REVIEW ARTICLE


Managing Problematic Usage of the Internet and Related Disorders in an Era of Diagnostic Transition: An Updated Review



Bernardo Dell’Osso1, 2, 3, Ilaria Di Bernardo1, *, Matteo Vismara1, Eleonora Piccoli1, Federica Giorgetti1, Laura Molteni1, Naomi A. Fineberg4, 5, 6, Calogero Virzì1, 7, Henrietta Bowden-Jones8, Roberto Truzoli1, Caterina Viganò1
1 Department of Psychiatry, University of Milan, Department of Biomedical and Clinical Sciences “Luigi Sacco”, ASST Fatebenefratelli-Sacco, Milan, Italy
2 Department of Psychiatry, Bipolar Disorders Clinic, Stanford Medical School, Stanford University, Stanford, CA, USA
3 Aldo Ravelli” Center for Neurotechnology and Brain Therapeutic, University of Milan, 20142 Milan, Italy
4 Hertfordshire Partnership University NHS Foundation Trust, Rosanne House, Welwyn Garden City, Hertfordshire AL8 6HG, UK
5 Center for Clinical & Health Research Services, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
6 School of Clinical Medicine, University of Cambridge, Cambridge, UK
7 Department of Clinical and Molecular Biomedicine, Psychiatry Unit, University of Catania, Catania, Italy
8 Central North West London NHS Trust, Division of Brain Science, Imperial College London, London, UK


Article Metrics

CrossRef Citations:
0
Total Statistics:

Full-Text HTML Views: 384
Abstract HTML Views: 164
PDF Downloads: 212
Total Views/Downloads: 760
Unique Statistics:

Full-Text HTML Views: 284
Abstract HTML Views: 85
PDF Downloads: 135
Total Views/Downloads: 504



Creative Commons License
© 2021 Dell’Osso et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Psychiatry, University of Milan, ASST Fatebenfratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy; Tel: +390239042803; +390239042904; E-mails: ilaria.dibernardo@unimi.it; dibernardoilaria1@gmail.com


Abstract

Introduction:

Problematic Usage of the Internet (PUI) refers to a broad and likely heterogeneous group of Internet-related conditions associated with behavioural disturbances and functional impairment.

Methods:

Within PUI several conditions have been reported, including Gaming Disorder, Shopping Addiction, Cyberchondria, Gambling Disorder, Cyberpornography Addiction and Cyberbullying. While increasing reports in the field try to define the epidemiologic and clinical boundaries of these conditions, the rapid and continuous evolution of Internet related behaviours as well as their problematic/pathological expressions are often difficult to diagnose, assess, approach with treatment interventions and follow-up.

Results:

In addition, some of the PUI-related conditions show characteristics of addiction to the Internet as a preferential tool to engage in specific behaviours, while some others exclusively manifest on the Internet, making it necessary to find distinct assessment and treatment pathways.

Conclusion:

The inclusion of Internet Gaming Disorder in Section III by the DSM-5 and the recognition of Gaming Disorder by the ICD-11 opened the way for a systematic clinical investigation of this and other PUI-related conditions, particularly in terms of preventive and therapeutic strategies. The present article is aimed at offering an updated clinical overview on the main expressions of PUI, focussing on the latest acquisitions in this evolving field.

Keywords: Problematic usage of the internet, Management, Internet gaming disorder, Online gambling disorder, Cyberchondria, Cyberpornography addiction, Cyberbullying, Online shopping addiction.



1. INTRODUCTION

Problematic Usage of the Internet (PUI) is an umbrella definition for a growing range of abnormal behaviours that manifest through the use of the Internet [1]. These behaviours share several core features, in particular, the loss of control leads to an increased priority given to online behaviours, resulting in the neglect of other important areas of daily life. Engagement in some forms of PUI (e.g., online gambling) bears the hallmarks of being largely motivated by addiction and being associated with craving, risky or harmful use of the Internet, tolerance and withdrawal symptoms. Behavioural addiction has been defined as repeated behaviour leading to significant distress and consequent functional impairment. This pathological behaviour persists over a significant period of time and can not be limited by the patient [2]. Indeed, the term Internet Addiction, initially proposed in the mid ‘90s [3], remains widely used nowadays to indicate Internet-related psychopathology. In the same period, the pioneering work of several researchers resulted in a set of proposed diagnostic criteria for Internet Addiction that resembled those formulated by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) for Pathological Gambling [4, 5]. Additional research contributed to elaborate meaningful conceptual differences between addictions on the Internet (those affecting individuals who simply use the Internet as a medium to engage in a specific behaviour that could be conducted offline) versus addictions to the Internet (where individuals are primarily addicted to content solely generated inside the world wide web) [6-9]. At present, it remains relevant to distinguish and clinically characterize different expressions of PUI that represent variants of conditions already recognized as problematic and/or included in the DSM and the International Classification of Diseases (ICD) classification systems.

For instance, this seems to be the case for disorders such as Cyberchondria/Hypochondriasis, Internet Gaming Disorder/ Problematic Videogaming, Cyberpornography Addiction/ Pornography Addiction, Internet Gambling Disorder/Gambling Disorder, Internet Shopping Addiction/Impulsive Compulsive Shopping Disorder, Cyberbullying/Bullying and so on. Nevertheless, between the aforementioned conditions, only Gambling and Gaming Disorder have been currently consi- dered as mental or potential mental disorders. Other forms of PUI, such as digital searching for medical information (e.g. Cyberchondria) may share closer similarities with Obsessive Compulsive Disorder and other Obsessive-Compulsive and Related Disorders. These subtypes of PUI appear to be largely motivated by compulsions, defined as irresistible urges to perform stereotyped or rule-bound behaviours aimed at reducing harm or distress [10, 11]. However, different factors overlay and interplay and many forms of PUI showed both addictive and compulsive phenomenology.

Ongoing efforts aim to define the phenomenological and epidemiological boundaries of specific phenotypes of PUI, to document their prevalence rates according to different countries and to identify long-term course and treatment outcomes [12-16]. However, to date, findings related to these issues remain largely inconclusive. While some of the conflicting evidence could be attributed to different methodological approaches and biases, the debate has also been fuelled by experts who feared the potential medicalization and stigmatization of PUI-related conditions and, conversely, by others who stressed the consequences that PUI can have on young people health and lifestyle [1, 2, 17, 18]. Among the firsts, some authors highlighted the risk of misdiagnosing ordinary life behaviours as behavioural addictions. In order to avoid this risk, functional impairment or distress and persistence over time need to be considered as mandatory elements to confirm the diagnosis [2, 19, 20].

In its last edition, the DSM made two important innovations that could pave the way for additional, evidence-based, investigation on PUI. For the first time ever, the DSM acknowledged the existence of behavioural addictions and classified pathological gambling (now Gambling Disorder) alongside substance addictions in the “Substance-related and Addictive Disorders” category (previously considered alongside “Impulse-Control Disorders”) [21]. This decision was based on research that demonstrated clinical, phenotypic, genetic and neurobiological similarities between gambling and substance-use disorders. Gambling Disorder has been therefore classified in this category acknowledging the addictive nature of problematic gambling and providing a possible conceptual framework for the next inclusion of other excessive behavioural patterns, conducted off-line and/or on-line, in the same category as well. The inclusion of Internet Gaming Disorder (IGD) in the DSM-5 Section III as a new condition worthy of further study [22, 23] represented another important and unprecedented change. The inclusion of IGD in the DSM-5 acknowledged for the first time the possible existence of a PUI-related condition as a potential mental disorder and proposed specific diagnostic criteria as the basis for further investigation in the field, including the future definition of other PUI-related conditions. Nevertheless, in the DSM-5 perspective of Internet Gaming Disorder also “non-Internet computerized game” conditions can be included as IGD subtypes. Other non-online repetitive behaviours, named behavioural addictions (i.e., sex, shopping and exercise addictions), are not included in the DSM-5 classification, because of the scarce literature evidence, lack of diagnostic criteria and data on course and outcomes. Most importantly, and building upon these developments, in June 2019 the World Health Organisation (WHO) included Gaming Disorder in the 11th Revision of the International Classification of Diseases (ICD-11) in the substance and behavioural addiction section, though with a slightly different phenomenological approach compared to the DSM-5 perspective and without requiring usage of the Internet as a key component of the disorder.

