網路成癮:事實還是虛構?


  March 11, 2008(喬治亞州沙凡那港市)—根據史丹佛大學醫學院的Elias Aboujaoude醫師在美國焦慮醫學會第28屆年會中發表的研究,網路成癮,或者網路濫用,影響將近1%的美國大眾。
  
  雖然需要後續研究檢視這是否為一種需要被加入精神疾病診斷與統計手冊(Diagnostic and Statistical Manual of Mental Disorders (DSM-V))第5版的新的異常,他表示,有網路濫用問題的人現在都出現在心智健康門診了。
  
  Aboujaoude醫師向Medscape精神病學表示,我認為網路成癮是公共衛生問題,身為心智健康專家,我們應詢問人們的網路生活。
  
  【何謂網路成癮?】
  Aboujaoude醫師表示,目前,約有71%的美國人慣用網路,且這個新興媒體造成了購物、娛樂和政治活動的革命;但對一些人來說,網路使用可能會變成問題。
  
  匹茲堡大學的Kimberly S. Young博士定義網路成癮,根據DSM-IV對病態賭博的規範,有下列症狀的其中5個以上:全神貫注於網路;花相當多的時間上網路上以獲得滿足;無法成功減少使用;當試圖減少時,感到無法休息或者急躁;上線時間遠超過所需求;設定隱藏/對線上追問說謊;因這行為感到痛苦或者機能失調;或者使用網路進行自我療傷(例如克服憂鬱)。
  
  Aboujaoude醫師表示,網路成癮和衝動控制疾患、物質濫用、以及強迫症有一樣的常見特徵。
  
  它類似衝動控制疾患,這類病患感到突然焦慮、且企圖馬上進行當下感到愉悅可是卻造成長期沮喪的一種行為;DSM-IV辨識一些衝動控制疾患 (拔毛症、竊盜僻、縱火狂以及衝動性賭博),而其他的(衝動性摳皮、強迫性濫交、強迫性購物) 屬於其他未註明(NOS)類別,他表示,這就是網路成癮可以適用的類別。
  
  類似物質濫用,網路濫用問題導致腦部多巴胺突增;越來越多人需要藉由使用網路來使心情高張,一旦沒有了網路就感到戒癮症候群;就像強迫症 (OCD),網路成癮也包括儀式化的重複行為,不過,和OCD不同的是,它可提供娛樂高潮,且人們會把時間搞混亂。
  
  【這有多常發生?】
  Aboujaoude醫師表示,已經發表之有關網路成癮的各種研究指出約有3%-10%的發生率,但這些研究有一些選樣偏見,因為是進行網路調查。
  
  兩篇最近的社區青少年研究指出的發生率更低;一篇韓國的研究,超過1,500名15至16歲的學生回覆問卷指出網路成癮發生率為1.6%,男女生的比率相同(Kim K 等人。Int J Nurs Stud. 2006;43:185-192);類似的是,挪威一篇超過3,200名青少年的研究發現這一年紀的族群有1.98%有網路成癮。
  
  為了研究美國成年人的網路濫用,Aboujaoude醫師等人進行了隨機數位撥打電話調查了50州的2513名成年人(Aboujaoude E等人。 CNSSpectr. 2006;11:750-755)。
  
  接觸的人之中有56.3%回覆調查,回覆者平均年齡為48歲。
  
  回覆者有4%至14%顯示有網路濫用問題:
  * 4% 表示,當他們離線時,他們全神貫注於網際網路;
  * 6% 的人際關係因為不適當的網路使用而有後遺症;
  * 6% 經常利用上線逃避憂慮或負面心情;
  * 9% 隱藏且認為自己應該掩飾他們的網路活動;
  * 11% 留在線上的時間比實際需要久;
  * 14% 表示很難連續4天不上線。
  
  網路濫用定義須符合3個規範(離線時還是專注於網路;無法成功戒斷或者經常留連網路超過實際需要的時間;因為使用網路而干擾了人際關係),研究者發現網路濫用問題的發生率為0.7%,男性和女性相同。
  
