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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 66-72

Internet and psychopathology: A complex paradigm


Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication22-Jul-2020

Correspondence Address:
Yatan Pal Singh Balhara
Additional Professor, Behavioral Addictions Clinic, Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_28_20

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  Abstract 


Psychopathology refers to the scientific exploration of abnormal mental states. The advent of internet has changed the way human beings experience their life and the world around them. There is hardly any aspect of the modern living experience that has remained uninfluenced from internet. The same is true for the field of psychopathology as well. The unprecedented pace of digital revolution with ever increasing utilization of internet-based technologies for different purposes, apart from providing a world of exciting opportunities, has also been associated with several negative consequences. This relatively newer addition to the human living experience is also reflected in the inclusion of newer diagnostic categories in the current diagnostic system (thereby meaning addition of new psychopathology). It has also impacted the experience, manifestation, and communication of psychopathology that existed for years even before advent of the Internet. The current article offers a description of the various clinically relevant human behavioral manifestations that are shaped by our exposure to the Internet and related technology. It also proposes a scheme for categorizing these clinically relevant human behavioral manifestations. This categorization is expected to have clinical and research implications going ahead.

Keywords: Behavioral addictions, Internet addiction, psychopathology


How to cite this article:
Singh Balhara YP, Singh S. Internet and psychopathology: A complex paradigm. J Mental Health Hum Behav 2019;24:66-72

How to cite this URL:
Singh Balhara YP, Singh S. Internet and psychopathology: A complex paradigm. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Sep 26];24:66-72. Available from: http://www.jmhhb.org/text.asp?2019/24/2/66/290510




  Introduction Top


Psychopathology refers to the scientific exploration of abnormal mental states.[1] The foundation of the scientific discipline of psychopathology is credited to Karl Jaspsers in the early 20th century.[2] Over the years, it has been a valuable tool in pursuit of understanding the mental experiences of the individuals. Its clinical relevance is reflected by the fact that it remains of paramount importance in understanding and labeling the mental experiences of the patients with mental disorders. Furthermore, it continues to be of great relevance while developing the diagnostic formulation.

The world that we live in has changed significantly over the years. There have been a multitude of technical advances over the past few decades. Internet has been credited with as one of the biggest inventions of the modern times.[3] The advent of Internet has changed the way human beings experience their life and the world around them. There is hardly any aspect of the modern living experience that has remained uninfluenced from Internet. The same is true for the field of psychopathology as well.

The unprecedented pace of digital revolution with ever increasing utilization of Internet-based technologies for different purposes, apart from providing a world of exciting opportunities, has also been associated with several negative consequences.[4] This relatively newer addition to the human living experience is also reflected in the inclusion of newer diagnostic categories in the current diagnostic system (thereby meaning addition of new psychopathology). It has also impacted the experience, manifestation, and communication of psychopathology that existed for years even before advent of the Internet.[5] The current article offers a description of the various clinically relevant human behavioral manifestations that are shaped by our exposure to the Internet and related technology. It also proposes a scheme for categorizing these clinically relevant human behavioral manifestations. This categorization is expected to have clinical and research implications going ahead. The ever-increasing use of Internet by an increasingly larger section of the population underlines the relevance of such an attempt.


  Internet-Related Psychopathology Top


The term “internet-related psychopathology” refers to the abnormal mental states or behaviors that have been influenced by the Internet. In this sense of use, it is a broader, umbrella term that includes all the experiences of abnormal mental states that have been impacted by the Internet in at least some way. The influence of Internet can be during the origin, progression, or maintenance of the psychopathology. Furthermore, the extent of the influence of the Internet can be variable. It can range from being the most important single factor contributing to the origin, progression, and maintenance of the psychopathology to being one of the multiple factors involved. Cyber psychopathology is another term that can be used to represent the same concept. The term “cyber” refers to “involving, using, or relating to computers, especially Internet.” In the current times, the scope of use of the term “computers” has been expanded to include several hand-held digital devices such as mobile phones and tablets. Hence, the term cyber-psychopathology and internet-related psychopathology can be used interchangeably to represent the psychopathology that has been influenced by the Internet.

