Journal of Mental Health and Human Behaviour

REVIEW ARTICLE
Year
: 2020  |  Volume : 25  |  Issue : 2  |  Page : 76--92

Cyberpsychiatric disorders: An overview of assessment and management


Sandeep Grover, Anish Shouan 
 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India

Abstract

The advent of computers and the Internet has resulted in both positive and negative changes in day-to-day human life. These “negative changes” include physical problems such as back pain to visual problems, as well as psychological problems such as prolonged Internet use. These negative changes in the human life, as a result of excess of Internet use, are understood as “cyberpsychiatric disorders,” which are defined as the co-occurrence of excessive Internet use and current psychiatric nosology. Some of the well-known conditions include problematic Internet use (PIU), online gambling disorder, Internet gaming disorder (IGD), cyberchondria, cyber suicide, cybersexual addiction, cyberbullying/cyberstalking, and online compulsive buying. However, current nosological systems have not recognized these conditions. This article reviews the current understanding about various cyberpsychiatric conditions, their assessment, and management. Current evidence suggests that, although some of these constructs are poorly defined, some constructs such as PIU, IGD, and cyberbullying have been researched more than the other constructs. In terms of prevention and management of these disorders, mental health professionals have a big role to play. At present, very few treatment models have been evaluated and have been found to be effective. With the passage of time and digitalization of the modern age, there will be an upsurge in the number of patients suffering from these ailments and the mental health professionals must be prepared to address these issues.



How to cite this article:
Grover S, Shouan A. Cyberpsychiatric disorders: An overview of assessment and management.J Mental Health Hum Behav 2020;25:76-92


How to cite this URL:
Grover S, Shouan A. Cyberpsychiatric disorders: An overview of assessment and management. J Mental Health Hum Behav [serial online] 2020 [cited 2021 Apr 11 ];25:76-92
Available from: https://www.jmhhb.org/text.asp?2020/25/2/76/309968


Full Text



 Introduction



Computers have come a long way from the first model designed in the 19th century by a British Mathematician Charles Babbage to the current high-tech generation that can be seen in every office or even household. There was a breakthrough in the area of computer science with the invention of the World Wide Web by computer scientist Tim Berners-Lee in 1990.[1] Now, with the advancement in technology, the size of the computer has been reduced so that it can fit in the palm of our hand in the form of mobile devices. Over the last decade, due to the change in data policies, anyone can access the Internet at any time of the day and night at a nominal price.

Internet is used for a variety of tasks, and it has encroached into all domains of human life, i.e., work, entertainment, shopping, and communication. The number of Internet users is increasing day by day. If one looks at the available data, the number of people having access to the Internet has increased from 0.05% of the world population in 1990 to around 33% in 2010.[2] Data also suggest that compared to the past, nowadays, Internet users stay online for a longer duration of time.[3] The various factors that have contributed to the increase in the duration of time on the Internet include the invention of smartphone or Wi-Fi and other factors such as ease to use, easy affordability, and perceived anonymity of using the Internet.

However, there is the other side of the coin that was unseen, novel but worry-inducing at the same time, which includes excessive use of the Internet to the extent of addiction and other negative mental health consequences. One of the initial reports on the Internet and mental health[4] described it as “the rapid communication resource that was beginning to have an impact on medicine and will soon have a major effect on psychiatry” is now looking to be more and more true. In view of this, there is a need to understand the psychiatric issues related to excess of Internet use. In this background, this review aims to evaluate the current status of cyberpsychiatric disorders, which can be useful for clinicians and also for planning future in this direction.

For this review, we searched PubMed, Google Scholar, and ScienceDirect search engines by using keywords such as excessive Internet use, cyberpsychia*, disorder, cybersex, online gambling, Internet gaming, cyberchondria, cyber suicide, cyberbullying, cyberstalking, online gambling, and online trading. Initial searches involved the use of each individual keyword while the later searches involved the use of more than one word in different permutation combinations. Relevant references were selected.

