Musa Sattar, London, UK
As we all know, the internet has drastically changed our lives. This change has only been accelerated in the COVID-19 era, when we used it to do everything: learn, work and socialise. According to Director of Addiction Consultation Service, Dr Howard Forman, of Montefiore Medical Center in New York, ‘An increased trend is observed in the number of people developing internet addiction during COVID-19.’ 
So the pandemic has only exacerbated the problem of internet addiction. And as with any other thing, the internet has its pros and cons. While the benefits of the internet have been touted for the past few decades – and rightly so – it’s also high time we start thinking about how to avoid its harms.
When we think of addiction, we usually think about alcohol or drugs. We don’t usually think of something as ordinary and everyday as the internet. But that makes it quietly dangerous. In fact, while internet addiction is a growing issue its risk factors are still poorly understood.
In the past few years, with the availability and mobility of new media, internet addiction has been potentially associated with public health issues.  A number of obsessive online behaviours that may lead to symptoms similar to substance-related addictions have been identified by researchers.  These symptoms can eventually cause internet addiction, also known as compulsive  or problematic internet use.  According to recent reports, children as young as ten years old may show problematic behaviour towards digital devices.  It is becoming increasingly evident that adolescents are more easily prone to social media addiction. ,  Several studies have connected the growing problem of internet addiction with depression,    bipolar disorder,  anxiety disorder  and obsessive compulsive disorder (OCD),  along with aggression , low self-esteem, loneliness , social anxiety and poor social skills. , ,  According to research carried out by the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, an average of 23% or one in four young people show ‘problematic’, ‘dysfunctional’ or ‘addictive behaviour’ towards smartphone usage. 
In order to understand the root cause of these behavioural patterns, we need to understand the nature of addiction. One interesting finding is that there is no ‘simple addictive personality’. 
The question of where to draw the line between abnormal and normal behaviour is still up for debate, but in the meantime, people continue to exhibit problematic behaviours. Symptoms such as craving, impaired control over behaviour, tolerance, withdrawal, and high rates of relapse can be observed in non-substance addictions just as in substance addictions. Clinical research suggests that pharmacotherapies used for the treatment of drug addiction may be successful in treating non-drug addictions as well.  In short, it’s not so much the substance that matters as the pattern of behaviour that contributes to addiction.
So far, scientists have been unable to find a real cure for these kinds of addictive disorders, aside from limiting use of the thing addicted to. As Dr Nicola Kalk from the Institute of Psychiatry, Psychology, and Neuroscience at King’s College London puts it, ‘Nevertheless, there is a need for public awareness around smartphone use in children and young people, and parents should be aware of how much time their children spend on their phones.’ 
To learn more about internet and behavioural addiction, pre-COVID-19 The Review of Religions team met with associate professor in psychology Daria Kuss, a chartered psychologist, chartered scientist, and a member of the International Gaming Research Unit and the Cyber-psychology Group. Her current teaching and research focus on Cyberpsychology, the psychology of internet and technology use, and addictive behaviours. Dr Kuss has authored several books, most recently Internet Addiction and is one of the co-editors of The Oxford Handbook of Cyberpsychology. Read on for the conversation between Dr Daria Kuss and Musa Sattar, Deputy Editor of the Science and Religion Section for The Review of Religions. This interview has been condensed and edited for length.
Briefly introduce yourself and tell us how you came up with this research of a combination of psychology and internet or gaming addiction.
I am Dr Daria Kuss from Nottingham Trent University, I am a chartered psychologist and a chartered scientist. I’ve been working in the area of addictive use of technology for over ten years now. So it is a very new and growing field and I have spent a lot of time researching the impacts that excessive use of different kinds of technologies can have on individuals doing things like gaming, social networking, as well as smartphone use.
In this day and age, we see it is very difficult to live without the use of technology and devices which have now become part of our lives. However, researchers like you are stressing the term ‘technological addiction’, and that it can be either problematic usage or addictive usage. Can you briefly explain the term and how we develop this kind of addiction?