  研究團隊結論表示,相當大部分的成年人看似有潛在的網路濫用問題;需要後續研究,以確認這是否是獨立的病理行為,或者是其他精神病理的症狀。
  
  在2007年6月,美國醫學會向國家健康研究中心、疾病管理局和美國精神科學會提出正式申請,要求更多研究以了解過度使用線上遊戲等網路活動的長期後遺症。
  
  【可能的治療】
  案例報告指出,鴉片受體拮抗劑naltrexone被用於賭博以及其他衝動性控制異常之治療,或許可用於這些網路濫用病患。
  
  紐約Mount Sinai醫學院的Eric Hollander醫師等人試驗了抗憂鬱藥物escitalopram (Lexapro,Forest 藥廠)用於19個衝動性-強迫性網路使用異常者,定義是耗時、無法控制、網路使用導致令人困擾的社會、職業或財經困境 (Hollander E等人。J Clin Psychiatry. 2008年2月27日;e1-e5)。
  研究對象在開放標籤期服用escitalopram 10週,之後將那些有反應者隨機分組到9週的雙盲安慰劑控制期,繼續服用此藥物或者換成安慰劑。
  Aboujaoude醫師表示,好消息是在開放標籤期間,他們對藥物有很健康的反應;花在網路的時間從平均36小時降為16小時;另一方面,在雙盲期,安慰劑和治療組效果都不錯;作者結論表示,需要後續的大型研究探討這個藥物和其他製劑對網路濫用的效果。
  
  Aboujaoude醫師表示,其他研究聚焦在認知行為治療(CBT)網路成癮,此法無法完全節制,因為並沒那麼實用。
  鼓勵病患避免問題網路行為且發展健康的替代方式—例如,從每天上線8小時減到3小時;CBT 的認知方面遇到一些困境,如悲觀想法、過度概括、以及負面核心價值和試著扭轉它們。
  
  他強調,同時治療共病症也是重要的,有許多網路濫用病患同時有心情異常,特別是憂鬱和其他焦慮狀況,這些都得加以治療。
  
  Aboujaoude醫師和 Hollander醫師的研究受Forest藥廠的贊助 。
  
  美國焦慮醫學會第28屆年會:口頭發表1C。2008年3月6-9日。

Internet Addiction: Fact or Fi

By Marlene Busko
Medscape Medical News

March 11, 2008 (Savannah, Georgia) — Internet addiction, or problematic Internet use, affects close to 1% of the general population of the United States, according to a study from Stanford University School of Medicine, in California, presented by Elias Aboujaoude, MD, in a talk here at the Anxiety Disorders Association of America 28th Annual Meeting.

While further studies are needed to determine whether or not this is a legitimate new disorder that should be added to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-V), patients with problematic Internet use are showing up now at mental health clinics, he said.

"I do think that Internet addiction is a public health problem," Dr. Aboujaoude told Medscape Psychiatry, adding, "As mental health professionals, we really should ask about people's online lives."

What Is Internet Addiction?

Currently, about 71% of the US population has access to the Internet, and this new medium has revolutionized such life aspects as shopping, entertainment, and political campaigns, said Dr. Aboujaoude, but for some individuals, Internet use can become problematic.

Kimberly S. Young, PhD, from the University of Pittsburgh, in Bradford, Pennsylvania, has defined Internet addiction, based on criteria from the DSM-IV for pathological gambling, as having 5 or more of the following symptoms: preoccupation with the Internet, a need to spend more time online to get the same satisfaction, unsuccessful attempts to decrease use, feeling restless or irritable when attempting to cut back, often staying online much longer than intended, secretive behavior/lying about online pursuits, distress or dysfunction as a result of this behavior, or use of the Internet to self-medicate (eg, to overcome depression).

Internet addiction shares features in common with impulse control, substance abuse, and obsessive-compulsive disorders, Dr. Aboujaoude noted.

It is similar to impulse control disorder, in that people experience a surge in anxiety and an urge to perform an act that is pleasurable in the moment but leads to long-term distress. The DSM-IV recognizes some impulse control disorders (trichotillomania, kleptomania, pyromania, and impulsive gambling), while others (impulsive skin picking, compulsive cruising for sex, and compulsive shopping) fall into the not-otherwise-specified (NOS) category, which is where Internet addiction might fit, he said.

Like substance abuse, problematic Internet use results in a dopaminergic surge in the brain. More and more Internet use is needed to achieve a high, and when going without the Internet, the person might suffer from withdrawal symptoms.