PUI represents a rapidly evolving field, as shown from the increasing number of investigations focusing on this topic that has almost tripled - in the last five years, compared to the previous five. As a result, clinicians need to be regularly updated about recent advances in this area. The present brief overview of the literature is therefore aimed to present main PUI-related phenotypes, with specific emphasis on pheno- menological, assessment and therapeutic issues, and to summarize current knowledge in this field without providing a systematic review of the literature.

2. MATERIALS AND METHODS

A literature search was performed on PubMed and Google Scholar electronic databases to identify recent clinical studies and other literature sources (published in the last 10 years, from January 2010 to January 2020) focusing on the phenomenology and management of PUI-related phenotypes in terms of: 1) characterization; 2) diagnostic and psychometric assessment and 3) therapeutic approaches. In addition, a specific section on prevention strategies was included. A search strategy was performed using the terms: “Internet Gaming Disorder” or “Online Gambling Disorder” or “Cyberchondria” or “Cyberpornography Addiction” or “Cyberbullying”, “Online Shopping Addiction” or “Internet Addiction” or “Problematic Usage of the Internet” and “Assessment” and “Treatment” or “Prevention”. The database search parameters yielded a total of 1158 papers. Among these, 105 studies that only contained anecdotal evidence (i.e., case reports or descriptive paper without measurable psychopathological assessment) or that were not focused on the management of specific PUI subtypes- (i.e., describing generically the negative consequences due to the internet use) were excluded. For the purpose of this study, we did not provide a systematic review of the literature, while an international group of experienced clinicians and researchers in this field selected the most relevant articles focusing on PUI assessment, treatment and prevention. Additionally, reference lists of selected articles were screened. Only articles in English were reviewed. Results are herein presented after grouping PUI-related phenotypes in 6 major conditions: 1) Internet Gaming Disorder, 2) Online Gambling Disorder, 3) Cyber- chondria, 4) Cyberpornography Addiction, 5) Cyberbullying and 6) Online Shopping Addiction.

3. RESULTS

3.1. Internet Gaming Disorder (IGD)

IGD is a condition characterised by a maladaptive use of the Internet to play video games with negative consequences on individual functioning. Different factors contribute to determining online video games’ reinforcing properties. These include the ease of access a game provides via portable or handheld devices, the possibility of engaging in competition with other gamers, the perception of oneself in a manner that is more rewarding and less impacted by real world issues and the specific genres, designs and contents of the games [24-27]. In some countries, high prevalence of IGD has been recorded: nevertheless, epidemiological data on IGD vary, depending on age, country, and screening instruments [28]. Asian countries seem to exhibit a higher prevalence (10-15% among young people in Asian vs 1-10% in Western countries). Men, adolescents and young adults are more likely to be problematic gamers [22, 25, 28-32]. Furthermore, IGD often shows comorbidity with anxiety, depression, ADHD or hyperactivity symptoms, social phobia/anxiety, and obsessive-compulsive symptoms [33].

For IGD, the DSM-5 proposed nine different criteria (preoccupation or obsession, withdrawal, tolerance, loss of control, loss of interest, continued overuse, deceiving, escape of negative feelings, functional impairment) and a threshold of at least five criteria lasting for at least of one year to make a diagnosis of IGD. In the DSM-5 perspective, internet access is acknowledged as a relevant feature, even though, as stated in the “Subtypes” paragraph, IGD can involve “non-Internet computerized game”. In addition, biological concepts, such as withdrawal and tolerance, are considered of particular relevance, while less emphasis is given to functional impairment and craving. Time and frequency were not necessarily red flags for PUI, even though adolescents and young adult males, who spend an average of 12 hours per week playing video games, were found to be at higher risk of experiencing problematic and pathological gaming [22, 25, 32]. However, the debate concerning the validity of DSM-5 criteria for IGD is still in progress. Proposed criteria do not probably allow to distinguish an increased but healthy involvement (high engagement) in video games from an excessive and pathological one. This approach may determine several false positives and an over pathologization of normal behaviours, failing to take into account that repeated and high engagement is not problematic per se. The engagement construct underlines a harmonious passion for video games, without negative consequences and functional impairment. Similarly to the present conceptualization of IGD, the diagnosis of gaming disorder in the upcoming ICD-11 classification should focus on the impairing nature of gaming from a functional point of view [2, 34-36].

According to ICD-11, a patient must exhibit 3 core symptoms to be diagnosed with Gaming Disorder (GD): impaired control over gaming, increasing priority given to gaming, continuation or escalation of gaming despite the occurrence of negative consequences. In the ICD-11 approach, both online and offline game accesses are acknowledged, with significant emphasis on functional impairment and, therefore, on more severe expressions of PUI [37].

The first review focusing on the quality of IGD psychometrics tools has been published in 2013, just before the launch of the DSM-5. The authors identified withdrawal, loss of control and conflict as the defining features of IGD [38]. Since then, the situation has not seen a substantial evolution. More recently, an article from a Spanish group identified seven principal assessment instruments, developed after DSM-5 introduction of IGD diagnosis: Internet Gaming Disorder Test (IGD-20); Internet Gaming Disorder Scale – Short Form (IGDS9-SF); Problematic Online Gaming Questionnaire (POGQ); Problematic Online Gaming Questionnaire – Short Form (POGQ-SF); Video Game Addiction Test (VAT); Clinical Video Game Addiction Test (C-VAT 2.0); and Internet Gaming Disorder Scale (IGDS), (Table 1) [39]. Overall, the IGDS9-SF was found to be the most widely used assessment tool worldwide, with numerous validations and translations into different languages. The IGDS9-SF [40] is a brief instrument consisting of nine items covering the nine DSM-5 diagnostic criteria. This tool aims to measure the severity of IGD and its pathological consequences, assessing online and offline gaming activities during the previous year. The IGD-20 needs to be mentioned for its ability to examine different gaming profiles and represents a valid and accurate tool to assess IGD, incorporating DSM-5 diagnostic criteria and reflecting the six dimensions of the Griffiths’ addiction model (2005): salience, mood modification, tolerance, withdrawal, conflict, and relapse [39, 41]. The POGQ consists of a 26 item questionnaire organized in six dimensions: preoccupation, overuse, immersion, social isolation, interpersonal conflicts, and withdrawal symptoms [42]. POGQ-SF comprises 12 items reflecting the six POGQ dimensions [43]. The VAT is a direct adaptation of the items of the Compulsive Internet Use Scale (CIUS), focusing specifically on video game playing, elaborated before the appearance of the DSM-5. C-VAT 2.0 is an adaptation of the C-VAT to the DSM-5 criteria. C-VAT 2.0 is composed of 11 items (Yes/No) about IGD symptoms in the previous 12 months (nine of which covering the nine DSM-5 criteria for IGD) [44]. IGDS is a 27-item German-language tool in which each DSM criterion is assessed through three items [45].