So, when we are thinking about addictive use, we’d use the kinds of criteria that are normally used for substance-related addictions. These include things like tolerance or increasing the amount of time you spend using technology; pre-occupation, so constantly thinking about the next time you can use technology; dreaming about technology use, etc. And then we’ve got a very important criterion, which is conflict: to thinking about both interpersonal conflicts, or conflict between you and your social relations, as well as intrapersonal conflict, which is conflict within yourself. That’s really related to losing control over your behaviours and not being able to stop yourself from actually engaging in this. And the most important criteria that really distinguishes a mental disorder like addiction from problematic use would be the experience of significant impairment in various areas within your life.
How do you compare behavioural addiction to substance addiction? Are there any similarities? Do we see similar symptoms in different types of addictive personalities?
Yes, it is a very good question. Recently, more and more research has emerged. It’s also neurobiological research, for example, to look at the similarities and differences across different types of addictions; behavioural addiction such as technology-related addiction as well as substance-related addictions. It seems from a neurobiological perspective that behavioural addictions like technology addiction or gaming addiction may indeed function on the brain in a similar way the substance-related addictions do. This has to do with the release of dopamine – increased release of dopamine in the context of technology use which the brain learns to associate with technology use. That is the reason why it continues with these kinds of behaviours. So it learns a kind of behavioural pattern and will build that kind of habit of technology use. There are quite a number of similarities across different kinds of addictions. I think the main difference, however, between internet addiction to a substance-related addiction on a neurobiological level is the fact that you are not ingesting a psychoactive substance with internet addiction. And that is the main difference between the two.
The kinds of symptoms that are being experienced across different kinds of addictions and substance-related behavioural addictions are very similar. When we have a look at the diagnostic system, for example, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders-5) by the American Psychiatric Association, or the ICD-11, by the World Health Organization, what we’ll find is that across different kinds of addictions symptoms will be similar. And I think that goes to show that they are very related behaviours in terms of neuro-cognition, neurobiology, as well as the cognitive behavioural elements that are part of it.
How reliable and validated is the research on internet addiction and problematic internet use?
The research into internet addiction is relatively new. And I think the first cases of internet and gaming addiction had been reported in the late 90s. However, only within the last ten or so years better research, more valid and reliable research, started to emerge in this kind of area. What we can see, in particular over the last few years, is that the research quality has increased substantially and I’m looking into a positive future where the research can be replicable and where the research can be helping individuals who are experiencing problems.
What are the potential disorders that are associated with internet-related addictions?
There are a number of comorbidities or concurrent mental disorders that tend to be associated, particularly in the clinical context. There are a number of them that are much more frequently experienced. For example, depressive symptoms are reported – quite a lot of mood disorders in general and then anxiety-related disorders. Specifically, social phobia, social anxiety, but also generalised anxiety disorder. In addition to this, you will find Obsessive-Compulsive Disorder (OCD); sometimes Attention Deficit Hyperactivity Disorder (ADHD) is mentioned as well. Autism spectrum disorders and in few instances schizophrenia spectrum disorders may be comorbid with gaming addiction. One of our PhD students is currently working on the research of co-occurring addictions and that is gaming addiction co-occurring with substance-related addictions. And there’s some literature out there on these concurrent disorders.
We see that these technologies are easily available for kids too, as compared to substances. Is there any age-related disorder with technological usage or addiction?
Young individuals can become addicted to using technology as well. There the problem may be more temporary given that they’re still progressing through developmental stages. Psycho-social development and the gaming addiction or technology addiction may indeed be a temporary thing, where the issue resolves itself in a natural course or within a couple of years. A problem may not be persistent as it may be in comparison to an adult population.
I think it is very easy for infants and small children to focus their attention on technology, including comics or the use of a smartphone or watching YouTube videos or something like that because technology can give them immediate gratification. It will respond to the needs straightaway. And this is something that they invariably are going to learn. It is easier for them to interact with technology whilst immediately responding, in contrast to maybe their social environments where parents might be busy and may respond in a couple of minutes rather than straightaway. There are reasons why children really like to engage with technology. It seems to make them happy. It seems to calm them down. It seems to give them some relaxation.
Do you think that factors like gender, geographical areas and literacy contribute to the aetiology of such addictions?
Yes, so we know that different kinds of addictions are common across different genders. For example, gaming addiction appears to be more prevalent in males whereas social media addiction is more prevalent in females and that has got to do with personality characteristics and the ways in which people interact socially with one another. In terms of geographical regions – particularly in Southeast Asian countries, problems with regards to internet addiction appear to be significantly more pronounced, and reasons for that include social-cultural differences across countries and how internet use is perceived in those countries. And when we are looking at literacy, then of course this is, in some instances, to do with whether or not the internet is available in those countries as well. In a country where the internet penetration rate is very low then addiction rates are going to be very low as well as a natural consequence of that.