 Relationship between Internet Use and Psychiatric Disorders



If we take into account the dual diagnosis model,[5] co-occurrence of excessive Internet use and current psychiatric nosology can be understood as: psychiatric disorders leading to the occurrence of excessive Internet use (for example, a patient with an anxiety disorder excessively using the Internet to search for information regarding the illness or for the search of treatment that he/she can do by him/herself), excessive Internet use as a possible cause of psychiatric disorder (for example, a person who spends excessive time on the Internet during the night time experiences loss of sleep, which triggers a manic or depressive episode or a relapse of the episode), and excessive Internet use altering the phenomenology and course of a psychiatric illness (clinical experience suggests that over the years, there is a change in psychopathology from religious delusions and hallucinations to more “high-tech” delusions/hallucinations involving surveillance gadgets and Internet).

However, it is now increasingly recognized that excessive Internet use can itself become a psychiatric disorder, depending on the purpose of excessive Internet use and its consequences. These disorders are loosely referred to as cyberpsychiatric disorders or cyber disorders.[6] There is no universally accepted definition of “cyberpsychiatric disorders,” but there is an upcoming consensus for defining these disorders. Broadly speaking, cyberpsychiatric disorders can be seen as a group of disorders involving co-occurrence of psychological disturbance/symptoms and excessive Internet use without taking the cause–effect equation into consideration.[6]

Accordingly, Internet-related disorders are broadly categorized as aberrant cyber behaviors or specific Internet-related psychopathology (the various categories of disorders specifically related to the Internet), psychopathologies influenced by Internet use (psychiatric disorders as recognized by nosological systems, arising due to or colored by the use of Internet [e.g., sleep problems, relapse of depression, and particular psychopathology in schizophrenia]), and a combination of both.[7]

 Current Nosological Status of “Cyberpsychiatric Disorders”



The current psychiatric nosological systems, such as Diagnostic and Statistical Manual, Fifth Revision (DSM-5)[8] and International Classification of Diseases, Eleventh Revision (ICD-11),[9] do not refer to these disorders, with few exceptions. Internet gaming disorder (IGD) is recognized as “Conditions for further study” in DSM-5. Further, Pedophilic disorder has a segment about an Internet-related component not written in the diagnostic criteria per se but mentions it as “associated features supporting diagnosis,” as “extensive use of pornography depicting prepubescent children is a useful diagnostic indicator of pedophilic disorder.” An online subtype of gambling disorder has been mentioned in IGD (under Conditions for further study) criteria in DSM-5, as “excessive gambling online may qualify for a separate diagnosis of gambling disorder.” An online subtype of hypersexual disorder was proposed but was not included in the final version of DSM-5.

As far as ICD-11 is concerned, it is slightly more vocal on the subject of gambling and gaming disorder as compared to DSM-5. As per the ICD-11, “gambling disorder is characterized by a pattern of persistent or recurrent gambling behavior, which may be online (i.e., over the Internet) or offline.” Although a new and separate entity of hazardous gambling is mentioned, there is no mention of an online component in that criterion. Further, in ICD-11, gaming disorder has been mentioned in the main text, unlike DSM-5.

 Historical Developments in Recognition of Various Disorders Related to Internet



Excessive Internet use was first recognized as a mental health issue in the 1990s and by using the DSM criteria of pathological gambling/substance use disorders? Young[10] designed a questionnaire to assess the excessive Internet use. This beginning led to a large number of studies, coming from various parts of the globe, which reported excessive use of the Internet, through various gadgets. In the mid-1990s, psychiatrists defined “typical characteristics of a long-term Internet user as a socially isolated, teenager boy with low self-esteem, whose main activity is related to his computer and Internet use.” However, much has changed from the mid-1990s, with the availability of cheap, fast, and large-scale Internet networks.

Over the years, many researchers have designed various scales to assess the excessive Internet use and have tried to understand it from the perspective of addiction,[11] impulse control,[12] and obsession–compulsion.[13] Further, with more and more people coming to mental health personals with the negative consequences of excessive Internet use, many new mental health terms have been introduced.

