IAD1.jpg
Courtesy of http://learnoutlive.com/wp-content/uploads/2011/05/internet-addiction.jpg
The Internet is a convenient and fantastic tool to gather information, maintain

social connections, and to entertain oneself. However, Internet overuse is becoming more prevalent as humans become even more dependent on it, to the point where it interferes with daily life. Unfortunately, chronic Internet overuse is not considered an addiction, but it is currently under review of being included as a diagnosable mental illness in the DSM-5. For it to be classified as dependence, it must meet at least three of the following criteria: tolerance, salience, withdrawal, difficulty controlling, neglecting other activities, continued use despite negative consequences and the desire to cut down.[1] Some countries such as Korea treat Internet overuse very seriously and psychiatrists are trained to identify the cues and symptoms of addictive behaviour. There is emerging evidence suggesting that there are negative neurological, cognitive, and behavioural changes in individuals with Internet addiction, particularly the prefrontal cortex, cingulate cortex, and the striatum – areas that are associated with impulse control, reward sensitivity, and other cognitive processes. Since Internet addiction is not a clinically recognized illness, there are some limitations interpreting the existing research, particularly the broad differences in definition and diagnosis of Internet addiction and its application for treatment. Nevertheless, this is an important step towards the recognition of Internet overuse as a social addiction.


Etiology in the Brain


In modern society, the Internet can now be regarded as a significant part of the human environment and the brain is adapting to this. Although IAD has received little neurobiological study, many observed changes have been noted between Internet addicts and non-addicts. The predominant areas are the prefrontal cortex, cingulate cortex and the striatum, with indications of various other areas being affected, suggesting that the brain undergoes many plastic changes that may not be beneficial in the long-term.



Prefrontal Cortex

The prefrontal cortex goes under multiple changes, notably in two subdivisions: the orbitofrontal cortex (OFC) and the dorsolateral prefrontal cortex (DLPFC). These areas are implicated in impulse control [2] [3] , reward sensitivity [4] , craving [5] , and desire [6] [7] . Researchers found that in adolescents with IAD there is an abnormal decrease in gray matter volume in the bilateral DLPFC. [8] In regards to online gaming addicts, fMRI scans show that in response to online gaming stimuli, there is an increased activation in the right OFC and right DLPFC [9] and in a guessing task, there is greater activation in the OFC in gain trials compared to normal controls.[10] FDG-PET scans have shown hypermetabolic changes in the prefrontal areas [11] and increased glucose metabolism
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Yuan, K., Qin, W., Wang, G., Zeng, F., Zhao, L., Yang, X., et al. Microstructure abnormalities in adolescents with internet addiction disorder. PLoS ONE 6 (6): 1-8 (2011).
in the right middle orbitofrontal gyrus [12] . Finally, when controlling for Internet game time, addicts as opposed to casual players showed increased activation in the right medial frontal lobe.[13]

Cingulate Cortex

The cingulate cortex is responsible for a variety of functions including: focusing attention on emotionally significant events [14] , regulating aggressive behaviour [15] [16] , motor control [17] , and visuospatial processes [18] [19] . Interestingly, one notable difference between professional video game players and online game addicts was an increased gray matter volume of the left cingulate gyrus in professional gamers [20] and adolescents with IAD also have lower gray matter density in the left anterior cingulate cortex [21] [22] . Research has shown through fMRI scanning that addicts have increased activation in the bilateral anterior cingulate. [23] However, in a guessing task, results revealed the opposite – decreased activation in the anterior cingulate in loss trials. [24] Nevertheless, the aforementioned research suggests that the cingulate cortex may contribute to the different clinical characteristics of professional gamers and online gaming addicts and that the cingulate plays a complex role in IAD.

Striatum

The striatum is an anatomical component of the basal ganglia consisting of the caudate nucleus, putamen and the nucleus accumbens and is associated with reward processing. [25] Internet game addicts have increased glucose metabolism in the left caudate nucleus [26] and increased activation in the right caudate [27] and the right nucleus accumbens [28] compared to the control group. Using the radiolabeled ligand [11C] raclopride, researchers determined that individuals with IAD showed reduced levels of dopamine D2 receptor availability in subdivisions of the striatum, particularly the bilateral dorsal caudate and right putamen. [29] This is the first line of research that has investigated IAD at the synaptic level and identified a receptor associated with IAD.

Other Areas of Interest

There have been some other observable changes in the brain that have been noted but have not been researched sufficiently and warrant future investigation. These include an increased activation in the thalamus [30] , parahippocampal gyrus [31] , occipital gyrus [32] [33] , precentral and postcentral gyrus [34] [35] , and the insula [36] .

Cognitive-Behavioural Changes


The presence of neurobiological changes indicates that individuals with IAD will manifest certain observable cognitive and behavioural changes which has been documented in the literature based upon the functionality of the aforementioned brain areas.

Cognitive Changes

Adolescents with IAD were administered the Korean adaptation of the WAIS and performed poorly on comprehension and digit span performance; criteria that evaluates social intelligence, conscience, morality development, and intellectual curiosity. [37] They also have low self-esteem [38] , are less efficient in information processing [39] and show impaired executive control ability during a Stroop task [40] . World of Warcraft (WoW) addicts have reduced decision making abilities in risky situations similar to individuals with pathological gambling.[41] In a Go/NoGo task, gaming addicts are consistently better and quicker at discriminating targets from distracters, but show greater disinhibition and cognitive bias towards symbols that represent the focus of their gaming behaviour. [42] This supports previous work that gamers show better visuospatial abilities (e.g. working memory), but simultaneously suffer the negative effects of gaming addiction. [43]

