MICROPROCESSOR ABUSE AND INTERNET ADDICTION

Summary by Richard N. Rosenthal, MD

Based on Principles of Addiction Medicine chapter by Richard N. Rosenthal,
MD, and Zebulon Taintor, MD

Microprocessor are ubiquitous, serving as prosthetic brains, guides,

knowledge sources and calculator ; while the help us manage many aspect of your
lives, and provide much stimulation they dont manage our time, our motivation
and our involvements. Some of us become dependent of the stimulation they
provide, with significant negative life consequences, not the deferent from
addiction to substances.
The internet has five mayor uses the affect clinicians and their patient : (1)
source of information on disease, diagnosis, treatment and therapists; (2) source of
support and self-help groups; (3) provision of advice, diagnosis, and counseling
whereby the person being helped has not met the helped has met the helper except
over the internet; (4) helps obtain addictive substances, both prescription and
nonprescription; and (5) enhances opportunities for people to do things (sex,
gambling, ect.) with intrinsic addiction vulnerability. internet addiction,
however, covers only par of patient problems using deviced built around
microprocessor. These problems are due to the interaction of the novel technology
and the people using it, compared to intrinsic mental disorders such as depression
and schizophrenia.

HISTORICAL PERSPECTIVE
The internet was established in 1969 at the University of Southern
California as a way of linking computers for national defense used. Computer
have always offered opportunities to impair functioning, even pre-Internet.
Problematic, if not necessarily pathologic, non work-related Internet used in the
workplace arose quickly after the internet became functional in the business
community. The first articles about Internet addiction appeared in the mid-1990s.
Some portion of problematic microprocessor use may be more due to social
adaptation to new technology than due to psychopathology. Internet social utilities
such us social networks, commercial dating site, special internet blogs, chats, and
other have made forming new relationships with fellow online user a mainstream
activity, when once it represented eccentric or problem behavior. Identity and the
internet is emerging as a separate field of study. One creates an identity often
quite opposite from ones regular self in virtual word applications.

