Report of Internet Addiction from Indian subcontinent: Diverse in geography but similar in form
Mamidipalli Sai Spoorthy1, Anoop Krishna Gupta2*, Mithun Dutta3 and Jagdish Narayan Vyas4
1Department of Psychiatry, Raipur Institute of Medical Sciences, India
2Department of Psychiatry, National Medical College, Nepal
3Department of Psychiatry, Raipur Institute of Medical Sciences, India
4Department of Psychiatry, National Medical College, Nepal
Submission: July 21, 2017; Published: August 01, 2017
*Corresponding author: Anoop Krishna Gupta, Lecturer, Department of Psychiatry, Block C, National Medical College, Birgunj-18, India, Tel: 00977-9842060809; Email: dranoopkrn@gmail.com
How to cite this article: Mamidipalli S S, Anoop K G, Mithun D, Jagdish N V. Report of Internet Addiction from Indian subcontinent: Diverse in geography but similar in form. Psychol Behav Sci Int J. 2017; 5(3): 555663. DOI: 10.19080/PBSIJ.2017.05.555663
Abstract
Background: Internet addiction is an emerging problem in the last decade. The main age group affected is adolescents and school children. Its association with depression and other psychiatric disorders is complex and bidirectional. Diagnosing internet addiction is often delayed and masked by the overlying comorbidities.
Case presentation: We present two cases of a 14 and 19 year old boys who presented with symptoms of internet use in a pattern characterised by tolerance, dyscontrol, withdrawal symptoms of irritability, preoccupation with internet, risking significant relationships and missing educational opportunities. In addition to above, the first case developed sadness of mood, decreased interest, easy fatiguability, pessimistic views and sleep disturbances while the second case developed aggression. Patient scored 85 and 82 points on internet addiction test respectively. The first patient was prescribed antidepressants while the second was given short term benzodiazepine. Family members were educated about the internet addiction and behavioural intervention was done in both.
Discussion: Internet addiction is an evolving psychiatric disorder which invites other psychiatric comorbidities. Sensitization into the aspect of disorder is need of an hour to understand and manage the menace.
Keywords: Internet Addiction; Depression; Adolescent; Comorbidity
Abbreviations: IA: Internet addiction; IAT: Internet addiction test
Introduction
Internet usage in the modern times has gone far beyond the limits of educational, occupational and recreational purposes. Though not given importance in the current diagnostic and classificatory systems, it is the concern of many parents of adolescents particularly in the recent past. Assessment of the problematic internet use or Internet Addiction (IA) is required because it has association with several of the psychiatric disorders leading to impaired functioning of the patient [1]. Several premorbid traits like shyness, social anxiety, low self esteem have been shown to be associated with problematic internet usage [2,3]. Depression and its association with internet use has been proved in the recent studies [4,5]. This association has also been substantiated by few Indian studies [6]. On the other hand, studies from Nepal are missing.
Case Presentation-1
We report the first case of a 14 year old male studying ninth standard coming from a middle socio economic and rural background of Raipur, India. The index patient was gifted laptop by father in early 2016 for his birthday. Initially the patient started to browse the internet on and off, for about 15 minutes each time. He would either use social media or would surf for subject related doubts. Gradually he started to use the internet for 4-6 hours in a day as he would use his play time also for online activities. As per him he would not be able to control the duration spent online and would prolong it by telling that it was just a matter of few more minutes. Even at school he would think about how to spend time online and remained preoccupied. As a result he was not able to pay much attention to his study
He started to remain awake till late night. It was then when he started watching pornography apart from using social media sites. Whenever his parents would scold him for wasting time he would get irritated and angry at them but would not stop the use of internet. Subsequently, he performed poor in the exams compared to his usual self. Family members also acknowledged the fact that they were not allowed to see patient's online activity as he used a password unknown to them. This pattern continued for 6 months. There after patient gradually started withdrawing himself. He would appear weak, would often get tired easily. He gradually stopped interacting with any of the family members. He stopped showing interest in playing with his siblings. He would not ask food by himself and eat only half of the previous amount when persuaded. As he appeared weak and had lost weight, he was taken to multiple doctors. Electrocardiogram, thyroid function test, complete blood count, serum electrolytes, blood sugar and renal function test were repeated multiple times but no abnormality was detected.
Patient started missing school frequently due to fatigue. He also developed ideas of hopelessness and wish to die but never voiced it to family members. In his last consultation from physician he was referred to us for sleep disturbance. On mental state examination he had sad affect, pessimistic views about future and self. General physical examination was unremarkable and patient denied of any recent or past use of substances. After the assessment diagnostic possibilities considered were problematic internet use and childhood depression. Fluoxetine 20 mg along with 0.25 mg of Clonazepam was started. Parents were advised to be more compassionate. Rewards were given for other activities like outdoor games. There was improvement in depression and dysfunctional internet use after 4 weeks of treatment.