 Current Understanding of Cyberpsychiatric Disorders



Accordingly, in recent times, Internet-associated psychiatric disorders can be conceptualized into two broad groups, i.e., general subtype (it basically includes persons who use the Internet in a nonspecific way resulting in excessive time spent in using it) and specific subtype (it includes persons who use the Internet in a particular way [indulging oneself in specific tasks] resulting in excessive time spent using it or is indicative of aberrant behavior) [Table 1].{Table 1}

Problematic internet use

Problematic Internet use (PIU) can be called “a disorder of many names” [Table 2], which is broadly defined as excessive time spent on the Internet, resulting in significant impairment in the person's physical, mental, social, financial, or interpersonal domains of life. It is probably the most researched cyberpsychiatric disorder.{Table 2}

Young,[15] a psychologist, proposed the criteria for Internet addiction modeled on DSM-4 definition of substance dependence and termed it as “Internet addiction.” However, she later updated it to a diagnostic questionnaire[10] in 1998. It was Shapira,[16] who coined the term “problematic Internet use.” Other authors have also proposed criteria for Internet addiction.[17]

From a psychopathological viewpoint, various researchers have tried to understand PIU and have conceptualized it to have an element of substance use disorder (craving when not using and dyscontrol), obsessive–compulsive disorder (OCD, compulsive component), and impulse–control disorder (uncontrolled urge). However, the exact understanding of psychopathology and biology of this entity is far from understood.

Many studies have evaluated the prevalence of Internet addiction or PIU. Prevalence studies in adults and adolescents, online and offline, in the USA,[2] Norway,[18],[19] South Korea,[20],[21] China,[22] Greece,[23] and Iran[12],[24] have shown a prevalence ranging from 0.7% to 21.2%, difference probably emerging from the assessment instruments used in different studies. A recent review that included 38 studies conducted among student population (school students to postgraduate students) of Southeast Asia reported a prevalence of severe PIU/Internet addiction to range from 0% to 47.4%.[25] These studies also suggest high psychiatric comorbidity among participants who are found to have Internet addiction/PIU. The psychiatric disorders more often reported in these participants include a higher prevalence of bipolar affective disorder, major depressive disorder, substance use disorders, gambling disorder, attention deficit hyperactivity disorder (ADHD), and social anxiety disorder.[26],[27],[28],[29],[30],[31] Data also suggest that PIU is associated with a host of negative physical health consequences,[32],[33],[34],[35],[36] such as insomnia, daytime sleepiness, headaches, neck ache, carpal tunnel syndrome, blurred or strained vision, and weight loss or gain. Various factors that have been shown to be associated with Internet addiction or PIU include male gender, using the Internet by using a personal device, longer duration of Internet use/day, smartphone use, remaining permanently logged in on the Internet, use of the Internet for chatting, befriending people online, online shopping, watching movies, online gaming, searching information online, and instant messaging.[37]

Online gambling disorder

Also known as Internet gambling disorder, it is not included in the main text of DSM-5, but it has been mentioned in IGD (under Conditions for further study) criteria. People have tried to describe it as an equivalent of gambling disorder but taking place on the Internet. Online gambling market had an approximate value of about 418 billion US dollars in 2016, which increased to 435 billion USD in 2017, with Asia contributing to 31.3% of the total market, casinos being the largest gambling sector (34.4%) and iGaming (online betting) accounting for about 11% of the total gambling market.[38] Internet gambling is likely to continue to grow on the online platform, possibly due to convenience and easy accessibility of this mode.[39],[40]

A recent study[41] which included adolescents aged 12–17 years reported that 6.5% of participants had a problem of online gambling. Studies which have evaluated online gambling disorders (OGDs) report that online gamblers are more often young male, from a culturally diverse background who also use illicit drugs while gambling, having low assertiveness, high impulsivity, and having lack of parental control.[41],[42],[43] They also have a history of cyberbullying, active sexting, and PIU.[41] There is a lack of consensus with respect to socioeconomic status, with some studies reporting online gamblers to be more often belonging to low socioeconomic status,[42] whereas others suggest them to be more often from higher socioeconomic status.[44],[45],[46] Other correlates of online gambling include higher educational backgrounds, higher frequency of substance use disorders (alcohol and tobacco), mood disorders, and self-harm.[39],[43],[45],[47],[48],[49]

Some of the studies have evaluated the similarities and differences between online and offline gamblers. A recent study[50] reported that online and offline gamblers differ in terms of nonsports Internet gamblers being of younger age, were in more debt, and had higher novelty seeking, low self-directedness, and cooperativeness as compared to offline and only sports online gamblers.