In relation to therapeutic approaches to IGD, several studies investigated the potential utility of different psychopharmacological agents, but, currently, no medication has been approved for this condition [24, 46]. As far as antidepressants are concerned, the administration of Bupropion has shown a reduction of average time spent online and craving dimension in open-label [47, 48] and randomized controlled studies [49]. Two open trials comparing the effectiveness of Bupropion and Escitalopram showed that both antidepressants were effective in reducing IGD symptoms, though Bupropion was more effective in improving attention and in impulsivity decrease [50, 51]. In a case report, Citalopram was combined with an antipsychotic in a young patient, showing an improved control over Internet use and decreased addiction [52]. Indeed, further studies are needed to investigate the efficacy of Selective Serotonin Reuptake Inhibitors (SSRIs) in the treatment of IGD [53]. Due to the high comorbidity with ADHD, the use of Methylphenidate and Atomoxetine has been investigated in a recent 3-month prospective trial, showing a significant improvement of ADHD and IGD symptoms [54].

Nevertheless, further studies are needed in this field, since available data show several limitations concerning the lack of standardized assessment and definitions of IGD, determining various difficulties in comparing treatment outcomes across studies. Additional limitations include small samples and lack of control groups, randomization, blinding, and key details like sample characterization [24, 45, 55].

With respect to psychological treatment approaches for IGD, several interventions have been assessed: Cognitive-Behavioural Therapy (CBT), motivational interviewing, family therapy, educational courses focused on speaking and writing, basic counselling, solution focusing-therapy, reality training and a combination of them [46, 56-61]. Among them, CBT has been the most extensively studied [55, 58, 62] thanks to four randomized controlled trials [59, 63-65]. CBT demonstrated the most robust evidence in terms of efficacy in reducing weekly gaming hours and IGD symptoms, showing the largest evidence base versus other therapies [57], [66-68]. A recent review by King and colleagues (2017) pointed out a stronger consensus on the benefits of CBT compared to other therapeutic approaches, particularly in comparison to pharmacological treatment [46]. More recently, another review showed that CBT, which is often considered the first-line therapy for IGD, can improve both primary IGD symptoms and comorbid depression. However, treatment improvements usually manifest in the short-term and their effect in reducing time spent gaming is unclear [69]. Concerning brain stimulation techniques, a 4-week Transcranial Direct Current Stimulation protocol was found to be useful for reducing gaming online and enhancing self-control, likely by improving interhemispheric balance of glucose metabolism in the Dorsolateral Prefrontal Cortex [70].

Table 1. PUI-related disorders: Assessment and treatment approaches.
PUI Phenotype Assessment Pharmacological Treatment Non Pharmacological Treatment
INTERNET GAMING DISORDER (IGD)
IGD-20
(examine different gamer profiles)

IGDS9-SF
(the most used)

POGQ

POGQ-SF

VAT

C-VAT 2.0

IGDS
2 reviews, 1 case report,
6 clinical studies

Escitalopram up to 20 mg/die (Song et al., 2016; Nam et al., 2017)

Bupropion up to 300 mg/die (Han et al., 2011; Han and Renshaw., 2012; Song et al., 2016; Nam et al., 2017; Bae et al., 2018)

Citalopram up to 40 mg/die + Quetiapine up to 200 mg/die (Atmaca et al., 2007)

Methylphenidate up to 40 mg/die and Atomoxetine up to 60 mg/die (Park et al., 2016)
2 reviews, 3 clinical studies

Psychological approach:
CBT (best evidence)
motivational interviewing
reality training
combination of psychological and/or counseling therapies
(King et al., 2017; Zajac and M.K, 2017)

Specialized psychotherapy: PIPATIC program
(Torres-Rodriguèz and Carbonell., 2017; Torres-Rodriguèz et al., 2017)

brain stimulation:
tDCS on DLPFC (4 weeks)
(Sang et al., 2018)
ONLINE GAMBLING DISORDER (OGD)
NODS-CLiP
(3-item screening test)


PGSI
(9-item test to assess severity)
1 clinical study

Bupropion up to 300 mg/die (Bae et al., 2018)
1 clinical study

internet based CBT without guidance should improve access to treatment among non help-seeking online gamblers
(Luquiens et al., 2016)
CYBERCHONDRIA (CYB)

CSS
(33-items, 5 domains)

CSS-SF
(12-items, 4 domains)
No studies

SSRIs have been proposed
No studies

CBT has been proposed
CYBERPORNOGRAFY ADDICTION

(CYA)
ISST
(25 true-false item screening test)





CPUI
(31-items to assess severity)
1 review, 2 case series, 2 case reports

Naltrexone as a monotherapy or as an adjunct therapy and with doses up to 150 mg/d (Bostwick et al., 2008; Kraus et al., 2015; Capurso, 2017)

Paroxetine 20 mg/die and CBT (Gola and Potenza, 2016)
1 review

CBT, Adlerian Counselling, Structural therapy, Couple Therapy, Structural therapy, Online Psycho-educational program, Acceptance and Commitment therapy, Group therapy. (Sniewski et al., 2018)
CYBERBULLYING

CQ
(88-item )



CT
(equipped with psychometric properties)



CVEIS
(regarding victim and bullies emotions)
No studies
1 review, 2 clinical studies

The most frequently proposed interventions included components like education on cyberbullying for the adolescent, coping skills, empathy training, communication and social skills, and digital citizenship
(Hutson et al., 2018)

Prev@cib program
(Ortega-Baròn et al., 2019)

RPC (Relazioni Per Crescere) teacher-based program
(Guarini et al., 2019)
ONLINE SHOPPING ADDICTION (OSA) OSASS
(predicted the self-perceived online shopping addiction )
No studies specifically focused on OSA, yet a feasible approach might be the adoption of interventions approved for comparable forms of behavioural addiction No studies specifically focused on OSA, yet a feasible approach might be the adoption of interventions approved for comparable forms of behavioural addiction

3.2. Online Gambling Disorder (OGD)

OGD refers to placing money at stake in the hope of a large pay-out, with gambling outcomes being only partially or not at all skill dependent [71]. Compared to traditional gambling, the use of the Internet allowed new types of online gambling, along with traditional ones (e.g. poker, casinos, sports betting), making OGD one of the most popular and lucrative businesses on the Internet. Internet gambling represents a fundamental shift in the way consumers engage in gambling, and several preoccupations have been expressed by various stakeholders about these changes. Specific concerns and disadvantages reported by Internet gamblers highlight the easy and convenient possibility to spend money online and the high accessibility to online gambling, likely increasing the risk for OGD particularly among technology-savvy youths [72, 73]. Consequently, the Internet represents a facilitating factor in the development of pathological gambling in vulnerable individuals, since it favours access to gambling possibilities [74]. This feature can perhaps explain why the prevalence of problematic gambling appears to be at a higher level among online gamblers than non-online gamblers [75].

On the other hand, an advantage of online gambling is that “self-exclusion” from gambling websites may be more effective than from offline gambling for those who wish to stop gambling. Indeed, in some countries (i.e., in the UK), specific websites concerning self-exclusion are available for the patients [76, 77].

Currently, literature data are not conclusive in confirming OGD as being more harmful or more problematic than offline gambling [78]. In terms of sociodemographic features, online pathological gamblers seem to be much younger than offline gamblers (i.e., 30 years old compared to 40 years old on average) [78]. Overall, in adolescents online gamblers, compared with offline gamblers, a stronger link between OGD severity, problematic alcohol use and poor academic performance was found [79].

