Uzależnienie od internetu – trudności diagnostyczne i leczenie

■ INTRODUCTION

With the growing popularity of the internet, addiction to online activities is becoming an increasingly important problem, especially among children and adolescents. Over the last two decades, the internet has been attracting more and more new users. In 2023, 77% of adults in Poland declared regular internet activity, whereas in 2002 it was only 17%. In 2023, 100% of 18-to-24-year-olds were internet users [1].
A nationwide study conducted in 2022 on a group of 4,984 Polish students (primary and secondary schools) and 1,255 parents and legal guardians indicated the importance of the internet in young people’s lives. In this age group, the aver­age time spent online is 5 hours and 36 minutes on weekdays and 6 hours and 16 minutes on weekends. Furthermore, 31% of the participants exhibited a high level of problematic internet use (assessed by the E-SAPS18 test), and 8.3% showed very high rates. Among the students surveyed, over 40% believe that lack of access to the internet would make their lives less satisfying and significantly reduce their quality of life [2].
A 2023 study conducted on 1008 Polish university students revealed that nearly 10% present problematic internet use and have a high risk of internet addiction. The higher prevalence of pro­blematic internet use was observed among male science students [3].
Access to the internet enables constant contact with other users, mainly by means of social media. This provides new opportunities for self-expression, making friends and creating communities. Social media sites like Facebook, Instagram and TikTok are extremely popular especially among the younger generation. In the last quarter of 2023, Facebook reported over 3 billion monthly active users [4]. A 2020 meta-analysis revealed a pooled prevalence of social media addiction of 24% with the highest prevalence among adolescents (35%), whereas university students and adults had lower rates at 23% and 19% respectively [5].
Another closely internet-related activity is computer gaming. Online games allow players to communicate and compete in a virtual world. This form of leisure can provide entertainment and does not have to be an adverse factor in the user’s life. However, it can turn into an addiction and be associated with a range of harmful consequences including chronic sleep reduction and deterioration in sleep quality, which translates into subsequent executive dysfunction [6]. To date, problematic gaming seems to be the best-studied disorder associated with the internet and new technologies [7].
In addition to the above-mentioned addictive activities, attention should be paid to phonoholism,i.e. smartphone addiction. Modern mobile devices, including smartphones, allow users to access the internet from anywhere at any time, becoming an indispensable tool for many people’s everyday functioning. A study conducted on a group of 368 adults revealed smartphone addiction in nearly 17% of participants. A more frequent occurrence of headaches and a shorter mean sleep duration were also observed among those diagnosed with phonoholism [8].
Smartphone addiction is often associated with internet or social media addiction. These disorders overlap and co-occur in a significant number of patients, which seems to be important in defining and diagnosing these addictions. There are many inaccuracies and controversies surrounding the diagnosis and treatment of disorders related to new technologies and the internet; however, understanding this issue is crucial to improving the quality of life and functioning of patients addicted to the internet.

■ SEARCH STRATEGY

A narrative review was performed. A comprehensive literature search was conducted in the PubMed and PsycInfo databases with the use of predefined keywords (“internet addiction” OR “problematic internet use” OR “social media addiction” OR “problematic media use” OR “internet gaming disorder” OR “online gaming addiction”). Additional relevant articles were identified in the reference lists of previously retrieved reviews or meta-analyses. Statistics of social media use, prevalence of internet access and time spent online, especially among children and adolescents were found online. The review does not present a systematic approach so no formal inclusion or exclusion criteria were applied. The aim was to provide a broad and critical overview of diagnostic and therapeutic aspects of internet-related addictions. The quality of the paper was assured by the authors’ independent screening and selection of the literature. Any inconsistencies were resolved through consensus, thereby ensuring methodolo­gical transparency while acknowledging that this review does not constitute a full systematic review.

