Internet Addiction Isn't

Allen Francis, MD recently wrote an article published by Psychiatric Times challenging the proposed adoption of Internet addiction in DSM-V. In his commentary Ronald Pies, MD referred to his article published last year in Psychiatry 2009 which also highlights problems with introduction of the concept of Internet addiction as a mental disorder.

The Internet is not a behavior. It is a complex network of people, devices, and a variety of technologies connecting them, including radio waves, fiber-optic cables, and electrical cables. It is a tool and a conduit analogous to the needle and syringe of a heroin addict or the bottle of an alcoholic. It makes no more sense to suggest that someone might be addicted to the Internet than to suggest that an alcoholic is addicted to bottles or a heroin addict to syringes.

At a minimum we must substitute the term "Internet use" when discussing its merit as a kind of behavioral addiction. We might then consider whether Internet use might represent a class or category of behavioral addictions such as Block's (Block JJ. Issues for DSM-V: internet addiction. Am J Psychiatry. 2008;165:306–307.) so-called "subtypes" of Internet addiction: gaming, sexual, and communication. None of these, however, requires use of the Internet, which begs several questions:

• Is gaming somehow more addictive when using the Internet rather than an isolated computer or no computer? 
• Is text messaging more addictive when conducted via the Internet rather than directly from one device to another? 
• Is solitaire more addictive over the Internet than using a computer? Is it more addictive using a computer than using paper cards?

More questions arise in discussing use of the Internet for sexual gratification. Use of the telephone for sexual contact predated use of the Internet. With today's cell phones it may not always be clear whether or not the communication from one telephone to another uses the Internet. Does that make a difference? References to use of the Internet to access "pornography" are confused by the difficulty in defining that term. I propose that we substitute the less pejorative "erotic media." Once more we must decide whether transmission of such media via the Internet plays a critical role in what ever addiction might be identified. The term "pathological use of electronic media" is equally problematic. If we are to identify behavioral addiction we must focus on the behavior, not the tools used to deliver the necessities of that behavior.
Perhaps there is an analogy here in the field of chemical addiction. Evidence suggests that use of pure cocaine and crack cocaine carries greater risk of addiction then chewing coca leaves. Do we have evidence to suggest that erotic media are more addictive when accessed via the Internet? And is Oxycontin any more addictive when obtained via the Internet than from a physician? What if the physician orders the drug by faxing the prescription via the Internet?

As for invoking psychoanalytic/psycho dynamic theory in this discussion, let me remind Dr. Pies that the DSM is a psychiatric, not psychoanalytic, nomenclature. I would also remind him of the dismal track record of psychoanalytic and psychodynamic treatments in patients suffering from substance use disorders.

Dr. Pies and others also focus too much on the purported "excessive" behavior as a problem existing in the individual patient. We must also learn about the purpose such behaviors serve in the larger family and social system.

It used to be that too much of anything was bad. Now too much of anything is addiction. But I do believe we have abundant evidence for one new diagnosis prevalent among some mental health professionals:

Addiction Addiction.

Testing the Unconscious

Freud called dreams the "royal road to the unconscious," but the authors of the Implicit Association Test seem to claim an ability to measure "implicit cognition" (Is that a euphemism for unconscious?) by using a computer administered psychological instrument.

This approach was previously reported to uncover racial bias in the practice of medicine: http://www.ama-assn.org/amednews/2009/09/28/prsa0928.htm, but according to an article in a recent issue of Psychiatric News a variation of the test appeared to predict suicide risk more accurately than by traditional means such as psychiatric interview. I took one of the tests myself. The result was not what I would have expected. Did the test err, or do I simply not know or acknowledge my true attitudes? I suppose the authors might claim the result proves that my attitude is unconscious, but as far as I know no method of tapping the unconscious exists that might provide researchers with a way to validate the results of such a test, except perhaps by looking at my subsequent behavior.