DIAGNOSTIC DILEMMAS
Addiction as used in popular media describes a much less serious
phenomenon that what clinicians mean and by addiction. In considering
whether the microprocessor are a bona fide substrate for addiction processes, it is
important to present some caveats:
Using the computer, cell phone, or videogame is not intrinsically illegal is
generally normal, prosocial, encouraged behavior.
When people experience new and powerful tools, there is learning curve to
information acquisition, time management, and social behavior.
High engagement in microprocessor use is not necessarily pathologic.
Calling maladaptive microprocessor-related behavior pathologic rather than
bed habit may medicalize a social problem.
Important questions arise in the context of considering whether internet
addiction is a discrete disorder and whether it is an addiction or some other type
disorder;
Are most surveys that present high rates of pathologic internet use suffering
from selection bias?
Is the term internet addition overstated and overgeneralized ?
It is be technology or that which it enables that people may become addicted
to?
Does the internet, as a conduit for other disorder such as pathologic gambling
or compulsive sexual behavior, become a substrate for addictive process?
 Is internet addiction component of another disorder, of if a discrete disorder,
does is frequently co-occur with other mental disorder?
Internet addiction disorder (IAD) was condifie By Young in 1998 as an
eight-item polytheltic? Diagnosis set modeled on pathologic gambling., and
neuroimaging studies show altered regional cerebral activity and structural change
generally consistent with studies of drugs and other behavioral addiction.
Individuals with IAD have increased glucose metabolism in the right orbitofrontal
cortex, left caudate, and right insula and decreased metabolism in the bilateral
postcentral gyrus, left precental gyurus, and bilateral occipital regions and
decreased dorsal striatal D2 receptor availability in men, which is inversely
correlated with IAD severity, consistent with a reward deficiency, model for SUD.
Men with high severity IAD have greater activity in the anterior and posterior
cingulated cortices, consistent with impaired inhibitory control and response
inhibition. Long-term IAD may lead to structural brain changes and altered
function, although a causal relationship has not yet been established. Decreased
gray matter volumes in been demonstrated in adolescents with IAD that were
significantly correlated with internet addiction duration.
A monothetic approach may create a narrow construct in which to
categorize and evaluate if internet addiction is a real disorder. All criteria must be
endorsed in a monothetic approach (compared to the DSM approach) in order to
make a diagnosis. It should have high sensitivity for diagnosing true positives. A
monothetic approach with good construct and predictive validity should allow a
clinically useful criterion set that reduces false negatives. Clinicians who treat
patients with chemical addictions will recognize the symptom set in their
patients, and thus the economy in the approach:
Salience: the drugs or behavior gained primacy in a persons life, as a
cognitive change, dominating the persons mental life, or behaviorally,
dominating a persons activity compulsively.
Mood modification: the substance or behavior gives one a rewarding high or
alleviates a negative mood stase.
 Tolerance: one must increase the amount or intensity of the substance or
behavior in order to achieve the desired effect.
Withdrawal symptoms: after stopping or reducing the substance or behavior,
the person demonstrates either physical symptoms or dysphoria characterize
by irritability, mood lability, depressive symptoms, ect.
Conflict: one has conflicts regarding the use of the substance or behavior that
manifests as interpersonal (e.g., marital strife) or intrapsychic (e.g., guilt)
Relapse: after same abstinence, the use or behavior is reinstated at the same
intensity.
The DSM-V workgoup had contemplated problematic internet use as a
compulsive-impulsive disorder in the group of impulse control disorder, and
Pathologic Internet Use could be conceived after pathologic gambling, a DSM-IV
ICD, but Gambling Disorder has been moved to the DSM-5 substance related and
addiction disorder section. ICD hallmarks are repeated failure to resist impulses
that are harmful to self or other and tension or arousal before and pleasure or relief
during the act, followed by guilt or self-reproach. However, internet addiction has
addiction-specific symptoms, such as development euphoria, craving, and
tolerance in addiction to some ICD symptoms (Internet preoccupation,
compulsive use, loss of control) pathologic internet use has also been proposed as
an OCD spectrum disorder, but the preoccupation is ego-syntonic and pleasurable,
whereas intrusions and compulsions are ego-dystonic in OCD. Internet addiction
ha been narrowed in DSM-5 to internet Gaming disorder and placed in the
appendix, but the placement of Gambling Disorder in the substance-related
disorder suggests other behavioral addictions may ultimately be validated for the
group.
Building a bottom-up construct of most frequent symptoms from factor
analysis of a group is another approach to developing stable and valid criteria for
internet addiction. Factor analysis of surveys of college student addiction factor
(salience items), loads upon all items of the monothetic model behavior addiction
criteria and is primary and causal to sex (downloading graphic material), and
excessive internet use factors. High computer engagement is also part of the
structure of computer addiction but is nor necessarily in and of itself pathologic,
such as a mother relationship with her newborn. So, consistent with the DSM
approach the symptom are insufficient for diagnosis without impairment,
impairment in a person daily functioning over and above symptoms of high
engagement, should be necessary for a diagnosis of internet addiction.
Chemical addiction occur at high rates with other mental disorder in the
population and there is a strong correlation of pathologic internet use with ADHD
and depression.