■ DIAGNOSTICS

Difficulties in the diagnosis of internet and internet-related activity addictions, including online gaming and social-network activity, stem from the inconsistency of diagnostic criteria [9] as well as insufficient differentiation in the spectrum of dia­gnosis of individual online activities. Problematic use of social networking sites, or even social media more generally, similarly to problematic cell-phone use, has not yet been included in any leading medi­cal classification. Internet use in a pathological context itself seems to be a complicated issue to categorise. It is a broad concept, which includes many activities like online gambling, shopping and online gaming. Many authors therefore criticise the concept of “internet addiction” pointing out that the internet is merely a medium for participating in specific activities, which in turn leads to the development of addictive disorders [10: 228].
One of the most recent diagnoses directly correlated with internet use included in major classifications is “Gaming disorder” (GD) from the 11th Reversion of International Classification of Diseases (ICD-11) [11]. This has its counterpart in the fifth edition of the American Psychiatric Association’s classification of mental disorders (DSM-5– Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) listed there as “Internet gaming disorder” (IGD). However, the DSM-5 authors emphasise the need for further research on this classification entity [12].
Both the DSM-5 and ICD-11 describe IGD/GDas a pattern of repetitive or ongoing, persistent gaming behaviour. A shared diagnostic criterion is a 12-month minimum of duration symptoms [11, 12]. However, the ICD-11 notes that the time required for diagnosis may be reduced if other diagnostic criteria are met and the severity of symptoms is elevated. Moreover, ICD-11 divides gaming disorder basing on internet access into mainly online, mainly offline and unclassified [11]. This is important because a significant increase in the severity of primarily online gaming disorder symptoms was shown [13]. An important part of the diagnostic process, therefore, seems to be to determine the type of undertaken activity to estimate potential exposure for the development of a gaming disorder and the intensity of it symptoms.
Considerable differences can also be seen in the diagnostic criteria of the two classifications. DSM-5 demands meeting a minimum of 5 out of 9 diagnostic criteria (engulfment in gaming, withdrawal symptoms, building tolerance, ineffec­tive control attempts, abandonment of other interests in favour of online gaming, continuation of overly intensive gaming despite awareness of negative consequences, lying about time spent playing, attempt to alleviate negative emotions and dysfunction e.g. job loss or loss of an important relationship) [12].
According to ICD-11, all 3 of the following criteria must be met: impaired control, increasing priority to gaming to the point where it becomes more important than other activities and interests and escalation of gaming despite the occurrence of negative consequences, causing significant impairment in functioning in other areas of life [11]. A comparison of two aforementioned classifications showed that ICD-11-based GD was associated with a greater severity of the disorder so the required criteria are more rigorous. In addition, there is stronger emphasis on the symptoms that significantly affect the patient like impaired functioning in other areas of daily life [14].
A noteworthy issue is the problematic nature of self-diagnosis in patients suggesting a diagnosis of GD/IGD. A study on a group of 273 adolescents was conducted to assess the over- and under-reporting of IGD based on patients’ self-assessment compared to its DSM-5-based clinical diagnosis by mental health professionals. A false-nega­tive rate in patients’ self-assessment of IGD as high as 44% was obtained with a false-positive rate of 9.6%. The false-negative group reported less time spent playing online games than the group with clinically confirmed IGD, even though their psychological profiles were like those of clinically diagnosed patients. The opposite was observed with the false-positive group reporting more time spent playing games than the group of individuals without a diagnosis of IGD. In the final result, they did not deviate from the group without a diagnosis of IGD in DSM-5-relevant diagnostic aspects of the disorder, with occasional exceptions in terms of self-restraint [15]. The presented results indicate that GD is under-diagnosed due to possible reluctance to undergo psychiatric diagnosis, low awareness of one’s mental health and fear of social stigmatisation as persons diagnosed with mental disorders.