The notion of a test of unconscious intent (Isn't that a contradiction in terms?) sends me on flights of fantasy. I imagine requiring psychiatric patients to undergo testing on a mobile device every 24 hours with results transmitted to a central clearinghouse. If the patient starts to lean toward suicide, the men in white coats home in on their GPS signal, pick them up, and hospitalize them until their attitudes right themselves, with or without treatment. Of course one would have to pass the test before purchasing a firearm, or razor blades, or matches. Or before being allowed to pilot an airplane or drive a car, or cross a street, or climb higher than the first floor of a building. Could we detect future suicide bombers?

Why limit the use of this technology to prediction of suicide, or to psychiatric patients? If such a test could detect intent to rob, rape or kill, to engage in insider trading, run a red light or shoplift, we could require everyone to take it and virtually eliminate crime. Maybe, rather than requiring formal testing, analysis of patterns of Internet use such as Web sites searched or visited could allow, for example, determination of how one might intend to vote in an election. Could such information be used to subtly influence attitude, intent or even religious belief by channeling selected stories through news sites and other media, or even what happens to you when you play World of Warcraft? And since it's all unconscious, how would you know? The possibilities for abuse approach infinity.

Somebody please make a movie!

You can take the tests yourself at: https://implicit.harvard.edu/implicit/, provided you can reign in your paranoia.

How Psychiatry Works

An admittedly oversimplified illustration of how psychiatry works:

Scenario One

You have been suffering from loss of energy and motivation for a month or so, so you visit your primary care physician. She orders a blood test and finds that your thyroid stimulating hormone (TSH) is high. She diagnoses hypothyroidism as the most likely cause of your symptoms, rules out more serious disorders with more tests, and prescribes thyroid replacement drugs. After you start taking them you get better. She recommends that you continue taking them indefinitely.

Scenario two

What doctors call the history of present illness is the same as in Scenario One, but this time when the doctor finds that all your blood tests were normal, she tells you she cannot find a physical illness that might explain your symptoms, diagnoses some kind of depression (i.e. it's all in your head) and refers you to me, the psychiatrist.

You have become a medical leftover. Specifically treatable physical illnesses do not explain your symptoms, so in many cases the only physician who will take care you is a psychiatrist. But not to worry: Psychiatrists generally like talking to people, are fascinated by mental and emotional problems, and like helping people like you solve them. In the past you might have been locked up in an asylum or referred for psychoanalysis, but today, fortunately, we have specific forms of psychotherapy that can treat mental disorders, and we have a host of drugs that for most people are relatively safe and effective, somtimes miraculously so.

Diagnosis

After collecting lots of information about your history and your symptoms I will probably have some vague idea of your diagnosis. Given all the recent controversy about DSM V you might think this is a critical step. In fact it is somewhat important. I don't want to treat someone with schizophrenia for panic disorder or someone with social phobia for bipolar disorder, but I usually make a mental jump to the most important phase which is to choose a treatment that is most likely to help you with minimal adverse effects and minimal delay. Another nice thing about many of the drugs we have today is that, for example, antidepressants, at least most of them, often work very well for anxiety as well. That makes it less critical to determine whether you suffer from, for example, dysthymic disorder, or generalized anxiety disorder. If I prescribe paroxetine and you come back two weeks later to tell me that you feel all better, who cares how we categorize your problem? (It may be important to rule out bipolar disorder since evidence suggests many drugs with antidepressant effects can exacerbate the condition.)

Over-diagnosis

Many people that get diagnosed with bipolar disorder or attention deficit disorder may have never had either. A researcher or two publish data suggesting that we have missed a few cases, and everybody jumps on the bandwagon trying to make sure they never miss the disorder. Often we overshoot the mark and apply the diagnosis inappropriately. What's wrong with that? Delay in getting the right treatment for the right problem and exposure to adverse effects of the wrong treatment. There can be other fallout from simply having the wrong label as well. For example, if a psychiatrist evaluates your child, and you tell her that Uncle Harry has bipolar disorder, this may influence how the psychiatrist diagnoses your child. So if Uncle Harry really did not have bipolar disorder, your child may get the wrong treatment.

Under-diagnosis

Missing diagnosis can cause problems too. Once more we can have delay in appropriate treatment. But when I tell a patient I don't believe they really suffer from a mental disorder, I can add that we can monitor the symptoms over time with a plan to reassess if they worsen.