OGD can be assessed with a 3-item screening test, the National Opinion Research Centre DSM Screen for Gambling Problems (NODS-CLiP) [80, 81]. According to the NORC (National Organization for Research at the University of Chicago) DSM-IV Diagnostic Screen for Gambling Disorders, the NODS-CLiP investigates the three main areas of malfunctioning: loss of control, lying and preoccupation. It was demonstrated that there are high rates of specificity and sensitivity in diagnosing Gambling Disorder when patients endorse one or more of these items [81]. When the diagnosis is certain, however, the most used tool is Problem Gambling Severity Index (PGSI), also available for OGD, a 9-item questionnaire validated in 2009 that measures gambling severity in the last 12 months, with a cut-off score of 8 indicating patients as “problem gamblers” [82, 83].

Preliminary data showing an earlier onset of pathological gambling in online gamblers compared with offline ones suggests that treatment may require more effort for online subtypes, including online interventions and dedicated public youth departments, as well as strategic partnerships with schools [78]. Currently, OGD treatment is comparable to Gambling Disorder one, without specific measures for online behaviours. No pharmacological treatments have received official indication for gambling disorder, although placebo-controlled trials suggest that medications, as opioid receptor antagonists, may be helpful. Naltrexone is one of the most investigated molecules for gambling disorder [84-88]. In one of the first Randomized Controlled Trials (RCTs) in the field, considering subjects reporting moderate or strong urges to gamble, naltrexone performed better than placebo in reducing gambling symptoms [86]. In a follow-up study, in which patients were randomized in a double-blind trial and assigned to one of the three different daily doses of naltrexone (50 mg, 100 mg or 150 mg) or to placebo, Naltrexone exhibited a greater reduction in gambling urges than placebo, with no significant differences between the different drug doses [85].

As far as Nalmefene is concerned, limited evidence has been published. In a double-blind, placebo-controlled trial design, patients prescribed Nalmefene showed greater improvements in problem-gambling severity compared to placebo [89]. Another multicentre trial reported less positive results for Nalmefene. However, in the post-hoc analyses, the group on Nalmefene had a greater reduction in problematic gambling severity than the placebo group [90].

Specific evidence on the utility of pharmacological therapy in OGD is scarce. Of note, a 12-week open-label study on 14 patients treated with Bupropion up to 300 mg/day highlighted a significant improvement of clinical symptoms [47]. In terms of psychotherapeutic interventions, a recent study demonstrated that Internet based CBT could improve access to treatment among non-help -seeking online gamblers [91]. Concerning psychological treatment, CBT has been reported to be the most commonly used intervention in and offline pathological gambling [92]. A recent review has specifically recommended 6 to 8 sessions of CBT to integrate motivational interventions. For subjects with less severe gambling, minimal interventions involving feedback related to one’s gambling may also be effective [93].

In conclusion, considering OGD treatment opportunities and according to the therapy of Gambling Disorder, the combined approach (psychotherapy and pharmacotherapy) could be more engaging than pharmacotherapy alone and provide individuals relevant and useful skills that could lead to sustained treatment improvements [94].

3.3. Cyberchondria (CYB)

CYB has been defined as an excessive or repeated online searching for health-related information, which is driven by a need to alleviate distress/anxiety about health, and ultimately results in the worsening of such symptoms and behaviours [10, 11]. CYB resembles an urge driven compulsive/repetitive behaviour and manifests a time-consuming nature. Very limited descriptions of CYB in clinical samples are available, with all studies investigating this behaviour in the general population/university students, mainly recruited through online surveys. A consensus on CYB definition is still lacking, but the link between CYB and other psychiatric disorders has been established in the literature. CYB appears to be a transdiagnostic multidimensional construct with a strong correlation with PUI, health anxiety/hypochondriasis and Obsessive-Compulsive and Related Disorders [95-98].

A 33-items self-reported questionnaire, the “Cyberchondria Severity Scale”, is a continuous severity assessment tool to measure CYB that explores 5 domains: compulsion, distress, excessiveness, reassurance, and mistrust of medical professionals [99]. A shorter 12-items (4 domains) questionnaire has been validated and is potentially more suitable for clinical and research application.

No studies have investigated the efficacy of any therapeutic approach in CYB. Psychoeducation and CBT have been proposed. Considering the strong link between CYB and health anxiety/hypochondriasis, a reasonable pharmacological intervention might be the use of medications that proved to be efficacious in hypochondriasis [26, 100]. Therapeutic approaches should be extended to a public health level in order to improve the way health related information is presented and accessed online.

3.4. Cyberpornografy Addiction (CPA)

When the act of using Internet to view or interact with pornographic material [101] becomes excessively time consuming, distressing and difficult to resist, it indicates the potential presence of a pathological behaviour named Cyberpornograpy addiction (CPA). Around 12% of cyberpornography users tend to become compulsive, showing comorbid, recurring and uncontrollable sexual concerns that favour adverse consequences [102, 103]. cyberpornography addicts were found to spend on average 110 minutes per day watching pornography and reported high levels of compulsivity and emotional distress, with sexual avoidance and low sexual gratification and impairment in several areas of functioning [103-105].

The Cyber Pornography Use Inventory (CPUI), a 31-item questionnaire, is the most widely used instrument to assess the three dimensions of pornography use: compulsivity, intensity of efforts to access pornography and emotional distress associated with pornography use [103, 106]. Another tool is the Internet Sex Screening Test (ISST) item, a 25 true-false item test that identifies low risk (1-8), at risk (9-18) and high risk (> 19) abnormal Internet sex behaviours [107, 108].

To date, evidence on the efficacy of psycho- pharmacological treatment for CPA is very limited: only scattered case reports and one review addressed this topic [105, 109-112]. Naltrexone was used in three patients, either as monotherapy or adjunct therapy, with doses up to 150 mg/day, with an improvement in functioning and a reduction in the time spent online [105, 109, 110].

Paroxetine was administered along with CBT in three male patients, showing mixed results: although a short-term reduction of anxiety and pornography use was observed, new compulsive sexual behaviours emerged later during the observation [111].

As far as psychotherapy is concerned, CBT, Couple Therapy, Structural therapy, Online Psycho-educational program and Acceptance and Commitment therapy showed a positive effect in reducing symptoms severity [112].

3.5. Cyberbullying

The term “cyberbullying” was coined to describe the use of digital technology to seek to harm, intimidate, or coerce other people online [113-115]. This behavior has reached the attention of scientific study in order to increase the knowledge about its causes and effects on the bully and on the victims. A strong association between cyberbullying and mental health problems (i.e., social anxiety, depressive disorders, substance abuse and suicide) has been reported [116].

Despite the severity of this condition, limited assessment instruments have been developed so far [117]. The Cyberbullying Questionnaire is an 88-item test whose purpose is to analyse the incidence of cyberbullying in and out of schools [115]. Two recent reports proposed novel assessment instruments: the Cyberbullying Test with confirmed reliability and validity and the Cybervictimization Emotional Impact Scale which assess the emotions experienced by victims and bullies [117, 118].

So far, validated interventions for cyberbullying in the healthcare setting do not exist. In a recent systematic review, several different programs were discussed and individual intervention components (like digital citizenship, coping skills, education on cyberbullying, communication and social skills and empathy) were identified and their inclusion into clinical practice guidelines could reduce both cyberbullying and cybervictimization [119].

In a recent study, the effectiveness of “Prev@cib program”, based on three theoretical frameworks including ecological model, empowerment theory and personal and social responsibility model, was evaluated. Results showed a significant decrease in cyberbullying and cybervictimization [120].

3.6. Online Shopping Addiction (OSA)

OSA may be classified in the category of specific addiction on the Internet [1, 121-125] and it has been defined as a tendency to excessively and compulsively shop online that results in economic, social and emotional negative consequences [126].