■ THE NEUROBIOLOGICAL SUBSTRATE AND TREATMENT OF INTERNET ADDICTION

Internet-related addictions belong to the group of behavioural addictions; i.e., disorders associated with repetitive, reward behaviour other than taking psychoactive substances [11]. Even though no exo-genous substance is introduced into the body, seve­ral biochemical changes similar to those occurring in the brains of compulsive psychoactive-substance users occur in the subject’s brain [12]. Disturbances in the functioning of the reward and punishment systems are responsible for the development and subsequent clinical presentation of addiction. The balance between the two is upset, the reward system is over-stimulated by repetitive stimuli that give immediate, readily available gratification [10: 58]. The mesolimbic and the mesocortical dopaminergic pathways are the ones associated with the reward system. These structures are responsible for compulsive behaviour and for reinforcement and motivation, both closely related to the withdrawal effect. Another dopamine-dependent process associated with addiction formation is the increase in sensitivity to incentives, which can be substances, behaviours and activities. This phenomenon in addicts causes an increase in behaviour leading to substance use or addictive activity repetition. The second addiction-related neurotransmitter is serotonin. Disorders in serotonergic transmission can lead to impulsive behaviours, negatively affect mood and prevent control of desires and drives [10: 58].
Functional magnetic resonance imaging (fMRI) allows us to determine the activity of specific brain regions; it has revealed similarities in the activity of certain parts of the brain in those addicted to psychoactive substances, gambling and internet gaming. Activity in the left parahippocampal cortex, left dorsolateral prefrontal cortex and left cuneus was greater in people who compulsively play a particular online game than in those who occasionally play the same game [16].
Similarities between psychoactive substances and behavioural addictions are also noticeable in the personality traits of those affected. A study comparing online gaming addicts with former compulsive heroin users (currently under methadone maintenance treatment) found some similarities in the personality profiles of the subjects. Respondents from both groups showed high expression of alexithymia, impulsivity, sensation-seeking and aggressiveness though were more intense in former heroin users [17].

■ PHARMACOTHERAPY

Medications that can help internet addicts are being sought among substances that have long been used to treat affective disorders, anxiety, attention deficit hyperactivity disorder (ADHD) and others. A considerable proportion of patients who problematically use modern technologies and the internet also suffer from other mental disorders that may not only coexist, but may also be the cause of developing an addiction. One disorder that often comorbidly accompanies IGD is major depressive disorder [18, 19]. Antidepressive drugs used in IGD include bupropion, escitalopram and fluoxetine among others. The action of the former is based on the inhibition of norepinephrine and dopamine reuptake, while the other two are examples of SSRI (selective serotonin reuptake inhibitors). These drugs, through their mechanism of action, can affect and even restore the neuronal structures and pathways associated with addiction. The effect of bupropion in the context of reducing addictive cravings is known from studies conducted on people addicted to cigarette smoking. Bupropion, in its sustained-release form (SR), has been shown to reduce the desire to light a cigarette, facilitating freedom from tobacco addiction [20]. Promising results have also been obtained in the treatment of internet gaming addicts. In a randomised double-blinded clinical study conducted on a group of 50 boys and men (13-45 years old) suffering from major depressive disorder accompanied by excessive online gaming, extended-release bupropion treatment was used. For the first 8 weeks, half of the participants received bupropion SR, while the rest received a placebo. During this phase of the study, not only was there a reduction in the severity of depressive symptoms observed, but also a reduction in the average time spent playing online. Four weeks after the end of treatment, the study group showed an increase in depressive symptoms, but the features of excessive online gaming did not increase, despite the discontinuation of bupropion treatment [18]. A prospective clinical study using fMRI to assess the activity of brain structures relevant to the phenomenon of addiction showed improvement in patients addicted to online gaming who received bupropion SR for 6 weeks [16]. A 2016 prospective, randomised clinical trial of 119 people diagnosed with IGD compared the effects of bupropion and escitalopram on symptoms associated with this addiction. Study participants were divided into 3 groups: 44 were treated with bupropion SR, 42 with escitalopram while the remaining 33 received no drug. Both drugs proved to be effective in treating IGD though bupropion showed greater efficacy in alleviating impulsivity and attention deficit. Its dual mechanism of action (inhibition of dopamine and norepinephrine reuptake) may be responsible for the better results of bupropion treatment [21]. A recent systematic review of pharmacological treatments confirms that evidence is still limited to small RCTs (randomized controlled trails) and observational studies, which limits the strength of clinical recommendations [22]. Internet and online gaming addiction often accompanies ADHD. It is suspected that excessive online gaming, which increases dopamine release and activates visual working memory, may be a form of self-therapy in children and adolescents with ADHD [23]. Methylphenidate, a stimulant drug that is considered one of the most effective in alleviating ADHD symptoms, can also be used to treat those suffering from IGD and GD. In addition, a 2022 meta-analysis showed that people with co-occurring IGD and ADHD have better treatment outcomes than patients with depression and IGD [24].