Getting It Just Right

We would like to be able to do this all the time, but it just is not possible. When I hear psychiatrists talk about patients as suffering from this or that disorder as though they are absolutely certain of the diagnosis it always makes me wonder. To me, especially if the patient has not responded very well to treatment, and even sometimes when they have, I tend to think of the diagnosis as what we call a working diagnosis. This is a provisional diagnosis we assume to be correct until proven otherwise, often by treatment failure. If I get too confident or locked in to a particular diagnosis there is a risk of barking too far up the wrong tree, usually trying treatment after treatment, all doomed to failure. Better to keep an open mind.

Drugs

You may feel like a guinea pig, but really you're the director auditioning drugs instead of actors. If we get it right with the first one that's terrific, but often patients have to try several medications before finding one that works and has acceptable side effects. Everyone seems to respond differently. Be warned though: You could keep trying different psychiatric drugs and combinations for years and never find one that makes the grade. At some point you may want to figure the solution is not in the (pill) bottle. If you haven't tried it already, consider psychotherapy. For more serious problems ECT and other biological treatments can work wonders.

Once you find a drug that works you have to decide how long to continue it. Some psychiatric drugs can prevent recurrence of your illness. You wouldn't stop oral contraceptives just because you didn't get pregnant. Many patients benefit from lifelong preventive or maintenance treatment, like for the hypothyroidism in Scenario One.

Ask your psychiatrist what to expect in the way of risk of dependence on medications and risk of adverse effects and whether there are ways to manage those risks. Sometimes additional drugs help control side effects of the primary drug. Be sure to keep the psychiatrist apprised of all other medications, conditions, symptoms, and side effects. And make sure the psychiatrist knows if you are disappointed in the effectiveness of the treatment.

Psychotherapy

It works, but not necessarily for your illness. For example, there seems to be no method of psychotherapy that treats schizophrenia, bipolar disorder, or ADHD, and certainly not Alzheimer's. But psychotherapy can help you and your family cope with any of them. Some kinds of psychotherapy actually effectively treat disorders like generalized anxiety disorder and panic disorder. Your psychiatrist may or may not provide psychotherapy. If she does, make sure it's the kind of psychotherapy that best treats your condition. If she doesn't insist that the two professionals communicate about your treatment.

Ask your psychotherapist what to expect, particularly how long the treatment lasts, how it works, and whether family members can be involved. Some kinds of psychotherapy can go on so long you can't tell whether the treatment or tincture of time got you better. Be sure to make the psychotherapist aware of any disappointment in the treatment. And if you don't like your psychotherapist, tell them so. A good one won't hold it against you, and will want to address it as just another interesting problem to work toward solving together.

Disappointment and Failure

If none of the above has produced acceptable results, ask for a consultation or second opinion, or just look for a different psychiatrist or psychotherapist. Most of us want you to get better, even if someone else gets to take some credit. And if you do get better, give yourself most of the credit.

Buprenorphine: First Aid for Overdose?

A couple days ago I read about a new statute in Washington state that protects overdose victims and witnesses from prosecution if they call 911 for help. I assume addicts have died of overdose of illicit drugs either because they feared that calling 911, while possibly summoning help, might also lead to conviction for some kind of narcotic offense.

Whenever I think about illicit drug overdose I recall the scene from Pulp Fiction in which (as I remember it) John Travolta's character jams a needle about three feet long into Uma Thurmond's chest, hoping to save her from death by overdose. He has the angle and approach all wrong for what should be intracardiac injection of epinephrine (I did this myself once with a surgeon at my elbow directing me.), but if only from the pain of her sternum stopping  a large needle, she regains consciousness and survives, maybe even until the end of the film. What this got me wondering was whether even an intoxicated addict faced with an overdose situation might have sufficient cognitive capacity to administer potentially life-saving first aid to self or other with minimal -- or at least acceptable -- risk.