Like obsessive-compulsive disorder (OCD), Internet addiction can include ritualized, repetitive behavior. However, unlike OCD, it offers a pleasurable high, and people can lose track of time.

How Common Is It?

Various studies have reported a prevalence of Internet addiction as high as 3% to 10% of the population, but these studies suffered from self-selection bias, since they were online surveys, Dr. Aboujaoude said.

Two recent community studies of adolescents reported a much lower prevalence. A Korean study of over 1500 15- and 16-year-old students who replied to a questionnaire reported an Internet addiction prevalence of 1.6%, with the same rates among boys and girls (Kim K et al. Int J Nurs Stud. 2006;43:185-192). Similarly, a Norwegian study of over 3200 adolescents found that 1.98% of this population was addicted to the Internet.

To investigate problematic Internet use in the adult general population in the United States, Dr. Aboujaoude and colleagues performed a random-digit-dial telephone survey of 2513 adults in 50 states (Aboujaoude E et al. CNS Spectr. 2006;11:750-755).

Of the people who were contacted, 56.3% replied to the survey. The respondents had an average age of 48 years.

From 4% to 14% of the survey respondents showed evidence of some aspects of problematic Internet use:

  • 4% said they were preoccupied with the Internet when they were offline.
  • 6% had personal relationships that suffered as a direct consequence of inappropriate Internet use.
  • 6% regularly went online to escape from depression or negative moods.
  • 9% were secretive and felt they had to hide their Internet activities.
  • 11% stayed online regularly for longer than they intended.
  • 14% had a very hard time staying offline 4 days in a row.

Defining problematic Internet use as meeting 3 criteria (preoccupation with the Internet when offline; unsuccessful attempts to cut back use or often staying online longer than intended; and interference with personal relationships caused by Internet use), the researchers found a prevalence of problematic Internet use of 0.7%, which was the same for both men and women.

"Potential markers of problematic Internet use seem present in a sizable proportion of adults," the team concluded. Future studies are needed to determine whether this is a separate pathological behavior or whether it is a symptom of other psychological pathologies.

In June 2007, the American Medical Association submitted a formal request to the National Institutes of Health, the Centers for Disease Control and Prevention, and the American Psychiatric Association asking that more research be conducted into the long-term consequences of excessive video games and other Internet pursuits.

Potential Treatments

Case reports suggest that the opioid receptor antagonist naltrexone, which has been studied in gambling and other impulse control disorders, might be useful to treat patients who have problematic Internet use.

Eric Hollander, MD, from Mount Sinai School of Medicine, in New York, and colleagues tested the use of the antidepressant escitalopram (Lexapro, Forest Pharmaceuticals) in 19 adult subjects who had impulsive-compulsive Internet usage disorder, defined as time-consuming, uncontrollable, distressing Internet usage resulting in social, occupational, or financial difficulties (Hollander E et al. J Clin Psychiatry. February 27, 2008;e1-e5). Study participants took escitalopram in an open-label phase for 10 weeks, and then those who responded were randomized in a double-blind, placebo-controlled 9-week phase to continue with this drug or switch to placebo. "The good news is that during the open-label phase they had a very healthy response to the drug; on average the number of hours spent online went from 36 hours to 16 hours," said Dr. Aboujaoude. On the other hand, in the double-blind phase, both placebo and treatment groups continued to do well. Further research in larger trials is needed to investigate the efficacy of this and other agents for problematic Internet use, the authors conclude.

Other research has focused on cognitive behavioral therapy (CBT) for Internet addiction. "The approach is not complete abstinence, since that's not so practical," said Dr. Aboujaoude, but rather treatment encourages patients to avoid problematic online behaviors and develop healthy alternatives — for example, to go from being online 8 hours a day to 3 hours a day. The cognitive aspect of CBT involves confronting faulty cognitions such as catastrophic thinking, overgeneralizing, and negative core beliefs and trying to reverse them.

It is important to also treat any comorbid conditions, he stressed, adding that a significant proportion of patients with problematic Internet usage also have a mood disorder, especially depression and other anxiety conditions, for which established treatments exist.

The studies by Drs. Aboujaoude and Hollander were supported by funding from Forest Pharmaceuticals.

Anxiety Disorders Asso

    
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