Behavioural Changes

Individuals with IAD exhibit very distinct behaviours that resemble other substance abuse and impulse control disorders.
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Courtesy of http://topnews.net.nz/images/Internet-Addiction-Depression.jpg
For example, adolescents are significantly more likely to be aggressive regardless of the Internet medium they are addicted to while controlling for other external factors. [44] In a Go/NoGo study, IAD university students showed lower impulse control [45] and in a guessing task, addicts have enhanced reward sensitivity and decreased loss sensitivity [46] . Gaming addicts also exhibit cravings and gaming urges when presented with WoW pictures. [47]


Directionality

Does IAD cause the manifestation of these cognitive-behavioural changes or do these behaviours cause IAD? Research suggests that Internet users who are characterized by an impulsive personality are less able to control their use of the Internet and thus are more susceptible to develop IAD. [48] Students with personalities characterized by dependence, shyness, depression, and low self-esteem have a high tendency to become addicted. [49] Also, individuals that are aggressive and narcissistic were positively correlated with IAD and negatively correlated with self-control. [50]

Experimental Treatment


Since Internet addiction is a relatively new phenomenon lacking universal diagnosable criteria and only recognized in some countries, there are a wide variety of experimental treatments that have been used. As research for this disorder is in its early stages, the field of research is constantly growing as it becomes a more prevalent issue. Both psychotherapeutic and pharmacological techniques have been used to combat Internet addiction with positive results.

Psychosocial Therapy

To deal with treating individuals with IAD, psychosocial therapy is a popular and common technique compromising of multiple approaches with distinct advantages to cater to the individual. Many studies in the literature have investigated various psychosocial treatments and are relatively rigorous and reliable.

Traditional Therapy

Cognitive-behavioural therapy (CBT) was one of the first psychosocial treatments made available for individuals with IAD. Early on, these clients comprised of primarily middle-aged men with college degrees, needing help with a situation that was relatively new in their lives. Research has shown that after twelve CBT sessions, there was an increase in the motivation to quit, online time management, engaging in offline activities, and improved offline sexual functioning, and felt less socially isolated. [51] Reality therapy effectively reduces addiction levels and increases self-esteem of university students.[52] Family therapy is effective in decreasing Internet use and enhancing family function and cohesiveness in adolescents. [53] Group therapy helps reduce emotional symptoms such as anxiety in middle school students. [54] Finally, motivational interviewing (MI) improves one’s quality of life while reducing depressive symptoms associated with online sex addiction in males. [55] All of the aforementioned approaches are effective in dealing with improving specific symptoms in an individual, but are very limiting as issues are left unaddressed.

Modern Therapy

Multimodal therapy has emerged as the primary treatment for IAD as it is flexible and incorporates multiple therapeutic approaches to help an individual improve in multiple areas in his/her life. Research has shown that multimodal school-based group CBT is effective in improving emotional state and regulation ability, behaviour and self-management style, such as time management. [56] Combining family therapy, CBT and Gestalt psychotherapy significantly increases feelings of social comfort, family function and perceived social support in Internet addictive adolescents. [57] An experimental multi-counselling intervention model consisting of MI, CBT, family and group therapy while incorporating research from the field of substance abuse was developed to assess its effectiveness. [58] Results showed a decrease in Internet addiction symptoms and positive changes in family functioning – most importantly, adolescents reported that the program was very helpful as it taught them how to deal with their own problems and when to seek counselling when they felt professional help was needed. [59]

The newest area of psychosocial treatment involves the use of an online intervention system called the Health Online Self-Helping Center (HOSC). A pilot study revealed that after completing the HOSC program, it effectively reduced participants’ online hours and improved online satisfaction. [60]

Pharmacological Therapy

Pharmacological treatment is a new avenue that researchers are exploring as an alternative solution to IAD as there seems to be an underlying neurobiological mechanism that may be malfunctioning. An early case study involved an Internet sex addict and was prescribed naltrexone. He reported a decrease in his sexual urges within one week, and after three years, he has been in nearly complete remission from compulsive Internet use. [61] Since the Internet encompasses many forms of entertainment (i.e. pornography, networking, and gaming), it is important to note that some pharmacological treatments may be more effective combatting particular addictive behaviours as opposed to others.

Escitalopram

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Escitalopram, commercially known as Lexapro. Courtesy of http://www.drug3k.com/imagepages/16227/image9.html
Individual case reports have evaluated the role of well-known pharmaceutical drugs and IAD. One patient recovered social functioning and had decreased urges for online gaming after receiving escitalopram over three months. [62] A follow-up study investigated the efficacy of escitalopram in patients with IAD. Results indicated that within 10 weeks, nonessential Internet usage decreased significantly compared to baseline. [63] For an additional 9 weeks, half of these patients received a placebo and interestingly there were no significant differences were observed. This suggests that both groups maintained the benefits from the initial 10 week treatment or that 9 additional weeks were not enough for the main effect to be lost in the placebo group.



Bupropion & Methylphenidate

Two newer pharmaceutical drugs that have been used as potential treatments for IAD are bupropion and methylphenidate. In the first study of its kind, Internet game addicts that took bupropion for six weeks spent significantly less time on the Internet, had a decreased craving for playing, and had decreased activation of the DLPFC. [64] Research also suggests that methylphenidate (used for individuals with ADHD) is also effective in significantly reducing Internet usage times and scores on the Young’s Internet Addiction Scale, Korean version after eight weeks. [65] These pharmacological interventions have had encouraging results and are an area that should be further explored to treat IAD.


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In modern society, the Internet can now be regarded as a significant part of the human environment and the brain is adapting to this. Although IAD has received little neurobiological study, many observed changes have been noted between Internet addicts and non-addicts. The predominant areas are the prefrontal cortex, cingulate cortex and the striatum, with indications of various other areas being affected, suggesting that the brain undergoes many plastic changes that may not be beneficial in the long-term. Braaaaiiinnn.gif6