E-commerce specific characteristics, such as products immediate availability, anonymity, easy accessibility and affordability provide a range of potential addictive features that reinforce OSA development [127-129]. Indeed, online shopping could be considered more addictive than shopping in the real world. In terms of individual characteristics, deficient self-regulation has been identified as the most important predictor for OSA [130, 131]. Prevalence data are not conclusive: a study found that 33.6% of compulsive shoppers manifested OSA [132]. In terms of assessment, the OSA scale, an 18-item questionnaire, has been developed to empirically measure OSA. This tool is based on previous research on a widely accepted six-factor component model (salience, mood modification, tolerance, withdrawal, conflict and relapse) [133]. The OSA scale scores predicted the self-perceived OSA to a relative high degree [126].

As far as treatment is concerned, no studies specifically focused on OSA. Yet, a feasible approach might be the adoption of interventions approved for comparable forms of behavioural addiction, such as Buying Disorder. In this respect, the use of antidepressants, mood stabilizers, opioid antagonists and CBT might be valuable options [134, 135].

In respect to psychotherapeutic interventions, a recent review found that the CBT was effective for the treatment of compulsive buying disorder, making this approach potentially applicable for the treatment of OSA as well [136].

3.7. PUI Prevention

Studies on prevention strategies for PUI are at a preliminary level: scarce RCTs were identified and frequently PUI was not the main focus of the investigation [137-141]. Researchers suggest that prevention programs for Internet-related disorders should mainly focus on children and adolescents [142, 143], using psycho-educational interventions, supporting resilience and adaptive coping strategies [144]. Considering an evolutive approach, several East Asian countries made a strong investment on primary prevention in schools [137, 143, 145-147]. Primary prevention should be complemented with an ecological perspective that includes the individual’s and familiar environment, social networks community and public policies [148]. In clinical settings, an evaluation of mental and psychological status might be useful to identify the presence of factors that might promote a maladaptive use of the Internet (i.e., personality traits, physiological characteristics, Internet use pattern and sociodemographic and clinical variables) [149-157].

With respect to secondary prevention, a valid strategy lies on the implementation of screening procedures in schools in order to measure the frequency of PUI [138, 144, 158-160]. However, it is important to state that interventions should be tailored on each specific phenotype of PUI. For instance, a recent review suggested that cyberbullying could be prevented by providing information about bullying to children, parents and school personnel through websites and other online resources and by implementing psychoeducational programs promoting empathy, perspective taking, communication skills, problem solving, and friendship skills [161]. Considering IGD, a useful strategy is “parenting” that consists of preventive approaches aimed at promoting a responsible use of the Internet. In particular, parents and responsible adults should put limitations on screen time for children and stimulate a more beneficial usage of this tool [32].

Considering tertiary prevention, some likely useful approaches include: self-help groups, psychoeducational interventions and social-skills rehabilitation [162]. Preliminary data suggest that mindfulness techniques may reduce craving and emotional dyscontrol [163, 164]

4. DISCUSSION

Management of PUI-related disorders represents an important challenge involving patients, families, psychiatrists, psychologists and social workers, with multiple repercussions on the whole society. A larger consensus on diagnosis and characterization of main PUI-related phenotypes, assessment, treatment and prevention is required in order to carry out evidence-based clinical interventions.

Previously, abnormal Internet-related behaviours mainly concerned Asian countries, but it is now established that PUI represents a global emerging public health issue, with relevant societal costs [13, 15].

In spite of the increasing reports on the cost and burden of PUI, specific clinical services for early detection and management are at this point limited and present only in some countries, and professional guidance and help are often limited or unavailable. Ultimately, inadequate resources and poor knowledge in the field of PUI contribute to its underdiagnosis and undertreatment. Lack of awareness, in turn, results in poor early intervention strategies, potentially contributing to the onset of secondary comorbid disorders and significant functional impairment (e.g., lower school-work performance). Conditions like insomnia, anxiety, depression, dysphoria, social phobia and social withdrawal (i.e., Hikikomori: a Japanese term meaning “being confined”, as an abnormal avoidance of social contact), and health risks, especially in the youth (i.e., a diet comprised of junk food, lack of exercise, obesity, postural pain syndromes in cervical or lumbar spine, repetitive stress injury) represent some of the most frequently observed correlates of untreated PUI. Achieving consensus on the definition, clinical course and assessment of different phenotypes of PUI, could be expected to reduce the burden of disease and help to identify the critical factors that are relevant for successful preventive interventions. In order to reduce the damaging consequences of PUI, the development of a valid and structured prevention program involving public health awareness and family involvement that extends to involve schools and local communities is needed.

Even though some progress has been made in recent years, in regard to PUI therapeutic strategies, it is still difficult to draw conclusions, due to methodological limitations and lack of adequate and homogeneous studies on specific therapeutic interventions. Overall, there are two overarching approaches to the treatment of behavioural addictions: the first one is to administer symptomatic therapy according to the clinical presentation and/or theoretical model of the disease, based on the pharmacological interventions approved for other forms of addiction. In this respect, it is useful to clarify whether the symptoms can belong to the obsessive-compulsive, impulsive or addictive spectrum. The second approach consists of intervening on comorbid mental disorders. In this regard, it is still unclear whether the chosen therapy merely addresses the potentially comorbid psychiatric disorder or is effective in treating PUI per se [165, 166]. Theoretical models on the pathogenesis of other substance and behavioural addictions provide a valuable rationale for the use of specific pharmacological classes, such as glutamatergic drugs (e.g., Memantine, Riluzole, metabotropic glutamate receptor agonists), mood stabilizers (antiepileptic drugs, lithium), opioid receptor antagonists (Naltrexone) and alpha-2 adrenergic receptor agonists [165, 166]. Regarding psychotherapeutic approaches, a review conducted by Liu and colleagues in 2011, which did not focus on specific PUI subtypes, indicated CBT combined with family therapy or group therapy as possibly effective for the treatment of Internet Addiction [167].

In a more recent meta-analysis (2017), counselling programs, cognitive behavioural therapies, and sport interventions were found to show a significant effect on Internet Addiction and related psychopathological symptoms [168]. Further studies need to be conducted in order to prove the effectiveness of these therapeutic tools, across various phenotypes of PUI. Unfortunately, at the present time, methodological problems limit the confidence in the conclusions that can be drawn from any of the aforementioned reports on therapeutic approaches. As recently pointed out by participants to the 4-year Cooperation in Science and Technology (COST) action “Manifesto for a European research network into Problematic Usage of the Internet”, investigation priorities for the next years in the field of PUI in order to improve the understanding of its different expressions include the needs to: achieve a consensus-driven conceptualisation of PUI; elaborate reliable assessment tools; establish the impacts on health and daily life; describe the clinical courses; encourage early interventions to remove risk factors; define the role of genetics and personality features; clarify the impact of social factors; validate effective interventions, both to prevent and to treat PUI and identify biomarkers as well as to improve early diagnosis [1].

While, to date, the scientific community and the priorities of mental health policy makers have largely overlooked the field of behavioural addictions and PUI, the time is now right for cultural change based on the acquisition of reliable epidemiological, clinical and social evidence. Public partnership with researchers, clinicians and health policy makers represent a key ingredient in the successful accomplishment of this task.

CONCLUSION

In conclusion, the present report was conceived as a non-systematic review of the literature that aims to describe different expressions of PUI with distinct prevalence rates, assessment tools and clinical characteristics. However, despite a growing body of evidence on the impact of Internet-related psychopathology on a personal and societal level, PUI needs additional research, in particular considering the widespread precocious exposure to digital technology, whose potential consequences are almost unknown. Certainly, the decision to acknowledge the existence of “behavioural addictions” operated by DSM-5 and ICD-11 through the inclusion of gambling and gaming disorders within the chapters of addictive disorders will provide new opportunities to implement an evidence-based approach for the investigation of PUI: a series of conditions with urgent need of rigorous field studies, particularly in the areas of prevention and therapeutic interventions.

The present report should be considered in light of the following limitations. First, the article stands as an overview presenting state of the art in the field of PUI and related conditions, without the aim to conduct a systematic review of the literature. Second, only Pubmed and Google Scholar electronic databases were considered as sources. Third, due to space limitation, it was not possible to discuss in detail every cited study. Last but not least, the present article was intended to be as inclusive as possible, but in light of the aforementioned limitations, we had to select only some of the most representative PUI related conditions. Therefore, other PUI expressions, including Cyberstalking, Cyberhoarding, and problematic forms of general web-surfing and mail checking, which also share a time-consuming and disabling use of the Internet, were not considered. Finally, some of the covered phenotypes exhibit an evident phenomenological heterogeneity (i.e., Cyberbullying, differently from other conditions, is not characterised by compulsiveness) which should be further characterized.

DISCLOSURE

Prof. Dell'Osso has received Grant/Research Support from LivaNova, Inc., Angelini and Lundbeck and Lecture Honoraria from Angelini, FB Health and Lundbeck.

Prof. Naomi A. Fineberg declares that in the past 3 years she has held research or networking grants from the ECNP, UK NIHR, EU H2020, MRC, University of Hertfordshire; she has accepted travel and/or hospitality expenses from the BAP, ECNP, RCPsych, CINP, International Forum of Mood and Anxiety Disorders, World Psychiatric Association, Indian Association for Biological Psychiatry, Sun; she has received payment from Taylor and Francis and Elsevier for editorial duties. In the past 3 years, she has accepted a paid speaking engagement in a webinar sponsored by Abbott. Previously, she has accepted paid speaking engagements in various industry supported symposia and has recruited patients for various industry-sponsored studies in the field of OCD treatment. She leads an NHS treatment service for OCD. She holds Board membership for various registered charities linked to OCD. She gives expert advice on psychopharmacology to the UK MHRA.

CONSENT FOR PUBLICATION

Not applicable

FUNDING

None.

CONFLICTS OF INTEREST

Dr. Bernardo Dell'Osso is the Editorial Board Member of Clinical Practice & Epidemiology in Mental Health.

ACKNOWLEDGEMENTS

European Cooperation in Science and Technology (COST), linked to the Project “European Research Network into Problematic Usage of the Internet (EU-PUI) and founded by the Horizon 2020 Framework Programme of the European Union in collaboration with: the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) and the Obsessive Compulsive and Related Disorder Research Network (OCRN) of the European College of Neuropsychopharmacology (ECNP), and the Anxiety and Obsessive-Compulsive Disorders Scientific Section of the World Psychiatric Association (WPA).