The internet-related psychopathology can be further divided into different sub-categories. These subcategories are based on the extent of role Internet plays in the origin, progression, and maintenance of the psychopathology as well as on the degree of exclusivity of the psychopathology in the context of Internet use. The internet-related psychopathology (cyber psychopathology) can be broadly divided into the two sub-categories of internet-exclusive psychopathology and internet-facilitated psychopathology [Figure 1].
Figure 1: Categorization of internet-related psychopathology (cyber psychopathology)

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Internet-exclusive psychopathology

Internet-exclusive psychopathology refers to abnormal mental states or behaviors that are primarily dependent on the Internet for its origin, progression, and maintenance. As a corollary, it can be reasonably assumed that the psychopathology would not have manifested in the first place in the absence of the Internet, hence, the term internet-exclusive. Some of the examples of the internet-exclusive psychopathology include internet gaming disorders that involve massively multiplayer online role-playing games (MMORPGs) and social media addiction.

Gaming disorders that involve massively multiplayer online role-playing games

The MMORPGs are a combination of role-playing video games and massively multiplayer online games in which a very large number of players interact with one another online. Only Internet offers a platform that is conducive to play such video games and these games cannot be played in the absence of Internet. The published research has highlighted that the MMORPGs due to its unique characteristics are the preferred internet-based games among persons with gaming disorder.[6],[7] In fact, problematic and uncontrolled involvement in playing MMORPGs is the most frequently reported activity by people seeking help for an internet-related problem.[8] The gamers playing MMORPGs create a digital avatar in the virtual cyber world, where things keep on happening 24 × 7 (by other players) even when the player is logged out (i.e., a permanent world). This along with several other features such as reinforcement schedule, advancement systems, interface favoring social exchanges, and avenues for hidden wish or fantasy fulfilment have been identified as the contributing factors toward the high addictive potential of such games.[9],[10] Internet acts as a perfect platform that supports and facilitates these features, and hence, plays an integral role in the emergence of addiction to these games.

Social media addiction

Social media addiction is another internet-exclusive psychopathology that is dependent on Internet for its manifestation. Social media addiction is viewed as one form of Internet addiction, where individuals exhibit a compulsion to use social networking websites or online platforms excessively.[11] Individuals with social media addiction are often overly concerned about social media and are driven by an uncontrollable urge to log on to and use social media. The underlying psychological process behind individuals developing social media addiction has been proposed as those individuals having a higher degree of “Fear-Of-Missing-Out” by a group of researchers.[12] Apart from this, the role of envy and a higher degree of need to belong have been suggested to contribute toward the vulnerability to develop social media addiction among certain group of individuals.[13] The published reports suggest that social media addiction affects around 12% of users across social networking sites.[14],[15] The prolonged use of social media has been associated with mental health problems such as stress, anxiety, and depression.[16],[17],[18] Therefore, Internet plays a pivotal role in the origin, progression, and maintenance of social media addiction and this psychopathology could not develop and/or manifest in the absence of access to internet.

Internet-facilitated psychopathology

Internet-facilitated psychopathology refers to the abnormal mental states or behaviors where Internet is not an essential prerequisite. While internet could play a role in origin, progression, and/or maintenance of these psychopathology, they might have emerged even in the absence of access to Internet. In case of internet-facilitated psychopathology, the Internet facilitates one or more of the following: origin, progression, and/or maintenance of the psychopathology. Internet contributes to the production of psychopathology by shortening the time of its onset or manifestation, facilitating its expression, adding newer dimensions to its manifestation, or facilitating its progression and/or maintenance. This sub-category of internet-related psychopathology can be further sub-divided into: Internet-modified psychopathology and internet-extended psychopathology.

Internet-modified psychopathology

Internet-modified psychopathology refers to those internet-related abnormal mental states or behaviors that existed even before the emergence of Internet. However, internet has modified their manifestation, progression, and/or maintenance. In other words, these psychopathologies have a preinternet era counterpart. The advent of Internet has offered an additional platform for their manifestation. Moreover, Internet adds additional dimension(s) to them so that certain characteristics of these psychopathology might be different when they manifest over Internet as compared to their traditional counterparts. Some examples of internet-modified psychopathology include cyberbullying, online gambling disorder, and cybersex.