■ NON-PHARMACOLOGICAL INTERVENTIONS

Alternatives to drug treatment, in the form of individual and group psychotherapy, are now immen­sely popular due to their variety and effectiveness [25]. Therapeutic interactions of this kind are very often used simultaneously with pharmacotherapy. This combination is widely regarded as the most effective method of treating many mental disorders. The effectiveness of combining cognitive-behavioural therapy (CBT) with bupropion treatment was studied in a randomised clinical trial on a group of 65 adolescents (13-18 years old) suffering from major depressive disorder and problematic online gaming. All participants took bupropion, but half of the group additionally participated in 8 CBT sessions. After 8 weeks of treatment, subjects were assessed for severity of online gaming addiction, average time spent gaming, severity of depressive and anxiety symptoms and the level of life satisfaction. Those treated additionally with CBT achieved more pronounced improvement than those receiving pharmacotherapy alone [19]. More precisely, one of the most important components of CBT, a cognitive reappraisal (an adaptive emotion regulation strategy involving reinterpreting a situation from a different perspective), reduced gaming craving and improved cue-specific inhibitory control in a randomised, unblinded trial [26].
Family and multifamily therapy is also used because of the vital role of the family system. This method of treatment was applied with promising results to 21 families of teenagers who were addicted to the internet. Before the therapeutic intervention, 100% of the adolescents met the criteria for internet addiction; after the therapy, it was only 4.8%; however, after another 3 months, the percen­tage was 11.1% [27]. This suggests the need for continued therapy to sustain positive treatment effects. Moreover, Parental Vigilant Care, an approach integrating open dialogue and active moni­toring, reduced problematic and unsafe internet use in children in unblinded randomised trial [28].
Less common therapeutic interventions used with internet and modern technology addicts include mindfulness, Craving Behavioural Intervention Group, MMORPG Speaking and Writing Course (MMORPG – Massively Multiplayer Online Role-Playing Game), rehabilitation camps and of other biological interventions and transcranial electromagnetic stimulation.

■ CLINICAL RECOMMENDATIONS, SCREENING TOOLS AND FUTURE DIRECTIONS IN POLAND

Caregivers represent the primary line of defence in identifying problematic electronic-device use among children and adolescents, emphasising the necessity for public education to enhance reco­gnition of early signs of internet addiction and facilitate timely psychiatric or psychotherapeutic intervention. In clinical practice, and particularly in outpatient and psychiatric settings, the limited use of standardised diagnostic instruments highlights the necessity for their broader implementation. There are foreign screening tools validated for Polish conditions (Table I). Particular attention should be given to the IAT-F (Internet Addiction Test for Families) [29], derived from the PCIAT (Parent-Child Internet Addiction Test), which despite the absence of a Polish adaptation remains a valuable tool that can incorporate caregiver and family observations.

■ CONCLUSIONS

The dynamic progress of digitisation implies the inevitable danger of risky use of modern technology leading to addiction. This is directly related to easy access to the internet, both on mobile and desktop devices. Many aspects of daily life, from work, to social interactions, to entertainment, are at play the virtual world. It is also natural that young people spend more of their time online. This is a genuine problem that is becoming the focus of numerous scientific studies.
In order to effectively prevent, diagnose and treat internet addiction, structured knowledge in this area, as well as effective diagnostic tools, is essential. The current versions of the major classifications (ICD-11 and DSM-5) only consider addictions related to computer games, leaving out other types of problematic internet use like smartphone or social media abuse. This limits the possibility of accurate diagnosis, which is the first step in the therapeutic process.
However, there is hope in various forms of addiction treatment, including pharmacotherapy and psychotherapy. Often used in the case of such a diagnosis, a drug with proven efficacy is bupropion, which, through its complex action, nullifies the symptoms of addiction. Satisfactory results are also obtained with certain types of psychotherapy, and the combination of both methods further enhances their effectiveness, thus presenting promising prospects for the treatment of disorders in this group.
The phenomena in discussion pose a serious challenge to modern medicine. Despite the many difficulties caused by the unclear situation related to the issue of addictions to modern technology, medicine seems to be meeting the expectations for effective diagnosis and treatment of this new group of disorders. However, this is a gradual process and every effort should be devoted to its more intensive development by exploring related issues in further scientific studies.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Financial support/Finansowanie

None declared./Nie zadeklarowano.

Ethics/Etyka

The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.
Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo