Internet Addiction Disorder – Case Files of Internet Addiction Disorder and Psychosis
A 17-year-old student was brought to the clinic by his parents with a one-week history of changed behaviour and unusual beliefs. He started believing that his movements and actions were controlled by an external force through his laptop and phone resulting in him stopping their use.
Also, he felt that he was being followed by an unknown group of people through electronic devices. So he was reluctant to leave the house.
He had been studying information technology and electronics for his university entrance exam and had been an academically well-performing student.
Over the last 6 months, he started using internet excessively with the intention of finding information to make a drone. Besides schooling, he avoided all other activities and spent hours in front of the laptop.
He slept only for 2-3 hours on some days because he somehow wanted to complete his wish of flying a drone created by him. His interactions with family and friends also became much less. He became agitated and irritable when his parents tried to control his internet use.
He came from a middle class closely knit family with an Asian background. Both parents were caring and showed reasonable parenting practices.
There was no significant history of medical or psychiatric illness or substance use. Also, there was no family history of psychiatric illness. He was a developmentally normal adolescent with average academic performance. He was a quiet person with few close friends who was ‘loved‘ by his teachers.
Mental state examination revealed perplexed mood, persecutory delusions, delusions of reference and delusions of control involving technological devices. He showed partial insight.
Blood investigations and neuroimaging studies did not reveal any abnormality.
He responded well to Risperidone 3 mg and was completely symptom-free by 3 weeks.
WHAT IS INTERNET ADDICTION DISORDER?
Excessive internet use, especially among adolescents and its health implications, have been a much-discussed topic recently.
Problematic internet use or Internet addiction disorder (IAD) is still not an official diagnosis in psychiatric classification systems.
Dr.Kimberly Young had first proposed diagnostic criteria for Internet Addiction Disorder (IAD) modifying criteria for impulse control disorder in DSM IV. 
Young (1998) described a seven criteria model for Internet Addiction Disorder diagnosis similar to other addictions. 
- A preoccupation with the Internet
- The need to use the Internet for increasing amounts of time,
- Unsuccessful efforts to stop using the Internet, mood change when attempting to stop or cut down Internet usage
- Staying online longer than intended
- Jeopardizing of significant relationships or opportunities due to excessive Internet usage
- Lying about Internet use
- Using the Internet as an escape from problems or seeking to relieve bad mood states
However, Young has not specified any duration criteria.
More recently Tao et al. (2010) stated the following criteria for Internet Addiction Disorder. 
(a) Symptom criteria (both must be present):
(2) Withdrawal symptoms;
(b) One or more of these criteria:
(2) Continued use despite problems,
(4) Loss of other interests
(5) Use of the Internet to escape or relieve dysphoric mood;
(c) Clinically significant impairment criterion:
Functional impairments (reduced social, academic, working ability), including loss of a significant relationship, job, educational or career opportunities.
(d) Course criterion
Duration of Internet addiction must have lasted for an excess of three months, with at least six hours of Internet usage (non-business/non-academic) per day.
Both sets of criteria describe feelings of a lack of control over internet use resulting in psychological, social, or professional dysfunction and mental preoccupation.
The common consensus is that problematic internet use has features similar to other behavioural addictions including substance addiction.
After much debate internet gaming disorder has been included in DSM V as an entity which needs further investigation and research. But DSM V does not include other types of excessive internet use other than gaming.
TYPES OF INTERNET ADDICTION DISORDER
Young has described five different kinds of IAD. 
- Cyber sexual addiction ( addiction to cyberporn or adult chat rooms)
- Cyber relationship addiction (Cyber affairs or using online relationships to replace real-life friends and family)
- Net compulsions (Obsessive online gambling or shopping)
- Information overloads (compulsive database searches)
- Computer addiction (obsessive game playing)
The patient described in the case report showed features like tolerance, inability to control use, preoccupation, and loss of interest in social, occupational and recreational activities justifying a diagnosis of IAD prior to the onset of psychotic symptoms.
He belonged to the fourth type of IAD, i.e. information overload described by Young. He almost succeeded in making a drone himself by compulsively searching for relevant information.
However, internet addiction as part of a prodromal psychosis cannot be ruled out.
INTERNET ADDICTION AND PSYCHIATRIC COMORBIDITIES
s Different types of psychiatric comorbidities in association with IAD have been identified, including ADHD, Anxiety, Bipolar disorder and depression. 
Several cases of withdrawal psychosis have been described in the literature.
The first documented case of psychotic symptoms during the withdrawal period of the internet is reported by Mendhekar and Chittaranjan in 2012. 
They described a case of a 15-year-old boy who had developed frank psychotic symptoms 36 hours after stopping internet use.
Paik et al. have described a psychotic episode in a 25-year-old male within one day after discontinuing an internet game. 
The authors of the above case concluded –
This case report suggests that brief psychosis can develop during withdrawal from long-term excessive use of the Internet and the central pathology beneath the IAD is more likely a form of addiction than impulse control.
Both cases showed rapid improvement and full recovery within one or two weeks. The theme of delusions was related to computer and technology. Even though our patient developed psychotic symptoms while using the internet (not during withdrawal), other features were similar to the above two cases.
Tzang et al. 2014 had described psychotic-like symptoms associated with IAD in a 19-year-old boy.
However, the patient had a history of untreated ADHD and a strong family history of mood disorder. 
In contrast, a genetic vulnerability in the form of family history or past psychiatric history was absent in our patient.
Nitzan et al. described 3 cases with no prior major psychiatric disorder, who presented for psychiatric treatment, due to psychotic symptoms which appeared de novo while they were immersed in computer-mediated communication.
In each case, a connection was found between the gradual development and exacerbation of psychotic symptoms, including delusions, anxiety, confusion, and intensified use of computer communications.
All 3 recovered completely within a short period similar to our patient.
Nitzan et al. identified shared factors like loneliness or vulnerability due to loss or separation from a loved one, relative inexperience with technology, and no prior history of psychosis or substance abuse. Our patient had the last two factors out of the factors highlighted.
An expert Japanese group has described Hikikomori syndrome, a condition characterised by a wide range of psychopathology, including excessive internet use. 
It describes a condition that mainly affects adolescents or young adults who live isolated from the world, cloistered within their parents’ homes, locked in their bedrooms for days, months, or even years on end, and refusing to communicate even with their family.
Similar cases have been reported from other parts of the world. The condition is characterised by features like social withdrawal, loss of interest for other activities, use of the internet to escape dysphoric mood, and functional impairment.
This condition appears to show an overlap of symptoms with internet addiction and emerging psychosis.
From a neurobiological perspective, internet addiction is associated with changes in white matter integrity. 
Seventeen IAD subjects and sixteen healthy controls without IAD participated in this study using diffusion tensor imaging (DTI) to investigate white matter integrity in adolescents with IAD.
According to the researchers –
It may be concluded that IAD in adolescence is not associated with morphological changes in white matter at the macroscopic level, but rather impaired white matter microstructural integrity, which might be attributed to demyelination.
Considering the expanding knowledge of technology, leading to societal changes in every part of the world, the internet has become a necessity in people’s lives nowadays.
With emerging evidence linking excessive internet use and psychiatric symptoms, further research is needed.
Considering the impact internet use has on people, and the emerging evidence of psychopathology in relation to excessive internet use, internet use history should become an essential part of traditional psychiatric history taking.
Tao, R., Huang, X., Wang, J., Zhang, H., Zhang, Y. & Li, M.
(2010). Proposed diagnostic criteria for internet addiction. Addiction,