Treatment Planning

The addiction field is used to epidemics of powerfulky 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-tmretionale forr 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/shuitability

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 thw 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 othwr "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.