REFERENCES

[1] Fineberg NA, Demetrovics Z, Stein DJ, et al. Manifesto for a European research network into Problematic Usage of the Internet. Eur Neuro Psycho Pharmacol 2018; 28(11): 1232-46.
[2] Kardefelt-Winther D, Heeren A, Schimmenti A, et al. How can we conceptualize behavioural addiction without pathologizing common behaviours? Addiction 2017; 112(10): 1709-15.
[3] Goldberg LR, Rosolack TK. The Big Five factor structure as an integrative framework: An empirical comparison with Eysenck’s PEN model. The developing structure of temperament and personality from infancy to adulthood 1994; 7-35.
[4] Young KS. Internet Addiction: The Emergence of a New Clinical Disorder. CyberPsychology Behav 1998; 1(3): 237-44.
[5] Young KS. Internet addiction: Symptoms, evaluations and treatmentInnovations in clinical practice: A source book 1999; 17(17): 351-2.
[6] Griffiths MD. The treatment of pathological gambling: A brief overview of cognitive approaches Clin Psychol Forum 1996; 98: 29-33.
[7] Griffiths MD. Exercise addiction: A case study. Addict Res 1997; 5: 161-8.
[8] Griffiths M. Internet addiction: Internet fuels other addictions. Student BMJ 1999; (7): 428-9.
[9] Duong X-L, Liaw S-Y, Augustin JPM. How has Internet Addiction been Tracked Over the Last Decade? A Literature Review and 3C Paradigm for Future Research. Int J Prev Med 2020; 11: 175.
[10] Vismara N, Caricasole V, Starcevic V, Cinosi E, Dell'Osso B. Is cyberchondria a new transdiagnostic digital compulsive syndrome? A systematic review of the evidence. Comp Psych 2020; 99: 152167.
[11] Starcevic V, Berle D. Cyberchondria: towards a better understanding of excessive health-related Internet use. Expert Rev Neurother 2013; 13(2): 205-13.
[12] Kaess M, Parzer P, Brunner R, et al. Pathological Internet Use Is on the Rise Among European Adolescents. J Adolesc Health 2016; 59(2): 236-9.
[13] Kuss DJ, Griffiths MD, Karila L, Billieux J. Internet addiction: a systematic review of epidemiological research for the last decade. Curr Pharm Des 2014; 20(25): 4026-52.
[14] Volpe E A U, Dell’Osso B, Fiorillo A, Mucic D. Internet-related psychopathology: clinical phenotypes and perspectives in an evolving field 2015.
[15] Carli V, Durkee T, Wasserman D, et al. The association between pathological internet use and comorbid psychopathology: a systematic review. Psychopathology 2013; 46(1): 1-13.
[16] Reiner I, Tibubos AN, Hardt J, Müller K, Wölfling K, Beutel ME. Peer attachment, specific patterns of internet use and problematic internet use in male and female adolescents. Eur Child Adolesc Psychiatry 2017; 26(10): 1257-68.
[17] Derbyshire KL, Lust KA, Schreiber LR, et al. Problematic Internet use and associated risks in a college sample. Compr Psychiatry 2013; 54(5): 415-22.
[18] Yamada M, Sekine M, Tatsuse T, Asaka Y. Prevalence and associated factors of pathological Internet use and online risky behaviors among Japanese elementary school children. J Epidemiol 2020.
[19] Billieux J, Schimmenti A, Khazaal Y, Maurage P, Heeren A. Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research. J Behav Addict 2015; 4(3): 119-23.
[20] Błachnio A, Przepiórka A, Gorbaniuk O, et al. Cultural correlates of internet addiction. Cyberpsychol Behav Soc Netw 2019; 22(4): 258-63.
[21] Potenza MN. Non-substance addictive behaviors in the context of DSM-5. Addict Behav 2014; 39(1): 1-2.
[22] Jo YS, Bhang SY, Choi JS, Lee HK, Lee SY, Kweon Y-S. Clinical Characteristics of Diagnosis for Internet Gaming Disorder: Comparison of DSM-5 IGD and ICD-11 GD Diagnosis. J Clin Med 2019; 8(7): 945.
[23] Diagnostic and Statistical Manual of Mental Disorders 5th ed. 2013.
[24] Greenfield DN. Treatment considerations in internet and video game addiction: A qualitative discussion. Child Adolesc Psychiatr Clin N Am 2018; 27(2): 327-44.
[25] Feng W, Ramo DE, Chan SR, Bourgeois JA. Internet gaming disorder: Trends in prevalence 1998-2016. Addict Behav 2017; 75: 17-24.
[26] Greeven A, van Balkom AJLM, van der Leeden R, Merkelbach JW, van den Heuvel OA, Spinhoven P. Cognitive behavioral therapy versus paroxetine in the treatment of hypochondriasis: an 18-month naturalistic follow-up. J Behav Ther Exp Psychiatry 2009; 40(3): 487-96.
[27] Lee S-Y, Lee HK, Choo H. Typology of Internet gaming disorder and its clinical implications. Psychiatry Clin Neurosci 2017; 71(7): 479-91.
[28] Mihara S, Higuchi S. Cross-sectional and longitudinal epidemiological studies of Internet gaming disorder: A systematic review of the literature. Psychiatry Clin Neurosci 2017; 71(7): 425-44.
[29] Gentile DA, Bailey K, Bavelier D, Brockmyer JF, Cash H, Coyne SM. Internet gaming disorder in children and adolescents. Pediatrics 2017; 140(Supplement 2): S81-5.
[30] Gentile DA, Choo H, Liau A, et al. Pathological video game use among youths: a two-year longitudinal study. Pediatrics 2011; 127(2): e319-29.
[31] Nakayama H, Mihara S, Higuchi S. Treatment and risk factors of Internet use disorders. Psychiatry Clin Neurosci 2017; 71(7): 492-505.
[32] Saunders JB, Hao W, Long J, et al. Gaming disorder: Its delineation as an important condition for diagnosis, management, and prevention. J Behav Addict 2017; 6(3): 271-9.
[33] González-Bueso V, Santamaría JJ, Fernández D, Merino L, Montero E, Ribas J. Association between internet gaming disorder or pathological video-game use and comorbid psychopathology: A comprehensive review. Int J Environ Res Public Health 2018; 15(4): 668.
[34] Deleuze J, Nuyens F, Rochat L, Rothen S, Maurage P, Billieux J. Established risk factors for addiction fail to discriminate between healthy gamers and gamers endorsing DSM-5 Internet gaming disorder. J Behav Addict 2017; 6(4): 516-24.
[35] Deleuze J, Long J, Liu TQ, Maurage P, Billieux J. Passion or addiction? Correlates of healthy versus problematic use of videogames in a sample of French-speaking regular players. Addict Behav 2018; 82: 114-21.
[36] Billieux J, Flayelle M, Rumpf H-J, Stein DJ. High involvement versus pathological involvement in video games: A crucial distinction for ensuring the validity and utility of gaming disorder. Curr Addict Rep 2019; 6(3): 323-30.
[37] Rumpf HJ, Achab S, Billieux J, et al. Including gaming disorder in the ICD-11: The need to do so from a clinical and public health perspective. J Behav Addict 2018; 7(3): 556-61.
[38] King DL, Haagsma MC, Delfabbro PH, Gradisar M, Griffiths MD. Toward a consensus definition of pathological video-gaming: a systematic review of psychometric assessment tools. Clin Psychol Rev 2013; 33(3): 331-42.
[39] Bernaldo-de-Quirós M, Labrador-Méndez M, Sánchez-Iglesias I, Labrador FJ. Measurement instruments of online gaming disorder in adolescents and young people according to DSM-5 criteria: a systematic review. Adicciones 2019; 0(0): 1277.
[40] Pontes HM, Griffiths MD. Measuring DSM-5 internet gaming disorder: Development and validation of a short psychometric scale. Comput Human Behav 2015; 45: 137-43.
[41] Griffiths M. A ‘components’ model of addiction within a biopsychosocial framework. J Subst Use 2005; 10(4): 191-7.
[42] Demetrovics Z, Urbán R, Nagygyörgy K, et al. The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS One 2012; 7(5)e36417
[43] Pápay O, Urbán R, Griffiths MD, et al. Psychometric properties of the problematic online gaming questionnaire short-form and prevalence of problematic online gaming in a national sample of adolescents. Cyberpsychol Behav Soc Netw 2013; 16(5): 340-8.
[44] van Rooij AJ, Schoenmakers TM, van den Eijnden RJJM, Vermulst AA, van de Mheen D. Video game addiction test: validity and psychometric characteristics. Cyberpsychol Behav Soc Netw 2012; 15(9): 507-11.
[45] Lemmens JS, Valkenburg PM, Gentile DA. The internet gaming disorder scale. Psychol Assess 2015; 27(2): 567-82.
[46] King DL, Delfabbro PH, Wu AMS, et al. Treatment of Internet gaming disorder: An international systematic review and CONSORT evaluation. Clin Psychol Rev 2017; 54: 123-33.
[47] Bae S, Hong JS, Kim SM, Han DH. Bupropion shows different effects on brain functional connectivity in patients with Internet-based gambling disorder and internet gaming disorder. Front Psychiatry 2018; 9(APR): 130.
[48] Han DH, Hwang JW, Renshaw PF. Bupropion sustained release treatment decreases craving for video games and cue-induced brain activity in patients with Internet video game addiction. Exp Clin Psychopharmacol 2010; 18(4): 297-304.
[49] Han DH, Renshaw PF. Bupropion in the treatment of problematic online game play in patients with major depressive disorder. J Psychopharmacol 2012; 26(5): 689-96.
[50] Nam B, Bae S, Kim SM, Hong JS, Han DH. Comparing the effects of bupropion and escitalopram on excessive internet game play in patients with major depressive disorder. Clin Psychopharmacol Neurosci 2017; 15(4): 361-8.