Cyberbullying

Cyberbullying can be defined as repeated hostile or aggressive behavior performed by an individual or a group on others, aimed to inflict harm or discomfort by means of electronic or digital tools.[19] The various terms such as “online aggression,” “cyber harassment,” “Internet harassment,” “Internet bullying,” “cyber victimization,” and “electronic aggression” have been used to describe it in the available literature. The main features of cyberbullying emphasized in most of these definitions were: the use of technological medium, hostile nature of act, intention to inflict harm or suffering, and repetitiveness. The Centers for the Disease Control and Prevention has de-emphasized repetitiveness of acts and has defined electronic aggression as any type of harassment or bullying that occurs through E-mail, a chat room, instant messaging, a website (including blogs), or text messaging.[20]

Cyberbullying differs from traditional face-to-face bullying in certain important ways.[21] For example, in cyberbullying physical strength of the bully is not important, rather his/her superiority in use of digital technology over the victim is essential; creating a new dynamic between the victim and the perpetrator. The use of digital technology also makes cyberbullying more ubiquitous as it could be carried out anytime and from anywhere, with greater difficulty in protecting the victim from bullying since it is not restricted to school bus or playground. Furthermore, the harm inflicted and the negative consequences of cyberbullying such as humiliation might get known to a larger number of people through “viral” dissemination of embarrassing videos, pictures, or other content online. Hence, cyberbullying can be categorized as internet-modified psychopathology.

Although available literature suggests that cyberbullying is associated with several behavioral problems and psychiatric disorders in the bullies, victims, and bully-victims (i.e., individuals who switched over from being a victim to being a bully themselves). The link between cyberbullying and suicidal thinking and attempt is of utmost public health concern, apart from its association with a range of other psychiatric symptoms and/or disorders including depression. However, since most of the studies conducted so far were of cross-sectional study-design, one could not establish a causal link between them.[22],[23]

Online gambling disorder

Online gambling encompasses a range of wagering and gaming activities accessed through internet-based devices such as computers, mobiles, tablets, and other digital hand-held devices. The available literature suggests that online gambling is not a separate or distinct type of gambling activity in itself, with internet acting as a medium for engaging in different forms of gambling activities instead of traditional in-person venue-based gambling or telephone-based betting by people.[24] However, Internet-based gambling differs from the traditional forms of gambling in certain ways which might make it potentially more addictive. These include easy accessibility, greater confidentiality, and ability to gamble online for uninterrupted periods at any time of the day while traveling on the go or sitting at home. Further, the interactive-immersive experience of gambling online and use of digital forms of money (e.g., credit cards, electronic bank transfers, and virtual currency) might lead to increased problem gambling and losses.[25] This is also reflected in the findings from the surveys conducted among gamblers, with 19%–28% gamblers reporting that they end up spending greater amount of digital money gambling online than in the traditional forms of gambling, and about 15% considering it to be more addictive than traditional forms of gambling.[26],[27] The initial prevalence studies also reported a greater percentage and severity of problematic gambling among online gamblers as compared to noninternet-based gamblers.[28],[29] However, when the results were reanalyzed after controlling the confounding factors, most importantly for the degree of gambling involvement (e.g., frequency, expenditure, and forms of gambling), online gambling was not found to be an independent predictor of problematic gambling severity.[30],[31] Thus, online gambling disorder is an example of internet-modified psychopathology, with internet providing one of the modes for engaging in gambling behaviors by people.

Cybersex

Cybersex can be broadly defined as the use of Internet and related technology to engage in search for and procurement of sexually pleasurable or gratifying activities.[32] It encompasses a broad range of activities such as online pornography with or without masturbation, sexting, sex webcams, searching for sexual partners and arranging offline sexual encounters, or engaging in three-dimensional sexual role playing. The cybersex behaviors could range from solitary acts to consensual or coercive partnered interactions. The purpose of cybersex is often to experience sexual pleasure, but it could also involve activities with an aggressive or illegal component (e.g., child pornography). A large majority of people are likely to engage in cybersex behaviors owing to the several potential advantages offered by it over the traditional sexual behaviors. These include easy accessibility (large number of online sexual platforms), affordability (free or cheap access to online pornographic material), option of selecting from a large range of online sexual activities and content, and provision of a virtual space for engaging in sexual experiences without some of the risks associated with traditional offline sexual activities (e.g., transmission of sexually transmitted diseases). Although, cybersex is likely to be harmless in majority, a small but a significant proportion of population have reported several negative consequences associated with it ranging from sleep disturbances or insomnia, financial, and professional problems (e.g., watching costly online content, skipping work or neglecting work-related commitments), real-life relationship problems (e.g., neglect of familial responsibilities and loss of sexual intimacy with real-life partner), diminished interest, satisfaction and even erectile dysfunction in offline physical sexual activity, and even legal problems (e.g., storing and watching pornographic content and increased tendency to indulge in sexual harassment of child).[33] However, there is no theoretical consensus on how to define and diagnose such harmful and dysfunctional pattern of internet use. This is also reflected in the use of different terminologies such as problematic cybersex, internet sex addiction, compulsive cybersex, and cybersex addiction among others to describe this phenomenon in the available literature. There is a lack of studies describing the epidemiology of this condition. Further, some researchers have debated that this might just be an online manifestation of another underlying mental health disorder (e.g., compulsive sexual behavior or hypersexual disorder and depression).[22],[23] Thus, there is a need to carry out qualitative studies exploring the phenomenology of cybersexual behaviors in the community as well as treatment samples to better characterize the psychopathological features of this condition. Further, longitudinal studies with standardized assessment of cybersexual behaviours are needed to better elucidate the associated risk factors and the course of this condition.

Internet-extended psychopathology

Internet-extended psychopathology refers to those internet-related psychopathology that are extensions of psychopathology that primarily manifest in non- internet settings; however, certain aspects of these psychopathology manifest over internet. The “internet-extended” component of these psychopathology could be a replication of the Non- internet manifestation or an entirely new dimension. Some examples of internet-extended psychopathology include cybersuicide and cyberchondria.

Cybersuicide

Cybersuicide refers to the use of internet and related technology for committing self-harm and/or suicide, and usually involves use of internet for carrying out all or any these three: recruiting; staging; and committing suicide.[34] The three types of cybersuicide described in the literature include suicide pact, webcam suicide, and fake suicide. A suicide pact could be defined as an internet-arranged agreement between two or more persons to commit suicide together at a particular time and place. Webcam suicides refer to broadcasting of one's process of committing suicide and/or the actual act suicide using an online broadcasting platform. Fake suicide involves false simulation by an individual of taking one life's online with no intention to die in reality. More recently, there are have been several online games or platforms which actively encourage the users to involve themselves in self-harm activities/challenges leading onto completed suicide in some of them, such as the “Blue Whale Suicide Challenge,” “human embroidery,” “choking game,” “salt and ice challenge,” “fire challenge,” “cutting challenge,” “eyeball challenge.”[35] Almost all of the above described methods commonly involve the use of internet for searching ways of committing suicide as their starting point. From a psychopathological point of view, suicide pacts might be a representation of power differential between individuals or romanticisation of suicide similar to the promise made between lovers who to escape the intolerable reality and/or an unaccepting society end their lives together.[22],[23] Webcam suicides and online suicide challenges might also involve some degree of cyberbullying. Cybersuicides are thought to particularly involve socially isolated individuals having a strong ambivalence regarding living. This might also fulfil the need to share suicidal thoughts and represent a cry for help in some individuals. However, the internet could also be used as a resource to seek help by a potentially suicidal individual, to identify and communicate with those at risk for committing suicide, and potentially prevent suicide.[36] This might be somewhat similar to the Werther and Papageno effects described in context of the role of media reporting of suicide in either promoting and protecting further suicidal behavior in others, respectively.[37] Thus, there is need to better understand the risk and protective factors for cybersuicide-related behaviors among the individuals. Further, the differences between traditional suicide and online suicidal behaviors have not been studied in detail yet and needs to be explored further in future.

