تابع الاعراض والتقييم والعلاج

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ASSESSMENT OF PATHOLOGICAL INTERNET USE

Symptoms of Internet addiction are ones that may not always be revealed in an initial clinical interview; therefore, it is important that clinicians routinely assess for the presence of addictive Internet use. In order to properly assess for pathological Internet use, I need to first review controlled drinking models and moderation training for eating disorders which have established that certain triggers or cues associated with past alcohol, drug, or food use will onset binge behavior. Triggers or cues which may initiate binge behavior come in different forms such as certain people, places, activities, or foods (Fanning & O’Neill, 1996). For example, a favorite bar might be a trigger for excessive drinking behavior, fellow drug users with whom the patient used to party might trigger his or her drug use, or a certain type of food may lead to binge eating.

Triggers go beyond concrete situations or people, and may also include negative thoughts and feelings (Fanning & O’Neill, 1996). When feeling depressed, hopeless, and pessimistic about the future, an alcoholic may resort to drinking. When feeling lonely, unattractive, and down about oneself, an overeater may binge on whatever is in the refrigerator. Depression or low self-esteem may act as triggers which initiate binge-like behavior in order to temporarily run away, avoid, or cope with such negative thoughts and feelings.

Finally, addictive behaviors may be triggered or cued in reaction to an unpleasant situation in a person’s life (Fanning & O’Neill, 1996; Peele, 1985). That is, major life events such as a person’s bad marriage, dead-end job, or being unemployed may trigger binge related behavior associated with alcohol, drugs, or food. Many times, the alcoholic will find it simpler to drink in order to cope with recent news of being unemployed than to go out and search for a new job.

Addictive behaviors often act as a lubricant to cope with missing or unfulfilled needs which arise from unpleasant events or situations in one’s life. That is, the behavior itself momentarily allows the person to "forget" problems. In the short term, this may be a useful way to cope with the stress of a hard situation, however, addiin the long run only end up making the problem worse. For example, an alcoholic who continues to drink instead of dealing with the problems in marriage, only makes the emotional distance wider by not communicating with one’s spouse.

Addicts tend to recall the self-medicating effects of their addictions, and forget how the problem grows worse as they continue to engage in such avoidant behavior. The unpleasant situation then becomes a major trigger for continued and excessive use. For example, as the alcoholic’s marriage gets worse, drinking increases to escape the nagging spouse, and as the spouse’s nagging increases more, the alcoholic drinks more.

In this same manner, Internet addiction operates on triggers or cues which lead to "net binges." I believe that behaviors related to the Internet have the same ability to provide emotional relief, mental escape, and ways to avoid problems as do alcohol, drugs, food, or gambling. Therefore, origins for such net binges can be traced back to the following four types of triggers which need to be assessed, (a) applications, (b) feelings, (c) cognitions, and (d) life events.

Applications

The Internet is a term which denotes a variety of functions accessible on-line such as the World Wide Web (WWW), chat rooms, interactive games, news groups, or database search engines. Young (1996) noted that addicts typically become addicted to a particular application which acts as a trigger for excessive Internet use. Therefore, the clinician needs to determine which applications are most problematic for the addicted user. A thorough assessment should include an examination of the extent of use among particular applications. The clinician should ask the patient several relevant questions, (a) What are the applications you use on the Internet? (b) How many hours per week do you spend using each application? (c) How would you rank order each application from best to least important? and (d) What do you like best about each application? If this is difficult to note, the patient may keep a log near the computer in order to document such behaviors for the next week’s session.

The clinician should review the answers to the above questions in order to determine if a pattern emerges, such as reviewing those applications ranked one or two in terms of importance and how many hours the patient spends on each. For example, the patient may rank chat rooms as number one in terms of importance and use them 35 hours per week compared to lower ranked newsgroups which are only used 2 hours per week. Another patient may rank newsgroups as number one and use them 28 hours per week compared to the lower ranked World Wide Web which is only used 5 hours per week.

Emotions

Peele (1991, pg. 43) explained the psychological hook of addiction as "it gives you feelings and gratifying sensations that you are not able to get in other ways. It may block out sensations of pain, uncertainly, or discomfort. It may create powerfully distracting sensations that focus and absorb attention. It may enable a person to forget or feel "okay" about some insurmountable problems. It may provide an artificial, temporary feeling of security or calm, of self-worth or accomplishment, of power and control, or intimacy or belonging." It is these perceived benefits which explain why a person keeps coming back to the addictive experience.

Addictions accomplish something for the person, however illusory or momentary these benefits may actually be. Because of the mental pleasure that people find in their addictions, they begin to behave more intensely about them. Feelings of excitement, euphoria, and exhilaration typically reinforce addictive patterns of Internet use. Addicts find pleasant feelings when on-line in contrast to how they feel when off-line. The longer a patient is away from the Internet, the more intense such unpleasant feelings become. The driving force for many patients is the relief gained by engaging in the Internet. When they are forced to go without it, they feel a sense of withdrawal with racing thoughts "I must have it,’ "I can’t go without it," or "I need it." Because addictions serve a useful purpose to the addict, the attachment or sensation may grow to such proportions that it damages a person’s life. These feelings translate into cues which cultivate a psychological longing for the euphoria associated with the Internet.

To best focus on emotional triggers, the clinician should ask the patient "How do you feel when off-line?" The clinician should then review the responses and determine if they range on a continuum of unpleasant feelings such as lonely, unsatisfied, inhibited, worried, frustrated, or troubled.

The clinician would then ask the patient "How do you feel when using the Internet?" Responses such as excited, happy, thrilled, uninhibited, attractive, supported, or desirable indicate that use of the Internet has altered the patient’s mood state. If it is difficult for the patient to determine such emotions, ask the patient to keep a "feelings diary." Have the patient carry a notebook or card in order to write down feelings that are associated with being both off-line and on-line.

Cognitions

Addictive thinkers, for no logical reason, will feel apprehensive, when anticipating disaster (Twerski, 1990). While addicts are not the only people who worry and anticipate negative happenings, they tend to do this more often than other people. Young (1996) suggested that this type of catastrophic thinking may contribute to addictive Internet use in providing a psychological escape mechanism to avoid real or perceived problems. In subsequent studies, she found that maladaptive cognitions such as low self-esteem and worth, and clinical depression triggered pathological Internet use (Young, 1997a, Young 1997b). Young (1997a) hypothesized that those who suffer from deeper psychological problems may be the ones who are drawn the most to the anonymous interactive capabilities of the Internet in order to overcome these perceived inadequacies.

Dr. Maressa Hecht-Orzack of McLean Hospital founded the Computer/Internet Addiction Service in the Spring of 1996. She indicated that the referrals she received were from various clinics throughout the hospital instead of direct self-referrals for Internet addiction. She reported that primarily depression and bi-polar disorder in its depressive swing were co-morbid features of pathological Internet use. Hecht-Orzack noted that patients typically hide or minimize their addictive Internet use while being treated for the referred disorder. Since it is likely that a patient will self-refer more readily for a psychiatric illness than for pathological Internet use, the clinician should screen for maladaptive cognitions which may contribute to the patient’s addictive use of the Internet. Clinicians should evaluate if patients maintain deep core beliefs about themselves such as "I am no good" or "I am a failure" in order to determine if these may contribute to their pathological Internet use. It is important to note that intervention should focus on effective management of the patient’s primary psychiatric illness and note whether this treatment ameliorates the symptoms of pathological Internet use.