Case Presentation-2
Our second case was a 19 year old male of lower socioeconomic status from Birgunj (Nepal) presented to our out-patient department with complaint of being physically and verbally abusive to his mother. He was angry with family members for being brought to psychiatry department. He was referred from emergency setting after being kept overnight to rule out mania. His mother reported that she did not buy a smart phone for the patient and thus he became violent. However, the patient had started showing abnormal behaviour 8 months back when he started being engrossed in mobile phone for 5-6 hours per day. As per mother, He started playing games in mobile phone. Later, he persuaded family members for buying internet data for his mobile. At starting phase, he used Face book and Whatsapp applications only but later he also started chatting over other social media applications like Omegle and Messenger.
After around 2 months he would be found chatting for even 6-8 hours continuously though he would experience head heaviness and intrusive images of mobile screen while sitting idle. He would remain awake till 3 am and at times he would fall asleep in evening and wake up at 2-3 am to use mobile. He would doze in daytime. On several occasions, he would be found carrying phone even in toilet. Unlike before he started browsing porn sites. His mother found that accidently. Patient reports that he would switch to and fro between chatting and gaming application as he would get bored after repeated use of one but could not imagine another pleasurable activity.
After around 6 months there was complaint from his school that he did not do homework. He studied in 12th standard and had been average student. He had been regularly promoted throughout his past academic years. As per patient he developed lack of interest in studying and did not worry for consequences. He remained confident in passing final exam. Then after, family members restricted his pocket money but only to see him indulge in street gambling. He had an aim to double his pocket money. His intention was to earn money in order to buy internet data. However, he was not found stealing or lying on other occasions. There was no history of animal cruelty or bullying.
He continued to score less marks in his internal exams but did not have remorse like premorbid self. He remained hopeful to make up in final exam. He continued to use mobile phone and internet in same pattern until few days back when his father seized his phone. He appeared irritable and was demonstrative for the act. He did not confront his authoritative father but showed his resentment to his mother. He demanded for his mobile. Father broke the set upon patient reaction. Immediately, patient threw glass at his mother. He also used abusive language towards his parents. On examination, he was restless and remorseful for his behaviour and did not want his mobile. He recognized the change in himself over past months. At the same time, he also told that he was not alone in recent internet indulgence. He had 3 classmates who were like him. They also shared new applications and games among themselves. He was taught anger control strategies and was give Clonazepam 0.25 mg for 10 days. Time out and negative reinforcement were used for his challenging behaviours. There was improvement in his sleep and anger.
Discussion
Diagnoses of IA in both the cases were based on the following signs and symptoms: preoccupation with the internet; use of the internet for longer duration of time in order to achieve satisfaction; repeated, unsuccessful efforts to cut down or stop Internet use; feelings of irritability when attempting to control the internet use; staying online for longer periods than intended; risking loss of significant relationships, educational opportunities because of Internet use [4]. Apart from this, there are several factors for internet dependence has been delineated [7], the discussion of which is out of the context. Our patients scored 85 and 82 points on internet addiction test (IAT) respectively which means internet caused significant problems in their lives [8]. Both the cases throw light on important issues in the context of problematic internet usage and psychological disturbances like emotional disturbances. First of all, depression in the first case was missed by many of the treating doctors. The reason for the same might be unawareness of the clinical presentation in the practitioners themselves and the explanatory models of illness held by the boy's parents. This led to impaired academic performance and poor attendance to the school. Secondly, even though parents were unhappy about the child's excessive use of internet they never sought help until either depressive symptoms or aggressive behavior started. This might be due to lack of information about the presentation and need for psychiatric treatment. Understanding and delineating internet addiction is difficult in India and Nepal where people still hold strong beliefs on witchcraft and supernatural causes.
Relationship between psychiatric disorders (depression & anxiety) and internet use is bidirectional as one may worsen the other. Patients with IA like most of the addictive disorders are at risk to develop depression [5]. Similarly, patients with depression use IA as a means of escape from their problems [9]. Hence understanding the context in which IA developed and its relationship with depression is important as it has social consequences and management implications [10]. However in the first case, IA preceded depressive symptoms. Though this relationship is not new most of the research in this area is from Korea and China [11-15]. Reports from countries like India and Nepal are few and confined to a specific centre (1,6).
Development of culture specific screening tools and education of the existing practitioners should be the target of continuing medical education. Training programs related to IA should be frequent. Further studies need to be done in order to understand the prevalence and for development of interventions targeted at IA and its psychiatric comorbidities. The recent rise in the use of internet should warrant strict consideration of IA in the diagnostic and statistical manuals. Like all studies our one had some caveats and limitations. It can be debatable that the addiction of these patients was either of internet or its content. For better clarification further studies need to be done with bigger sample size and stronger methodology.
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