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International Parkinson and Movement Disorder Society
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When Does Social Media, Email and Internet Use Cross the Line to a Psychiatric Disorder?

Internet AddictionDate: August 2017
Authors: Francisco Cardoso, MD, PhD, FAAN, and Marc N. Potenza, MD, PhD
Editors: Michael S. Okun, MD, Stella Papa, MD, and Daniel Weintraub, MD

Psychiatrists, neurologists and general practitioners commonly encounter patients who excessively use technology. However, our understanding of when the Internet and social media habits cross a line to become a psychiatric disorder remains murky.

On August 6, 1991 a new era for communication was launched when Tim Berners-Lee posted a summary on the World Wide Web and launched what we know today as the Internet. Though email was invented in the 1970’s by Ray Tomlinson, it was not until the 1990’s that AOL, Prodigy, and CompuServe provided commercial Internet service and facilitated what became web-based mail. Social media was born more than a decade later in August 2003, first with Myspace, and then in February 2004 with Facebook. Twitter and the 140 character communication revolution arrived on March 1, 2006. This advance was followed in October 2010 by photosharing with the app called Instagram. Psychiatrists, neurologists and general practitioners commonly encounter patients who excessively use technology. However, our understanding of when the Internet and social media habits cross a line to become a psychiatric disorder remains murky.

One area where movement disorders neurologists have encountered the excessive use of the Internet and social media has been in the setting of dopamine agonist use, most commonly in the treatment of Parkinson’s disease. Dopamine agonists have been associated with impulse control disorders (ICD), primarily excessive gambling, sexual, buying or eating behaviors, but it can involve other activities to excess, including Internet use. An ICD is characterized by impulsivity which has been defined as a failure to resist a temptation, urge or impulse. Weintraub and colleagues have published extensively on this topic. They note that “ICDs have been most closely related to the use of dopamine agonists, perhaps more so at higher doses; in contrast, dopamine dysregulation syndrome (DDS) is primarily associated with shorter-acting, higher-potency dopaminergic medications, such as apomorphine and levodopa. Possible risk factors for ICDs include male sex, younger age and younger age at PD onset, a pre-PD history of ICDs, and a personal or family history of substance abuse, bipolar disorder, or gambling problems (Weintraub, 2015).”

Dopamine agonists and other dopamine replacement therapies have also been associated with punding. Punding is when a person performs repetitive, mechanical tasks, such as assembling and disassembling a device. Punding can also manifest as collecting, sorting objects, or as an inability to stop a more purposeful  activity, also called hobbyisjm (e.g. painting, golfing, fishing). Finally, Evans and colleagues recently reported an elevated response to a wearable monitoring device designed to track Parkinson’s symptoms and medication-related side effects. In the Evan’s experience the authors reported on several patients who manifested a type of impulse control behavior where they “pressed the button,” even when the monitored behavior was not occurring, representing repetitive, impulsive responses (Evans, 2014).

Internet addiction syndrome was first described by Ivan Golberg as "important social or occupational activities that are given up or reduced because of the Internet use, fantasies or dreams about the Internet, and voluntary or involuntary typing movements of the fingers." Though recognized as a new phenomenon many experts still struggle with the disorder. Kuss and colleagues recently pointed out that there is no gold standard of Internet addiction classification or time spent online. These authors also commented that without a gold standard, prevalence rates widely vary among studies. Studies do show that a “number of core symptoms (i.e., compulsive use, negative outcomes and salience) appear relevant for diagnosis, which assimilates Internet addiction and other addictive disorders and also differentiates them, implying a conceptualisation as syndrome with similar etiology and components, but different expressions of addictions (Kuss 2014).”

Van Rooij and colleagues proposed that “the models of Internet addiction share some criteria, including feeling a loss of control over Internet use; ensuing psychological, social, or professional conflict or problems; and preoccupation when not using the Internet. Other criteria inconsistently mentioned include: mood management, tolerance, withdrawal, and craving/anticipation. The models studied here share the assumption that the Internet can produce a qualitative shift to a diseased state in humans” (Van Rooij, 2014).”  A specific manifestation of Internet addiction is Internet Gaming Disorder, which is listed in DSM-5 (APA, 2013) as a condition for further study.  Interestingly, pathological gambling was moved from Impulse Control Disorders in DSM-IV to Substance-Related and Addictive Disorders in DSM-5, highlighting the overlap between these disorders and consistent with disorders such as Internet addiction syndrome being classified as behavioral addictions (Holdon, 2001).

