane said. “For them, it was hack proof.” Around the same time though, Willy had aced a national merit test and was called down to the school office for being a semifinalist. “Two hours later, they called him again,” said Jane. The police wanted to inquire about the computer crime. Willy was suspended for a week. And then, again, a couple more times. After graduation, the family insisted that he stay at home and not go to college immediately, fearing it would have been money down the drain. Willy worked at a bakery for a year after high school.

He is now enrolled in a degree program in the University of Connecticut, and has an interest in biochemistry. He still works four days a week at the bakery, and commutes to the campus. He wants to work a couple of years after college, said Jane, and then go for his masters and doctorate. “If we force him to be very busy, it works well,” said Jane. “But he’s going to be 21, and he’s going to have to leave the nest.”  

It was around three o’clock in the morning in December 2006, and 13-year-old Willy’s family was asleep, deep in the winter darkness of their small Connecticut town. But Nashaal was wide awake, and ready for the raid. His cohort of warriors—their “guild”, they called it—needed Nashaal’s special powers; if the raid was successful, they could loot armour, maybe even the Royal Crest of Lordaeron shield. For Nashaal, the cold night held promise; everything was perfect.

Except, that is, for the jarring hum from the desktop computer in the otherwise quiet living room. Nashaal, 13-year-old Willy’s alter ego in the online role-playing game World of Warcraft, needed complete focus. Plus, if Willy’s parents found out he was still awake, they would throw a fit. Such interruptions would not do. Willy silently covered the computer with blankets to muffle the internal cooling fan. There, that should do it, he thought. Nashaal and his guild were ready.

Nashaal had transformed family dynamics. Developing his powers and plotting game strategies had become Willy’s main activity, as though he lived for and through Nashaal. His mother, Jane, thought she was looking at Willy when she saw her red-eyed son. But now, that figure appeared to be a medium for Nashaal, the new member of the household. To only know Willy, and not Nashaal, was not to know her son at all.

Jane agonized. Was Willy hooked on something she and his father, Bill, did not understand? Or was it just a game, Willy just a child, and the whole thing just a phase that would fade away? She couldn’t help but worry, though. She could hardly recognize Willy anymore; he was under the game’s spell. Was there such a thing as an addiction to a game, she wondered. Is that what she should call it? Would anyone believe her if she said that Willy was addicted? Should anyone?

"Trapped in the net: Will Internet Addiction become a 21st century epidemic?” was the sensational headline of an editorial in the October 2009 issue of the Archives of Pediatric and Adolescent Medicine (now known as the Journal of the American Medical Association Pediatrics), the oldest continuously published paediatric journal in the United States. Studies on Internet addiction have featured in about 100 scientific journals. Research spans numerous fields—from psychology to sociology, neuroscience to anthropology, and health policy to human-computer interaction. Cyberpsychology and Behaviour (not to be confused with Computers in Human Behaviour) publishes about a quarter of the research. But, despite a massive number of studies, there is no consensus on what to call the phenomenon. Video-game addiction or excessive use? Internet addiction disorder, Internet use disorder, problematic Internet use, pathological Internet use, or—of course—Internet addiction?

Without clear criteria for what constitutes these problems, understanding the scope of Internet addiction has proven to be difficult. Estimates of problematic Internet use vary between less than 1 per cent to over 8 per cent in the United States. In China and South Korea, anywhere from 2 per cent to over 35 per cent of adolescents are considered to have an Internet use problem. South Korea considers excessive Internet use as one of its most serious public health issues, with increasing reports of fatalities. A South Korean gamer collapsed and died in 2005 after playing the game Starcraft for 50 hours at an Internet café, and a 2007 paper estimated that over 210,000 South Korean children—about 2 per cent of those between 6 and 19—were afflicted with Internet addiction. There has been no test across India for excessive Internet use; even if one were attempted, it would be difficult to get credible numbers. For one thing, only 11 per cent of Indians have access to the Internet. Moreover, if a researcher sent a survey to a private school in Delhi, how and when a kid logs on (everyday, at home) might be vastly different from a public school in a smaller city (sporadically, at a cafe).

This year, a group of researchers from the University of Adelaide in Australia and the International Gaming Research Unit at Nottingham Trent University in the UK published an extensive analysis of Internet addiction tests. They looked at 63 studies that sampled 58,415 participants in 11 languages. There were 18 different tests, and no two tests were alike. The researchers found that the tests were broadly incompatible with one another, and that various measurement scales could not adequately measure addiction over time.

One recent study tried to address such testing inconsistencies. In 2012, a European Union project, Saving and Empowering Young Lives in Europe (SEYLE), conducted a coordinated Internet addiction survey across 10 European countries and Israel. They gave 12,000 adolescents aged between 14 and 16 years a questionnaire designed by Kimberly Young, a psychiatrist and professor of management sciences at St Bonaventure University in New York. Pathological Internet use averaged about 4 per cent across the 11 European countries, with boys notching up higher addiction rates than girls. But there was wide and inexplicable variation from country to country. A nation with more Internet access did not necessarily have more Internet addicts. Italy scored the lowest at a little over 1 per cent; Israel tipped the other end, at 12 per cent. Aviv Weinstein, an Israeli psychologist who studies dependence on alcohol, drugs, and, of late, the Internet, said that he was deeply concerned by such trends. (Weinstein was not part of the SEYLE research group.) “It’s like we are creating a whole new generation of zombies,” he told me.

By the early 1990s, the Internet, which began as a wired network of academic and government institutions, had expanded to include residential homes. It soon became a global communication medium, and online chatting, games and browsing developed into everyday habits. Usage exploded, from about two million worldwide Internet users in 1990 to 40 million in 1995. The increase in Internet use inspired discussion forums on Internet addiction. That year, a New York psychiatrist named Ivan Goldberg posted a memo detailing the “Seven Symptoms of Internet Addiction” on psycom.net, an online psychiatry bulletin board. One symptom was if someone accessed the Internet “more often or for longer periods of time than was intended.” Chalk up three or more of these listed symptoms, and you could call yourself an Internet addict. People thronged the site to evaluate their behaviour and self-diagnose, and soon many Internet users began to refer to themselves as addicts.

They had fallen for a prank. Goldberg’s post was a parody of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The leading reference for psychiatric research and diagnosis across the world was also the subject of ridicule for being a boundless Bible of disorder symptoms. He was contemptuous of what he considered a growing trend towards over-diagnosis among psychiatrists and the public. (In a 1997 New Yorker article, he said that having an Internet addiction support group was equivalent to having a support group for coughers.) Using the DSM’s criteria for pathological gambling, Goldberg cooked up a diagnostic protocol for Internet addiction.

Around the same time, the psychiatrist and professor of management sciences Kimberly Young began earnestly conducting research into Internet addiction. Adapting the same DSM criteria for pathological gambling that Goldberg had used in his prank, she formulated an eight-item questionnaire to assess Internet addiction among study participants. Cases were positive if they answered yes to five or more questions, including “Do you stay on-line longer than originally intended?” and “Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction?” Over 600 subjects responded after viewing college campus flyers, advertisements in local newspapers and postings on online Internet-addiction support groups.

Young’s findings, presented at the 1996 American Psychological Association meeting in Toronto, in one of the first detailed papers written on the issue, were startling. Based on her questionnaire, Young determined that over half her study participants were “dependent” on the

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