Looking at this construct from the viewpoint of psychopathology, OGD is hypothesized to have a link with offline gambling disorder and Internet addiction along with some evidence of a link with cluster C personality disorder, but the evidence is too thin to rest any argument on it.[51]

Keeping all the above evidence in mind, OGD appears to be a discrete but heterogeneous group as compared to offline gambling or Internet addiction, but there is paucity to evidence to make any strong comment or recommendation for the same.[52]

Internet gaming disorder

Computer/Internet gaming may vary from a fun and enjoyable activity[53],[54],[55] to a pathological and addictive behavior[56],[57],[58] that can have a profound negative effect on a person's life. Technology-based gaming has taken a major leap over the years, from simple offline computer-based games to online gaming, involving multiple players at the same time. It is also taking shape of a professional game, with the occurrence of many tournaments and competitions, involving different types of Internet-based games collectively named as esports.[59] Nowadays, as compared to the good old so-called “social days,” children are spending more time in front of the screen, playing online games than they do with their friends.[60]

IGD is the second behavioral addiction disorder that was able to secure a place in the DSM-5 after gambling disorder, but in the segment of “Conditions of further study.” However, this has a separate mention in the main text for ICD-11. DSM-5 defined IGD as “IGD is a pattern of excessive and prolonged Internet gaming that results in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of substance use disorders.” As per King et al.,[61] conflictuousness, withdrawal symptoms (mood disturbances, irritability, and anxiety), and loss of control are the core symptoms of IGD. King et al.[61] also subtype it as mild, moderate, and severe as per the degree of disruption of daily activities.

Some authors have tried to subtype gamers on the basis of impulsivity and self-esteem:[62] into two nonproblematic types, i.e., regulated recreational gamers and regulated social role players, and three problematic types, i.e., unregulated achievers, unregulated escapers, and hardcore gamers (highest level of dysfunction).

IGD is mostly studied among adolescents, and there is a paucity of evidence in younger children. There is striking, five times higher rate of cyberbullying among males as compared to females.[63] A recent review[64] reported a median prevalence rate of 2.0%, but all of these studies were from the developed world.

Looking at comorbidity of various social and psychiatric problems, IGD has been found to be associated with poor grades and academic decline,[65] poor quality of life,[66] increased rates of anxiety and depression,[67] high suicidal ideas and planning,[68] and sleep disturbances.[69]

In many neurobiological studies, it has been seen that pathological gamers share similarities as well as neurobiological correlates with behavioral and substance-related addiction.[70],[71],[72],[73] Based on neurobiological, psychological, social, cognitive, and behavioral aspects, various models have been proposed by different researchers over the last decade.[74],[75],[76],[77] However, recently, an integrated model of IGD has been proposed by Paulus et al.,[64] talking about internal factors (structural brain changes; executive dysfunction; poor self-regulation, decision making, mood regulation, and self-worth) and external factors (social factors, game-related rewards, and parental influences) as well as the interplay between the two, resulting in IGD. He also proposed the continuum of gaming fun to pathological gaming to gaming addiction on the basis of these factors.

Cyberchondria

Cyberchondria is a phenomenon characterized by repetitive searching of the Internet for health-related information with an aim to reduce the underlying health-related anxiety. However, this actually leads to a further increase in anxiety.[78] It is considered to be an abnormal pattern of behavior rather than a diagnosable disorder per se.[79]

It is not included overtly in the DSM-5, but a description of illness anxiety disorder mentions a description in the form of “they research their suspected disease excessively (e.g., on the Internet),” suggesting some mention regarding the above construct. As far as ICD-11 is concerned, two disorders namely hypochondriasis and bodily distress disorder do not have any mention of the Internet while describing these disorders.