From your ten years of research on technological and gaming addiction, can you share some of the worst case studies that you came across?
Well, there is case study evidence that would suggest that gamers, excessive gamers, are not able to look after themselves anymore – where they are not eating and drinking; they are not sleeping, etc. And this may indeed lead to very significant, not only psychological, but also physiological problems to the extent that in some instances, the media reports show that some gamers didn’t look after themselves and who as a consequence died. Now the question, of course, is to what extent was this related to their gaming; it may be more related to the neglect of themselves. But some cases do indeed have very negative consequences as a result of technology use.
Does the game or the problematic use of technology lead to violent behaviour or is it the other way round: the game addict plays the game due to his vicious attitude or being addicted to other substances?
There is research on the so-called game transfer phenomenon, whereby gamers who are using game-related content are using that content also in a non-game-related context, so it’s also referred to as a ‘Tetris effect’. So theoretically if gamers were to play very violent games such as the first-person shooter, just for example, to an excessive extent, there might hypothetically be the possibility for them to do similar things outside of the game. And this would be related to the game transfer phenomenon. Now I’m not aware of any research that would actually suggest that. But from a hypothetical perspective, it might be possible.
We use technology in our daily routines but why do some of us easily become prey to such technological devices to an extent that they become addicted?
There are a number of risk factors that may contribute to an increased vulnerability of developing addictions, including gaming addiction or social media addiction, some of which are related to neuro-biological vulnerability. So from a biological perspective, you may have a higher susceptibility to developing an addiction. In addition to this, there may be some social and psychological elements as well that come into play. For example, if you’re being exposed to the specific technology or the environment is using the technology a lot, then you’re more likely to engage with its use as well which may potentially be addictive. From a psychological perspective, if the gaming and technology are used in order to cope with everyday life problems then the likelihood is increased for developing an addiction as well. So, if a number of these factors come together then the risk is indeed higher for the individuals.
In your view what are the safety measures that parents or individuals can take to avoid such addiction?
Well, prevention is always the key in my opinion. And that would really rely on being very aware of, for example, the amount of time that you spend on technology use on an everyday basis; talking about your technology use and making sure that some time in your personal life is used without actual technology being present; creating spaces in the house where technology is not used at all and situations where limited or no technology is used. This may indeed be very helpful in terms of preventing problems from occurring in the first place.
Knowing the links between addictive gaming, substance abuse, and psycho-social behaviour, do you feel enough is being done to combat this problem by the government?
At the moment when we’re looking at the UK government, not much is being done but the government has recently made calls for evidence to be submitted to their committees on science and technology use where they want to collate evidence of gaming and social media addiction. And I think this is a first step in the right direction because it allows us to have a look at the scientific evidence base and see how this may impact future policies.
In June 2018, WHO classified gaming disorder as a mental health disease and a first clinic is being established in London. Is this just for the treatment of gaming addiction or does it deal with other social technological addictions?
Gaming disorder has been included in the ICD-11 which is a diagnostic manual that has been used across the world and I’m part of the World Health Organisation’s team that has put together the diagnosis. I think it is a really good step in the right direction. However, this is looking only at gaming, so no social media-related problems or smartphone-related problems. I’m collaborating with a psychiatrist at the gaming disorder clinic in London. I think it’s a really good development in the right direction because people who have problems with their gaming can indeed be helped by professionals who are trained in that area.
Looking at the future alongside the advancement of technology what pattern can we predict about addictive behaviours?
Theoretically, given the important place that technology has taken in our everyday lives, one would assume that the likelihood of addiction rates to increase is rather high.
There is much more research and policy work that needs to be done on addiction to the internet and to gaming. It is important to examine the correlation between internet use, mental health, and risk behaviours.
Especially since the pandemic, all facets of our lives have been lived online for the past year. That makes it even more vital that we cultivate awareness of how we and our children use technology so we can avoid unwanted consequences.