What is the current state of what we know about Internet overuse as a syndrome and what should we do about it? We asked two specialists in the field.

What is the current state of the literature on Internet-use behavioral disorders?

Marc N. Potenza, MD, PhD
Professor of Psychiatry, in the Child Study Center and of Neuroscience; Director, Center of Excellence in Gambling Research; Director, Yale Program for Research on Impulsivity and Impulse Control Disorders; Director, Women and Addictive Disorders, Women's Health Research at Yale

“The extent to which Internet-use behaviors (in general) may represent psychiatric disorders is currently an area of considerable discussion, dialog and debate. There are multiple recent articles focused on Internet gaming, with fewer articles considering other uses of the Internet like accessing and participating in social-media-related behaviors.  How Internet-use behaviors may relate to neurological conditions like Parkinson’s disease (which itself is characterized by brain psychopathology) may be an important consideration. However, the literature on this topic is not robust, and more research is needed.” 

What should we do as clinicians when we encounter a potential Internet-use behavioral disorder?

Dr. Potenza: 
“I think that as clinicians we should be alert to conditions that individuals may be experiencing that may be affecting them in adverse fashions.  I also think that it is important to acknowledge the complex and incompletely understood nature of psychiatric conditions (including those characterized by poor impulse control) as we do not know their causes. The large DOMINION study provided important information about how certain impulse-control behaviors were related not only to medications but also other factors like marital status and geographic location.  However, Internet-use behaviors were not specifically assessed in this study, and I would caution against over-generalizing with the existing data.  That being said, I think that we all should be mindful about how digital technology use has been changing rapidly, and researchers should examine more carefully the potentially positive and negative impacts that different types and patterns of Internet-use behaviors may have.”

Could overusers of Facebook and Twitter be modern versions of zeitgeist?

Francisco Cardoso MD, PhD, FAAN
Professor of Neurology at the Medical School of the Federal University of Minas Gerais, Brazil; Past President of the Pan American Section of the International Parkinson’s Disease and Movement Disorders Society

“We occasionally see patients who use a lot of Twitter. To start with, it would be helpful to compare the frequency of posting comments to the average Twitter user. It is possible that there is a proportion of users of this medium who post at the same pace as the normal population. We think of impulse control disorders in movement disorders usually associated with Parkinson’s disease and the concommitant use of dopamine agonists. Could overusers of Facebook and Twitter be modern versions of “zeitgeist.” Zeitgeist is the set of ideals or beliefs that motivate action in a society at a particular time. In this sense Internet overuse would just be a symptom of the disease of our civilization where those who move with more speed come to dominate the territory. This has been well studied by Paul Virilio in his publications about “dromology.” Personally, I tend to think that there is a pathological form of Internet overuse syndrome.”

Selected References

1: Weintraub D, David AS, Evans AH, Grant JE, Stacy M. Clinical spectrum of impulse control disorders in Parkinson's disease. Mov Disord. 2015 Feb;30(2):121-7. doi: 10.1002/mds.26016. Epub 2014 Nov 5. Review. Erratum in: MovDisord. 2015 Jun;30(7):1010. PubMed PMID: 25370355.

2: Evans AH, Kettlewell J, McGregor S, Kotschet K, Griffiths RI, et al. (2014) A Conditioned Response as a Measure of Impulsive-Compulsive Behaviours in Parkinson’s Disease. PLoS ONE 9(2): e89319. doi:10.1371/journal.pone.0089319

3: Kuss DJ, Griffiths MD, Karila L, Billieux J. Internet addiction: a systematic review of epidemiological research for the last decade. Curr Pharm Des.2014;20(25):4026-52. Review. PubMed PMID: 24001297.

4: Van Rooij AJ, Prause N. A critical review of "Internet addiction" criteria with suggestions for the future. J Behav Addict. 2014 Dec;3(4):203-13. doi:10.1556/JBA.3.2014.4.1. Review. PubMed PMID: 25592305; PubMed Central PMCID: PMC4291825.

5: De Leo JA, Wulfert E. Problematic Internet use and other risky behaviors in college students: an application of problem-behavior theory. Psychol Addict Behav. 2013 Mar;27(1):133-41. doi: 10.1037/a0030823. Epub 2012 Dec 31. PubMed PMID: 23276311.

6: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing, 2013.

7: Holden C. 'Behavioral' addictions: do they exist? Science 2001;294:980-982. 

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