The repetitive searching of the Internet for health-related information is seen to be time-consuming, repetitive, having a negative emotional state, and having physiological reactions to the Internet searches and is seen to be unwanted and reassurance seeking along with the feature of continuous conflict of trusting the doctor or not.[80] A recent network meta-analysis trying to find any central symptoms associated with this entity was not able to find any but mentioned compulsion, distress, excessiveness, and reassurance as the characteristics of the symptoms.[81] Throughout the literature, a relationship of cyberchondria has been seen with health anxiety,[82],[83] hypochondriasis,[84] OCD,[85],[86] and PIU,[87] but the strongest relation has been seen with health anxiety leading to the proposition of the index entity being a consequence of health-related anxiety.[81] A recent study in students concluded that people who catastrophize their pain may be more prone to develop cyberchondria.[88]

A recent survey in medical, dental, and nursing students found that 14.2% of the students get health-related information via the Internet in case of a health problem.[89] A recent large-scale survey,[90] which included >5000 patients, conducted in outpatient clinics of cardiology, endocrine, gastroenterology, and respiratory medicine departments in a tertiary care center found an increase in health anxiety from 14.9% to 19.9% over a period of 2 years, especially in gastroenterology clinics, and this was attributed to cyberchondria due to rapid growth of Internet use, especially for the interpretation of symptomatology. A recent cross-sectional study from India found the prevalence to be 55.6%, with a significant association with general mental health.[91]

Though inadequately studied, overall but this entity has been shown to be associated with significant functional impairment and excessive utilization of healthcare resources.[82]

Cyber suicide/cyber suicidal behaviors

“Cyber suicide refers to self-inflicted death promoted by websites that provide the know-how and encourage people to perform suicidal behaviors, sometimes via simultaneous suicide pacts,” as described by Alao et al.[92] It broadly means the interaction of Internet and suicide-related behavior in any way. It may include the following entities, ranging from a simple suicide-related online searches[93] to chatting on suicide-related forums,[94],[95] suicide pacts[96],[97] that are made on these forums (even social media platforms such as Twitter[98] are used for the same) and a more recent and more dangerous, playing the suicide game named Blue Whale challenge[99],[100] or live streaming of the suicide on social media platforms,[101],[102] especially if that is associated with the negative replies from the responders.[102]

As compared to a quantum of information available online that encourages/promotes suicide,[92],[103],[104] there are certain support forums,[105],[106] contact links to suicide help services,[107] and links to mental healthcare apps[108] that may be helpful for a person contemplating suicide.

However, this domain of cyberpsychiatric disorders is under-researched so as to make any recommendation about this entity per se. However, it is becoming more and more apparent that the prevalence of disorder with similar symptomatology is likely to escalate in the near future due to boom in the sheer number of people having access to Internet[109] and there is an urgent need to do more research on this entity.

Cybersexual disorders

Cybersexual disorder is supposedly defined as the use of the Internet for deriving sexual gratification.[110] Several terms[111] have been used to address this entity, namely, cybersex, Internet sex addiction, problematic cybersex, compulsive cybersex, cybersexual addiction, and problematic pornography use. It includes behaviors such as watching pornography, engaging in sex chats, engaging in sexual activity using web cameras, searching for sexual partners on the Internet, and participating in three-dimensional sexual role-playing gs[112],[113] Of all the above, watching pornography is the most popular, especially among men.[114],[115] Though not certain, Triple-A model[116] describes the accessibility, affordability, and anonymity as the factors leading to the ubiquitous use of cybersex.

Till now, three sets of criteria[117],[118],[119],[120] have been proposed for the diagnosis of cybersexual disorder, sharing the symptoms of loss of control and excessive time consumed in this behavior, resulting in significant harmful consequences in day-to-day life.[111] However, as per now, no validated guidelines/criteria exist for its reliable diagnosis. Though the exact origin has not been agreed upon, it is said to be related to Internet addiction and sexual addiction.[116]

Its prevalence ranges from 1.8% to 12.9%[115],[121],[122],[123] across various studies, but this finding should be taken skeptically as different definitions and criteria have been used to understand the construct in different studies, and also, all the types of cybersexual behaviors were not included in the studies. If we take a look at a typical profile of the patient, it is usually more common in males,[115],[124] usually preferring a solitary activity such as watching pornography,[125],[126] and females preferring a partnered act like sex chat. These persons usually have the background of a higher education[115],[122] and have easy access to the Internet. These persons have two profiles[124],[127] taking into account the relationship status, i.e., singles reporting more addictive use and recreational use being reported in users who have a stable relationship. These people more often have a history of sexual abuse and emotional insecurities in relationships.[128]

These two subtypes also differ in the motive of use with recreational users reporting sexual arousal, to get relaxed and educational reasons as the reason for use and stress reduction, emotional regulation, and compensating unfulfilled sexual fantasies are the same for problematic users.[110]