. Han-Ting Wei, Mu-Hong Chen, Po-Cheng Huang, and Ya-Mei Bai. “The Association Between Online Gaming, Social Phobia, And Depression: An Internet Survey”. BMC Psychiatry 12 (1): (2012). doi:10.1186/1471-244x-12-92.
. D J Kuss, J R Antonius, W S Gillian, M D Griffiths, D. van de Mheen, “Internet Addiction In Adolescents: Prevalence And Risk Factors,” Computers In Human Behavior 29: (2013), 1987-1996.
. J Meerkerk, R. J. J. M Van Den Eijnden, A. A. Vermulst, H. F. L. Garretsen, “The Compulsive Internet Use Scale (CIUS): Some Psychometric Properties,” CyberPsychology and Behavior 12(1): (2009). doi.org/10.1089/cpb.2008.0181.
. S E Caplan, “Theory and Measurement of Generalized Problematic Internet Use: A Two-Step Approach,” Computers In Human Behavior 26 (5): (2010), 1089-1097. doi:10.1016/j.chb.2010.03.012.
. Tim Schulz van Endert, “Addictive use of digital devices in young children: Associations with delay discounting, self-control and academic performance,” PloS One, 16(6): (2021) e0253058. doi:10.1371/journal.pone.0253058
. “Smartphone Use Is An Addiction For A Quarter Of Youngsters – Study Shows,” 2019, Sky News, https://news.sky.com/story/smartphone-use-is-an-addiction-for-a-quarter-of-youngsters-study-shows-11873083.
. J Parsons, “Young People Getting More Addicted to Their Phones, Researchers Warn,” Metro.Co.Uk, 2019, https://metro.co.uk/2019/11/29/young-people-getting-addicted-phones-researchers-warn-11237513/.
. B U Stetina, O D Kothgassner, M Lehenbauer, I Kryspin-Exner, “Beyond The Fascination of Online-Games: Probing Addictive Behavior And Depression In The World Of Online-Gaming,” Computers In Human Behavior 27 (1): (2011) 473-479.
. A A Ceyhan, E Ceyhan, “Loneliness, depression, and computer selfefficacy as predictors of problematic internet use,” CyberPsychology and Behavior 11, (2008) 699–701.
. N A Shapira, T G Goldsmith, P E Keck, Jr. U M Khosla, S L McElroy, “Psychiatric features of individuals with problematic internet use,” Journal of Affective Disorders 57, (2000) 267–272.
. N A Shapira, T G Goldsmith, M C Lessig, S T Szabo, M Lazoritz, M S Gold, “Problematic internet use: Proposed classification and diagnostic criteria,” Depression and Anxiety 17: (2003) 207–216.
. R M Sheperd, R J Edelmann, “Reasons for internet use and social anxiety,” Personality and Individual Differences, 39: (2005), 949–958.
. M L Ybarra, C Alexander, K J Mitchell, “Depressive symptomatology, youth internet use, and online interactions: A national survey,” Journal of Adolescent Health 36: (2005), 9–18.
. S M Grüsser, R Thalemann, M D Griffiths, “Excessive computer game playing: Evidence for addiction and aggression?” CyberPsychology and Behavior 10: (2007), 290–292.
. H K Kim, K E Davis, “Towards a comprehensive theory of problematic internet use: Evaluating the role of self-esteem, anxiety, flow and the self-rated importance of internet activities,” Computers in Human Behavior 25: (2009), 490–500.
. S E Caplan, “Relations among loneliness, social anxiety, and problematic internet use,” CyberPsychology and Behavior 10: (2007), 234–242.
. S E Caplan, “A social skill account of problematic internet use,” Journal of Communication 55: (2005), 721–736.
. S E Caplan, “Preference for online social interaction: A theory of problematic internet use and psychosocial well-being, ”Communication Research 30: (2003) 625–648.
. “1 In 4 Young People ‘Addicted To Their Smartphones,’” 2019, The Independent, https://www.independent.co.uk/life-style/smart-phone-addiction-children-gen-z-social-media-mental-health-a9225556.html.
. B Owens, “Addiction,” Nature 522, S45: (2015).
. O M Christopher, “Natural Rewards, Neuroplasticity, and Non-Drug Addictions,” Neuropharmacology 61(7): (2011) 1109-1122.
. “Young People ‘Panicky’ When Denied Mobile Phones,” 2019. BBC News. https://www.bbc.co.uk/news/education-50593971.