ASSESMENT
Functional impairment is a good proxy for a clinically relevant misuse of
microprocessors. One can discuss the intensity and impact of use of
microprocessor-containing devices and assign general risk categories based upon
the information provided. A simple screening cutoff can begin to establish
whether use is normal or problematic:
Use: a reasonable time spent accomplishing specific goals using
microprocessors, such as getting back your dog that strayed because the staff
at the pound found the chip under his skin. High engagement does not
necessarily mean pathologic.
Problem use: the use is causing clinically significant impairment. The patient
repeatedly takes on undue risk, gets into legal problems, continues the use in
spite of recurring social or interpersonal problems related to use, or the use
interferes with fulfilling major role obligation.
Dependence: the patient experiences inability to get along without it. Here the
problem is the lever of functioning. There may be a false sense of being in
control and able to stop any time when one cannot.
Nervousness, aggression, agitation, insomnia, anorexia, tremulousness,
and depression have been noted after microprocessor deprivation, but
microprocessor activity withdrawal has not been well documented for inclusion
into the DSM.
INTERNET CHARACTERISTICS
The internet has advantages over other agents with high liability for abuse
and dependence including the following:
Always available: 24/7, lending itself to impulsive access and marathon
sessions
Convenient: no need to leave home or work.
Inexpensive: now just the cost of the hookup and there are no dealers to pay.
Rewarding: content-rich web sites calculated to please with interactivity, and
novelty.
Controllable: the user can go wherever desired and leave at will
Validating: one can find content according to ones interests and tastes, and
verify as legitimate since others feel similarly
Escapist: sites of interest to the potentially addicted often a welcoming reality
where all sex likely to be won, women can act like men, and introverts can act
like extroverts.
The internet may differentially support addictive process, as internet
communication is anonymous, isolated from normative feedback, and provides
easy access to reinforcing stimuli. Risk of internet addiction might be ameliorated
thought education and training.

TREATMENT MODEL
Motivation is key. If reward are the issue, others must to be found. If
obsessive-compulsive concerns are more important, efforts and medication are
directed at developing different habits and thought patterns. Recovery is about
leaning to avoid triggers for impulsive internet use, making use of social support
for healthy reinforcers found in everyday life, and relearning how to use
microprocessors in nonpathologic ways.
TREATMENT PLANNING
The addiction field is used to epidemics of powerfully rewarding
substances that die down and become endemic. Incidence estimates for Internet
addiction range from 1% to 3% of the American population.
Rating scales serve as diagnostic aids and can help patiens to realize the
extent of their problems by offering objective data for feedback in motivational
approaches. The 20-question Internet Addiction Test (IAT)
(http://netaddiction.com/resources/internet_addiction_test.htm) is best established
and covers six factors: salience, excerssive use, neglecting work, anticipation, lack
of control, and negleting social life on a 100-point scale with ranges of 20 to 49
indicating average online use, and 50 to 79 indicating occasional or frequent
problems. Many of the items correspond to similar items in the DSM-IV
diagnostic categories of substance abuse and substance depwndence.

INDICATIONS FOR TREATMENT

Patiens and families understand and feel impairment, so responses to the
scale above and issues of morbidity and mortality can help all concerned
understand indications for treatment.

MORTALITY
Murder and suicide have been reported (mostly in South Korea) after
microprocessor deprivation, usually an adolescent killing the depriving parent or
demonstrating through suicide that life without the microprocessor is not possible.
IAT-identified Internet addiction has been significantly associated with depressive
symptoms.

MORBIDITY
Real-life social relatioships get less time, as more satisfyng relationships
are developed on the Internet. Clinicians may rate these relationships less
favorably, like an alcoholic's driking buddies, so cclinicians must assess cyber
relationships in detail and without bias. Identity fragmentation may occur if one's
Internet persona is markedly different from one's rel-life persona. Impairment can
result from prolonged sittibg in front of screens, with increased obesity and less
exercise, but inactivity is prefeeable to acvidents that occur while multitasking.
The American Collage of Emergency Physicians issued an alert against "text
waking" as the number of vehicle hits, falls and running into trees, lamp posts,
and other people has become noticeable in emergency rooms.

PRETREATMENT ISSUES
Motivation-Rationale for Choice of Treatment
Motivation prior to engagement in treatment may be scant or absent.
Patiens minimalize retionlize, or deny problems. A nonconftontationl diacussion
of impairment using the principles of motivational interviewing (MI), helps the
patient's microprocessor overuse are elicited and then fed back to assist the patient
to use his or her native analytic capacity and valies in determining that the overuse
is actually problematic or impairing and to help tip the decisional balance toward
seeking help.
A departure from the abstinence-oriented approach of classic addiction
treatment is therapeutic use of the Internet and microprocessors, aligned with
moderation management concepts. Online support groups are thought to help, but
there is no robust evidencw of efdects.