In various studies, cybersex has been seen to have an association with depression and anxiety,[129],[130],[131] lower sexual satisfaction,[132] loss of interest in offline sexual activity,[130],[133] poor penile erection,[130] high-risk sexual behaviors,[134],[135] and feeling of shame after indulging in that act.[136]

Cyberbullying/cyberstalking

Term cyberbullying was first used in 1999, and many authors have tried to define it. In general, it is understood as the use of the Internet for the purpose of bullying.[137],[138],[139],[140] It also has all the three characteristics of bullying,[141] i.e., intention, repetition, and power imbalance. Though from the surface, it appears that bullying and cyberbullying are correlated as most of the victims and perpetrators of cyberbullying are also the same for bullying and vice versa;[142] however, it has been proposed that both these require separate consideration as the cyberbullying can cause harm and troubles on a much wider scale than the bullying.[143] However, some authors have proposed that cyberbullying should be considered as a subtype of bullying.[144]

There are various media[145] through which cyberbullying can occur, i.e., e-mail, instant messaging, chat rooms, text messaging (SMS), and social networking websites. The most common platform for cyberbullying has been found to be e-mail[146] and instant messaging.[147] Based on the online behavior of the perpetrator of cyberbullying, various types of cyberbullying have been described [Table 3].{Table 3}

In terms of prevalence, studies mostly were done among undergraduate and college-going students, with a report prevalence ranging from 9% to 37%.[146],[149],[150],[151],[152] However, it should be noted that this vast range may be explained by different definitions used to ascertain cyberbullying across various studies.

Like other cyberpsychiatric disorders, cyberbullying victims[149],[152],[153],[154],[155],[156],[157],[158],[159],[160] showed high association with higher rates of anxiety and depression, social phobia, and social exclusion and lower self-esteem, school violence, delinquent behavior, and even leading to suicidal ideations in some cases with cyberbullying perpetuators,[161],[162] showing high chances of social anxiety, low self-esteem, and self-harming behavior.

Online compulsive buying

“Compulsive buying disorder is characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding shopping and spending, leading to adverse consequences.”[163] However, with the advancement in technology and advent of the Internet, this offline behavior has shifted to the online realm with an increasing number of individuals buying their general and specific goods on the Internet,[164],[165] with probable reasons being 24 × 7 availability, convenience, and easy payment methods.[166],[167]

The prevalence of online compulsive buying has been reported to range from 16% to 17.7%.[168],[169] It is suggested that compulsive online buyers prefer buying online due to exhaustive offers and immediate positive rewards and also prefer using mobile phones for that purpose. An inverse relationship has been seen between financial literacy and online compulsive buying.[170]

If we see from a psychopathological viewpoint, some authors compare the construct to Internet addiction[171],[172] while others conceptualize it as a behavioral addiction.[173] However, lately, a combined model has been proposed,[174] suggesting general and addiction-related behaviors such as low self-esteem,[175] low self-regulation,[172] negative emotional state,[175] and female gender[176] along with medium-specific behaviors such as enjoyment,[177] social anonymity,[178] and cognitive overload[179],[180] as the factors leading to online compulsive buying.

Assessment for Internet use

In the changing world and the increasing online connectivity, mental health professionals need to increase their knowledge and awareness about ever-changing cyberspace. Assessment of Internet use and its consequences should not be limited to persons presenting with Internet-related disorders but should be done in all patients. The assessment should include evaluation of the pattern of Internet use, impact of Internet use on various aspects of life, gadgets purchase behaviors, the impact of Internet use on the physical health, concomitant substance use pattern, personality and psychological vulnerability factors, the relationship of Internet use with psychopathology, stress factors, coping abilities, structural factors, and ongoing legal issues [Table 4]. In addition, clinicians should not forget to carry out age-appropriate Internet use [Table 4].{Table 4}

While evaluating, it is also important to know that whether the person has excessive Internet use with respect to certain specific aspects or it is generalized excessive use. The evaluation of specific aspects should focus on the content of Internet use, in terms of gaming, watching pornography and seeking relationships, suicidal behaviors, gambling, shopping, etc., [Table 5]. The excessive generalized Internet use pattern may be an outcome of the use of Internet for socialization, chatting, texting, e-mail, etc.{Table 5}