Cyberchondria

Cyberchondria refers to the excessive and repetitive searching of health-related information online for seeking reassurance, which paradoxically results in further increase in the health-related anxiety in these individuals.[38] However, it needs to be differentiated from simple use of internet to seek health-related information, which is a fairly common use of internet among the normal population in the present age of digital technological advancement. The people with cyberchondria often end up spending an excessive amount of time online while performing health-related searches to an extent that they neglect participation in other activities of daily living or work leading to negative consequences. The main distinguishing feature in people with cyberchondria is the anxiety amplification effects of online health-related information seeking.[39] This might be due to a combination of contributions from certain individual and internet medium-related characteristics. The inability to tolerate uncertainty regarding one's health condition and limited ability to differentiate between credible and noncredible sources of online health-related information, which in turn could be related to individuals' level of education, information-processing capability, and technological proficiency. In contrast to the traditional reassurance seeking behavior from medical health professionals or family members, the internet as medium is not designed to always give relevant, accurate, unambiguous, nonconflicting and reassuring information to the individual. Moreover, online anxiety amplifying distractions (e.g., inadvertently encountering information related to a hitherto unknown disease or health risk) and information overload could in turn make it difficult for people to manage and interpret available information on the internet. From a psychopathological point of view, cyberchondria has been conceptualized as multi-dimensional construct with compulsions (unwanted nature of online health-related searches), distress (negative emotions associated with online health-related searches), excessive reassurance-seeking behaviors, and mistrust of medical health professionals as its key characteristics. However, a group of researchers consider cyberchondria as an online manifestation or part of classical hypochondriasis/health-related anxiety. This might be due to the lack of consensus on the direction of causality between health-related anxiety and excessive health-related online searches.[22],[23] A high level of health-related anxiety might lead to repetitive health-related searches over the internet in turn amplifying the anxiety. However, in some individual excessive health-related searches might be reported in the absence of any history suggestive of significant health-related anxiety or hypochondriasis; possibly secondary to some different motivations (e.g., curiosity, searching for an explanation for a new symptom) in them. Thus, further research is needed to better understand the relationship between cyberchondria, hypochondriasis, and excessive online health-related searching.


  “Drawing a Line in the Sand”: Internet and Psychopathology Top


Importantly, some of the psychopathology that has been listed as internet-modified psychopathology can manifest as internet-extended psychopathology as well. For example, cyberbullying can be a mere extension of bullying. In such a scenario, the presence of internet offers an additional avenue for its manifestation without significantly altering its dynamics. Similarly, online gambling can be an added manifestation of pathological/disordered gambling in an individual, where internet provides an alternative platform to manifest the psychopathology without significantly modifying or impacting the original manifestation (i.e., offline traditional gambling activities) of the gambling disorder. Hence, one needs to explore the role internet plays in emergence, progression, and maintenance of the psychopathology and accordingly categorize it either as an internet-modified or internet-extended psychopathology in an individual. Further, excessive internet use might produce or worsen the symptoms of traditionally described psychiatric disorders. For example, exposure to pro-eating disorder websites (“pro-ana” promoting anorexia nervosa and “pro-mia” promoting bulimia nervosa) has been reported to worsen eating disorder behavior in patients, but not normal individuals.[40] There has also been a case of social-media induced psychosis reported in the literature.[41] Further, excessive internet use has been suggested to promote certain potentially problematic personality traits such as impulsivity, narcissism, and aggression.[42] Internet might also provide an alternative medium for the expression of the underlying psychiatric symptoms or disorder. For example, a person suffering from a depressive episode might indulge in excessive online gaming to alleviate his/her mood symptoms and display symptoms similar to an individual having internet gaming disorder.[43] Therefore, the motivations and purpose behind internet use are equally important in identifying and correctly labeling the internet-related psychopathology. Finally, there is a need to further study and delineate the various different internet-related psychopathologies to better identify people at risk and develop effective preventive and treatment strategies [Box 1].




  Conclusions Top


Psychopathology continues to be a valuable tool in pursuit of understanding the mental experiences of the individuals and is of great clinical relevance. Internet-related psychopathology (or cyber pathology) is an emerging area of clinical and research interest. The current article offers a practical and simple approach toward categorization of internet-related psychopathology. This categorization is expected to have clinical and research implications going ahead. It is also important to be cognizant of the fact that there are several conceptual and methodological concerns about the definition and assessment of different internet-related psychopathologies. There are contrasting opinions and viewpoints existing, and most of these require further research before we can have definitive answers. The use of a systematic categorization approach has a potential to generate consistent and comparable findings by different group of researchers working in this field, in turn helping us to synthesize the literature more effectively and derive meaningful conclusions. Thus, it contributes towards enhancing our understanding about various internet-related psychopathologies and the future revisions to the nosological systems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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