The other controversial element related to the use of the Internet addiction is that unlike chemical dependency, the Internet offers several direct benefits as a technological advancement in our society and not a device to be criticized as "addictive" (Levy, 1996). The Internet allows a user a range of practical applications such as the ability to conduct research, to perform business transactions, to access international libraries, or to make vacation plans. Furthermore, several books have been written which outline the psychological as well as functional benefits of Internet use in our daily lives (Rheingold, 1993; Turkle, 1995). In comparison, substance dependence is not an integral aspect of our professional practice nor does it offer a direct benefit for its routine usage.

In general, the Internet is a highly promoted technological tool making detection and diagnosis of addiction difficult. Therefore, it is essential that the skilled clinician understand the characteristics which differentiate normal from pathological Internet use.

Proper diagnosis is often complicated by the fact that there is currently no accepted set of criteria for addiction much less Internet addiction listed in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV; American Psychiatric Association, 1995). Of all the diagnoses referenced in the DSM-IV, Pathological Gambling was viewed as most akin to the pathological nature of Internet use. By using Pathological Gambling as a model, Internet addiction can be defined as an impulse-control disorder which does not involve an intoxicant. Therefore, Young (1996) developed a brief eight-item questionnaire which modified criteria for pathological gambling to provide a screening instrument for addictive Internet use:

1. Do you feel preoccupied with the Internet (think about previous on-line activity or anticipate next on-line session)?
2. Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction?
3. Have you repeatedly made unsuccessful efforts to control, cut back, or stop Internet use?
4. Do you feel restless, moody, depressed, or irritable when attempting to cut down or stop Internet use?
5. Do you stay on-line longer than originally intended?
6. Have you jeopardized or risked the loss of significant relationship, job, educational or career opportunity because of the Internet?
7. Have you lied to family members, therapist, or others to conceal the extent of involvement with the Internet?
8. Do you uses the Internet as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)?

Patients were considered "addicted" when answering "yes" to five (or more) of the questions and when their behavior could not be better accounted for by a Manic Episode. Young (1996) stated that the cut off score of "five" was consistent with the number of criteria used for Pathological Gambling and was seen as an adequate number of criteria to differentiate normal from pathological addictive Internet use. I should note that while this scale provides a workable measure of Internet addiction, further study is needed to determine its construct validity and clinical utility. I should also note that a patient’s denial of addictive use is likely to be reinforced due to the encouraged practice of utilizing the Internet for academic or employment related tasks. Therefore, even if a patient meets all eight criteria, these symptoms can easily be masked as "I need this as part of my job," "Its just a machine," or "Everyone is using it" due to the Internet’s prominent role in our society.

NEGATIVE CONSEQUENCES OF ADDICTIVE USE OF THE INTERNET

The hallmark consequence of substance dependence is the medical implication involved, such as cirrhosis of the liver due to alcoholism, or increased risk of stroke due to cocaine use. However, the physical risk factors involved with an addiction to the Internet are comparatively minimal yet notable. While time is not a direct function in defining Internet addiction, generally addicted users are likely to use the Internet anywhere from forty to eighty hours per week, with single sessions that could last up to twenty hours. To accommodate such excessive use, sleep patterns are typically disrupted due to late night log-ins. The patient typically stays up past normal bedtime hours and may report staying on-line until two, three, or four in the morning with the reality of having to wake for work or school at six a.m. In extreme cases, caffeine pills are used to facilitate longer Internet sessions. Such sleep depravation causes excessive fatigue often making academic or occupational functioning impaired and may decrease one’s immune system, leaving the patient vulnerable to disease. Additionally, the sedentary act of prolonged computer use may result in a lack of proper exercise and lead to an increased risk for carpal tunnel syndrome, back strain, or eyestrain. While the physical side-effects of utilizing the Internet are mild compared to chemical dependency, addictive use of the Internet will result in similar familial, academic, and occupational impairment.