Further, the evaluation of excessive Internet use should also focus on evaluating the core elements such as salience (i.e., the activity is valued highly and it takes precedence over other activities), mood modification (the emotional response to the behavior), tolerance (the need for using the Internet for increasing amounts to achieve the desired level of mood modification), withdrawal symptoms (experiencing physiologic withdrawal symptoms when attempting to cut down or stopping the activity), conflict (impairment in relationships with other persons due to the behavior or activities of life), and relapse (returning back to the initial behavior).[7]

Further, the clinical assessment may be supplemented by the use of scales designed specifically to assess various aspects of excessive Internet use or scales focusing on the specific content associated with excessive Internet use [Table 6]. Many scales have also been designed to assess smartphone addiction [Table 7] and Cyberbullying [Table 8]. In general, the use of these scales is limited to research setting.{Table 6}{Table 7}{Table 8}

 Management of Excessive Internet Use and Other Cyberpsychiatric Disorders



The management of excessive Internet use and other cyberpsychiatric disorders should focus on specific symptoms and addressing underlying dynamics. If a person presents with known psychiatric disorders, as identified by the nosological systems, they should be managed as per the recommended guidelines. However, the management of cyberpsychiatric disorders, not recognized by the present nosological systems, involves evaluating and addressing the factors contributing to the onset, continuation, and continuation of Internet-related psychopathology.

In terms of general measures, mental health professionals should also provide Internet use education[212] to all the patients using the same, covering various aspects, such as making them aware about the potential harm and the risk factors of developing cyberpsychiatric disorders, as well as learning how to circumvent the dangers and seeking help, how to collaborate with experts from information technology specialists to make the online experience safer (e.g., via blocking “high-risk” websites that have caused harm to the person in the past), and how to deal with specific triggers, such as websites with problematic content and problematic Internet or video game content which serve as gateways to pathologic use.

For people presenting with excessive Internet use, the initial goal should be to detoxify the person from the most troublesome/problematic websites and content and then learn technology use, which is mindful and judicious. Depending on the need help can be obtained from the experts of information technology to block the triggering sites on the devices/gadgets of the sufferers, providing alternatives to avoid access to the most problematic sites and content, without hampering the use of safer Internet content that may be useful for daily living. Various monitoring software can be set up with the help of information technology experts, which can provide weekly reports to the clinicians detailing the patient's Internet use which in essence can act as an Internet abuse “toxicology screen,” akin to a urine toxicology screen for substance-based addictions. However, it must be remembered that measures such as blocking, monitoring, or filtering a patient's online behavior on its own will not be sufficient to treat Internet addiction.

 Nonpharmacological Measures for the Management of Cyberpsychiatric Disorders



There are limited data in the form of evidence-based treatments for the management of various cyberpsychiatric disorders. Some of the measures that have some level of evidence for the management of various cyberpsychiatric disorders[213],[214],[215] include cognitive behavior therapy (CBT), problem-solving, interpersonal therapy, cognitive enhancement therapy, cognitive bias modification, mindfulness-based stress reduction, motivational interviewing, motivational enhancement, and harm reduction.

The CBT,[75] in general, helps the person to become aware of the addictive feelings and actions and to learn new coping skills to deal with cues and triggers to avoid relapse. The CBT is usually carried out over a 3-month period at the frequency of weekly sessions. During the initial CBT sessions, the client's Internet use patterns are evaluated, and then, the client is given alternatives or is asked to generate alternatives to develop a new schedule to change the past entrenched patterns of Internet use. Further, as part of the CBT, external activities that demand the person to leave the Internet can be implemented.