SELECTION AND PREPARATION OF PATIENS/SUITABILITY

Microprocessor abusers are technically competent, often innovative, and
well educated, which makes them typically sutable for treatment. There are high
rates of current and life-time co-occurring mental disordees that tend to have a
negative impact upon recovery, and there is frequently secondary gain in abuse.
Retreat into cyberspace may mask co-occueeing social phobia and/or other
anxiety disorders, much as alccohol abuse can mask social phobia.
TREATMENT AND TECHNIQUE
Similar to disorder of compulsive food intake, complete abstinence is not a
feasible long-term treatment goal, as use of microprocessors is unavoldabe in
today's world, and non-use is associated with significant vocational and social
disadvantage. Restricting microprocessor access by significant others in control
may increase motivation or result in destructive anger, so clinicans must expect to
hear about and perhaps participatw in decisions.
Since cognitive process maintains IAD, appropriate psychotherapeutic
strategies would included cognitive restructuring focused on the internet
applications of choice, behavioral exercises, and graded exposure therapy with
increasing duration of offline activity. Reintroduction into the real world must be
done in stages to ease transitions, replacing the rewards of the microprocessor
abuse with more natural and socially appropriate reinforces. A desensitization
process with iterative steps will suport a sense of success and increased self-
esteem. Consistent with comunity reinforcement principles, therapy is a rewarding
process that helps the patient get in real life what was available only on the
Internet. Treating co-occurring mood, anxienty, psychotic, and sybstance use
disorders is helpful in supporting recovery and reintegration into the real word.
Social skills training may also be helpful.

RELEVANT TREATMENT RESEARCH

Much of the available epidemologic and treatment outcome research on
Internet addiction has been based upon case studies and survey data, wich is
subject to selection bias.

EFFICACY
Meta-analysis of the extant treatment research for IAD, suggests from pre-
post analyses that there are effective treatments for IAD, time spent online,
depression and anxiety. Pilots sgudies of pharmacotherapy for IAD have found
success with escitalopram, and with sustained release bupropion. Treating
comorbid psychiatric disorders may have utility as well. Methylphenidate
treatment for aDHD (mean dose 30,5 mg/d) alsi reduced scores on hours of
Internet use and the InternetAddiction Scale. However, if IAD follows suit with
chemical addictions, then effective treatment of co-occurring other mental
disorders will generally have effect sizes insufficient to treat the IAD.

EFFECTIVENESS-EXTERNAL VALIDITY
There are no controed studies of psychosocial treatment for IAD other than
cognitive behavioral therapy (CBT), although there are case respons of the
efdicacy of typical addiction clinical interventions and self-help interventions.
Probable validity for these impulse-control/obsessive-compulsive model of
addictions to microprocessor abuse, but will require controlled trials of
standardized interventions in target populations using established and validated
diagnostic criteria and outcomes measures.

KEY POINTS
1. Some portion of problematic microprocessor use may be more due to social
adaptation to new technology than with psychopathology.
2. As with other "behavioral addictions", it remains to be demonstrated that
Internet Addiction is it self a discrete disorder, is inclusive of other
microprocessor-releated disorders, or is a substrate for other behavioral
diorders.
3. Although there is high comorbidity with mood and anxiety disorders and
ADHD. Internet Addiction symptoms overlap but appear to be a separate
from those disorders.
4. Internet Gaming Disorder is included in the DSM-5 section 3 (appendix)
5. Treatment should entail MI engagement strategies and CBT, with graded
reintegration into the outside world and its healtheir pleasures.
6. Co-occurring other mental disorders should be identified and treated as they
typically help reduce symptoms and lower the risk for relaps.