We have known for years that naltrexone and naloxone reverse the effects of opiate agonists like heroin and oxycodone. Show up unconscious in an emergency department, and you'll probably get an injection of naloxone (Narcan) just in case you OD'd on an opiate. But I dare say few opiate addicts keep a supply of naloxone on hand for overdose emergencies. They might, however, have another drug that can block the effects of opiate agonists and can be procured on the street: buprenorphine. And what's more, you can administer the drug by dissolving it under the tongue like nitroglycerin, which is probably safer than swallowing for an unconscious victim. No need for an injection. I even wonder whether it might be adequately absorbed rectally to save a life. Buprenorphine, if it works at all, might also offer the advantage of working longer. Naloxone works rapidly, but has been known to wear off after the patient leaves the ED. Then the drug with which they overdosed, still on board, takes over again, and death ensues.

What would be the downside? Perhaps the worst might be delay in calling for help while attempting this measure, especially if something other than an opiate overdose caused the loss of consciousness. The new WA law might help. And perhaps 911 operators could walk callers through the procedure while help is enroute. Of course if the individual was addicted to opiates and regains consciousness they will likely be in withdrawal. I would be surprised if a number of addicts out there didn't think of this and try it years ago. Should we educate all addicts about it?

What we need now is for experts on management of opiate overdose to collect some evidence and offer their opinions as to whether the idea really works and is safe and feasible, and if so to get the word out. Maybe docs who prescribe opiate analgesics for chronic pain will want to order a few buprenorphine (off label of course) for patients to keep on hand for such emergencies.

Unhinging Dr. Carlat

No, this is not a review. I have not read the book, and I don't entirely disagree with Dr. Carlat's ideas.  I did, however, read a review, which I cannot now locate, but which included a short case said to have come from the book. A brief look may demonstrate the extent to which a different perspective can influence a psychiatrist's approach and challenge the notion that psychiatrists prescribing medication should also provide psychotherapy to most patients. (Let's not blame Dr. Carlat for any of this. The reviewer may have misread Carlat, and I may have misread the reviewer. If I didn't get it right, apologies to Dr. Carlat.)

As I recall the case involved a patient prescribed zolpidem for insomnia. Because of oversedation he nearly or actually wrecked his car. The patient had not been able to muster the courage to contact the doctor about the sedation because of his reluctance to confront authority figures, such as physicians. According to the reviewer Dr. Carlat argued that had he been treating the patient with psychotherapy the patient might have overcome his reluctance, telephoned the physician, and avoided the accident.

Here's how I would approach the case: First, I never prescribe zolpidem. Even if I prescribe a drug for insomnia I prefer melatonin, gabapentin, or a very sedating antidepressant like mirtazapine or trazodone. But before prescribing I want to know the source of the insomnia, and in some cases will recommend a sleep medicine consultation. I also like to address sleep hygiene (behavior) before resorting to a drug. Why would I want to prescribe a drug like zolpidem that can lead to dependence and has been associated with patients eating a buttered cigarette or driving while asleep?

But suppose, against my best professional judgment, I do prescribe zolpidem. I would do so only after warning the patient about the risks involved. And in fact the pharmacist would probably offer the same warnings orally and in writing when dispensing the drug.

But let's say it still boils down to that problem of psychological reluctance to call the authority figure. Successfully addressing such a problem in psychotherapy could take months or years, and there's no reason to believe it would happen any faster if the psychiatrist were providing the psychotherapy rather than a non-physician. Furthermore, we should not assume that psychotherapy would address said reluctance. Many kinds of psychotherapy don't address such problems at all, at least not directly. What would make a difference, however, is how often the patient visits the physician, even for a short visit to talk about medication effects, wanted and unwanted, and even with no psychotherapy.

This case also begs the question of whether psychiatrists should provide psychotherapy so patients can muster the courage to call between appointments about a side effect. I argue that psychotherapy should address a diagnosable mental disorder (however we choose to define it).

And wait. Suppose a sleep medicine physician, or heaven forbid an orthopedic surgeon, prescribed the zolpidem. Would we want all physicians to provide psychotherapy? Orthopods don't even do physical therapy.

This case provides little or no support for the position that psychiatrists should provide psychotherapy. It does underscore the importance of careful selection of medication, avoidance of medication when possible, and adequate patient education. In some cases there may be advantages to one-stop psychiatric shopping, but in this case the frequency of contact, rather than overcoming a psychological problem with psychotherapy might have made the difference.