In terms of various models, the CBT-Internet addiction model[216] is considered to be a comprehensive approach, with three phases, i.e., behavior modification, cognitive restructuring, and harm reduction therapy [Table 9]. Behavior modification focuses on specific behaviors and situations that cause marked difficulty and are used to control excessive Internet use and reduce the time spent online. Cognitive restructuring helps in identifying, challenging, and adjusting cognitive disruptions and negative beliefs that are responsible for excessive Internet use. Harm reduction recognizes and addresses psychiatric issues related to Internet addiction and targets the social problems such as problems in relationships with families, peers, and friends, arising due to excessive Internet use.{Table 9}

CBT has the best evidence against PIU. There is much evidence for the individual-based CBT; however, evidence for multimodal and group counseling, though present,[217],[218] is not that strong. Numerous studies have shown successful use of psychological measures such as CBT and problem-solving combined with pharmacological measures, especially if occurring in the presence of other psychiatric disorders.[219],[220]

Various non-randomized controlled trials (RCTs)[184],[221],[222] and RCTs[223],[224],[225],[226] show significant superiority of CBT for reducing the severity of symptoms of IGD. PIPATIC (ProgramaIndividualizadoPsicoterapéuticopara la Adicción a lasTecnologías de la Información y la Comunicación) Program[182] is an intervention program designed for 12–18-year-old adolescents with IGD. This is a 6-month duration including twenty-two 45-min weekly sessions each for both individuals and family members. It is divided into six modules, namely, psychoeducational (3 sessions), addictions treatment as usual adapted to IGD (5 sessions), intrapersonal (5 sessions), interpersonal (2 sessions), family intervention (3 sessions), and development of a new lifestyle (2 sessions). Preliminary evidence shows it to be effective in the management of IGD. The treatment strategies which have been suggested for the management of cybersexual disorders include group therapy[227] including Motivational Interviewing sand CBT techniques, individual acceptance and commitment therapy,[228],[229] online recovery program[230] (based on a CBT approach), and systems couple's therapy.[231] However, as of now, there have been no comparison studies evaluating these interventions, and hence, no specific recommendation can be made for using a specific treatment modality in managing cybersexual disorders. Some experts recommend using integrative approach including a combination of pharmacological and psychological modalities.

Various measures have been used to counter cyberbullying. Most of these interventions focus on the prevention of cyberbullying rather than managing cyberbullying. Some of the suggested interventions include an e-course including online classes[232] and reasoned action-based cyberbullying prevention program for students,[233] empathy training to adolescents,[204] and increasing the awareness of educators about cyberbullying.[234] Strategies to help cybervictims cope better with cyberbullying including asking for help from an adult after being cyberbullied[235] and using technical coping strategies such as blocking the cyberbully or reporting to the platform authority.[236]

Management of constructs such as cyberchondria, cyber suicide, and compulsive online buying is not well researched. It is suggested that CBT may also be useful in the management of these disorders.

 Pharmacological Measures for the Management of Cyberpsychiatric Disorders



In terms of pharmacological measures, the evidence is sparse. A 1-year naturalistic study involving patients with OCD having PIU showed a beneficial effect of Selective Serotonin Reuptake Inhibitors (SSRIs) on PIU.[237] In a small study involving 19 patients, escitalopram showed significant improvement in a 10-week discontinuation study that further continued for another 9 weeks and the improvement persisted.[238] Two nonrandomized trials[239],[240] and two placebo-controlled RCTs[241],[242] suggest that bupropion is useful in limiting symptoms of IGD and one study showed the superiority of bupropion over escitalopram.[242] One case report reported the beneficial effect of naltrexone in managing problematic cybersexual disorders.[243] In terms of cyberbullying, a recent study involving adolescents with ADHD showed a decline in cyberbullying incidents in those receiving methylphenidate as compared to treatment-naïve adolescents.[244]

 Conclusions



Cyberpsychiatric disorders are a group of disorders in which Internet use, general or specific, forms an integral/central part of the psychopathology. They are presently not represented properly in the current nosological systems, apart from a minimal mention in the DSM-5. However, with the increasing chances and notoriety of Internet/gadgets to encroach into every area of human life, we may have to consider these entities seriously. Accordingly, there is a need to include these disorders in the nosology. Although these have not been included in the existing nosology, the practitioners should be aware of contribution of Internet use to the manifestations of well-known disorders and how the presentations of these disorders is colored by the Internet. Available research suggests that various pharmacological measures such as SSRIs and psychological measures such as psychotherapy, based on the CBT model, have been shown to be effective in managing these disorders though the strength of evidence is minimal at best.

We are far from the proper understanding of these disorders. These entities are understudied so as to make any comment regarding prevalence, risk factors, and diagnostic and management guidelines. There is an urgent need for future studies utilizing validated and reliable measures for better identification, assessment, and management of these ailments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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