[51] Song J, Park JH, Han DH, et al. Comparative study of the effects of bupropion and escitalopram on Internet gaming disorder. Psychiatry Clin Neurosci 2016; 70(11): 527-35.
[52] Atmaca M. A case of problematic internet use successfully treated with an SSRI-antipsychotic combination. Prog Neuropsychopharmacol Biol Psychiatry 2007; 31(4): 961-2.
[53] Dell’Osso B, Hadley S, Allen A, Baker B, Chaplin WF, Hollander E. Escitalopram in the treatment of impulsive-compulsive internet usage disorder: an open-label trial followed by a double-blind discontinuation phase. J Clinc Psych 2008; 69(3): 452-6.http://www.ncbi.nlm.nih.gov/pubmed/18312057
[54] Park JH, Lee YS, Sohn JH, Han DH. Effectiveness of atomoxetine and methylphenidate for problematic online gaming in adolescents with attention deficit hyperactivity disorder. Hum Psychopharmacol 2016; 31(6): 427-32.
[55] King DL, Delfabbro PH, Griffiths MD, Gradisar M. Assessing clinical trials of Internet addiction treatment: a systematic review and CONSORT evaluation. Clin Psychol Rev 2011; 31(7): 1110-6.
[56] Mihajlov M, Vejmelka L. Internet addiction: A review of the first twenty years. Psychiatr Danub 2017; 29(3): 260-72.
[57] Torres-Rodríguez A, Griffiths MD, Carbonell X, Oberst U. Treatment efficacy of a specialized psychotherapy program for Internet Gaming Disorder. J Behav Addict 2018; 7(4): 939-52.
[58] Zajac K, Ginley MK, Chang R, Petry NM. Treatments for Internet gaming disorder and Internet addiction: A systematic review. Psychol Addict Behav 2017; 31(8): 979-94.
[59] Li H, Wang S. The role of cognitive distortion in online game addiction among Chinese adolescents. Child Youth Serv Rev 2013; 35(9): 1468-75.
[60] Pallesen S, Lorvik IM, Bu EH, Molde H. An exploratory study investigating the effects of a treatment manual for video game addiction. Psychol Rep 2015; 117(2): 490-5.
[61] Kim PW, Kim SY, Shim M, Im CH, Shon YM. The influence of an educational course on language expression and treatment of gaming addiction for massive multiplayer online role-playing game (MMORPG) players. Comput Educ 2013; 63: 208-17.
[62] King D L, et al. Treatment of Internet gaming disorder: An international systematic review and CONSORT evaluation 2017.
[63] Li W, Garland EL, McGovern P, O’Brien JE, Tronnier C, Howard MO. Mindfulness-oriented recovery enhancement for internet gaming disorder in U.S. adults: A stage I randomized controlled trial. Psychol Addict Behav 2017; 31(4): 393-402.
[64] Kim SM, Han DH, Lee YS, Renshaw PF. Combined cognitive behavioral therapy and bupropion for the treatment of problematic on-line game play in adolescents with major depressive disorder. Comput Human Behav 2012; 28(5): 1954-9.
[65] Park SY, Kim SM, Roh S, et al. The effects of a virtual reality treatment program for online gaming addiction. Comput Methods Programs Biomed 2016; 129: 99-108.
[66] Young KS. Treatment outcomes using CBT-IA with Internet-addicted patients. J Behav Addict 2013; 2(4): 209-15.
[67] Zhang JT, Yao YW, Potenza MN, et al. Effects of craving behavioral intervention on neural substrates of cue-induced craving in Internet gaming disorder. Neuroimage Clin 2016; 12: 591-9.
[68] González-Bueso V, Santamaría JJ, Fernández D, et al. Internet Gaming Disorder in Adolescents: Personality, Psychopathology and Evaluation of a Psychological Intervention Combined With Parent Psychoeducation. Front Psychol 2018; 9: 787.
[69] Stevens MWR, King DL, Dorstyn D, Delfabbro PH. Cognitive-behavioral therapy for internet gaming disorder: A systematic review and meta-analysis. Clin Psychol Psychother 2019; 26(2): 191-203.
[70] Lee SH, Im JJ, Oh JK, et al. Transcranial direct current stimulation for online gamers: A prospective single-arm feasibility study. J Behav Addict 2018; 7(4): 1166-70.
[71] Petry NM, Zajac K, Ginley MK. Behavioral addictions as mental disorders: To be or not to be? Annu Rev Clin Psychol 2018; 14(1): 399-423.
[72] Gainsbury SM. Online Gambling Addiction: the Relationship Between Internet Gambling and Disordered Gambling. Curr Addict Rep 2015; 2(2): 185-93.
[73] Li W, Mills D, Nower L. The relationship of loot box purchases to problem video gaming and problem gambling. Addict Behav 2019; 97: 27-34.
[74] Griffiths M, Barnes A. Internet gambling: An online empirical study among student gamblers. Int J Ment Health Addict 2008; 6(2): 194-204.
[75] Griffiths M, Auer M, Research G. Aapproaches to understanding online versus offline gaming impacts. Casino and Gaming International 2011; 7(3): 45-8.
[76] Self exclusion from gambling - How to self exclude “BeGambleAware”. Available at https://www.begambleaware.org/safer-gambling/how-to-self-exclude/
[77] “GamStop - Gambling self-exclusion scheme”. Available at https://www.gamstop.co.uk/
[78] Hubert P, Griffiths MD. A Comparison of Online Versus Offline Gambling Harm in Portuguese Pathological Gamblers: An Empirical Study. Int J Ment Health Addict 2018; 16(5): 1219-37.
[79] Potenza MN, Wareham JD, Steinberg MA, et al. Correlates of at-risk/problem internet gambling in adolescents. J Am Acad Child Adolesc Psychiatry 2011; 50(2): 150-159.e3.
[80] Gerstein D, et al. Gambling impact and behavior study: Report to the National Gambling Impact Study Commission 1999.
[81] Toce-Gerstein M, Gerstein DR, Volberg RA. The NODS-CLiP: a rapid screen for adult pathological and problem gambling. J Gambl Stud 2009; 25(4): 541-55.
[82] Ferris J, Wynne H. The Canadian Problem Gambling Index: Final Report 2019.http://www.jogoremoto.pt/docs/extra/TECb6h.pdf
[83] Holtgraves T. Evaluating the problem gambling severity index. J Gambl Stud 2009; 25(1): 105-20.
[84] Potenza MN, Balodis IM, Derevensky J, et al. Gambling disorder. Nat Rev Dis Primers 2019; 5(1): 51.
[85] Grant JE, Kim SW, Hartman BK. A double-blind, placebo-controlled study of the opiate antagonist naltrexone in the treatment of pathological gambling urges. J Clin Psychiatry 2008; 69(5): 783-9.
[86] Kim SW, Grant JE, Adson DE, Shin YC. Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling. Biol Psychiatry 2001; 49(11): 914-21.
[87] Dannon PN, Lowengrub K, Musin E, Gonopolski Y, Kotler M. Sustained-release bupropion versus naltrexone in the treatment of pathological gambling: a preliminary blind-rater study. J Clin Psychopharmacol 2005; 25(6): 593-6.
[88] Toneatto T, Brands B, Selby P. A randomized, double-blind, placebo-controlled trial of naltrexone in the treatment of concurrent alcohol use disorder and pathological gambling. Am J Addict 2009; 18(3): 219-25.
[89] Grant JE, Potenza MN, Hollander E, et al. Multicenter investigation of the opioid antagonist nalmefene in the treatment of pathological gambling. Am J Psychiatry 2006; 163(2): 303-12.
[90] Potenza MN, Potenza MN, Hollander E. Pathological gambling and impulse control disorders. Neuropsychopharmacology: The 5th generation of 2002 2020.http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.525.9754
[91] Luquiens A, Tanguy M-L, Lagadec M, Benyamina A, Aubin H-J, Reynaud M. The Efficacy of Three Modalities of Internet-Based Psychotherapy for Non-Treatment-Seeking Online Problem Gamblers: A Randomized Controlled Trial. J Med Internet Res 2016; 18(2): e36.
[92] Menchon J M, Mestre-Bach G, Steward T, Fernández-Aranda F, Jiménez-Murcia S. An overview of gambling disorder: From treatment approaches to risk factors [version 1; referees: 2 approved] 2018.
[93] Petry N M, Ginley M K, Rash C J. A systematic review of treatments for problem gambling. Psychol Addict Behav 2017; 31(8): 951.
[94] Ginley MK, Rash CJ, Petry NM. Psychological interventions in gambling disorder.Gambling Disorder 2019; 181-94.
[95] Fergus TA, Russell LH. Does cyberchondria overlap with health anxiety and obsessive-compulsive symptoms? An examination of latent structure and scale interrelations. J Anxiety Disord 2016; 38: 88-94.
[96] McMullan RD, Berle D, Arnáez S, Starcevic V. The relationships between health anxiety, online health information seeking, and cyberchondria: Systematic review and meta-analysis. J Affect Disord 2019; 245: 270-8.
[97] Norr AM, Albanese BJ, Oglesby ME, Allan NP, Schmidt NB. Anxiety sensitivity and intolerance of uncertainty as potential risk factors for cyberchondria. J Affect Disord 2015; 174: 64-9.
[98] Starcevic V, Baggio S, Berle D, Khazaal Y, Viswasam K. Cyberchondria and its Relationships with Related Constructs: a Network Analysis. Psychiatr Q 2019; 90(3): 491-505.
[99] McElroy E, Shevlin M. The development and initial validation of the cyberchondria severity scale (CSS). J Anxiety Disord 2014; 28(2): 259-65.
[100] Fallon BA, Ahern DK, Pavlicova M, Slavov I, Skritskya N, Barsky AJ. A randomized controlled trial of medication and cognitive-behavioral therapy for hypochondriasis. Am J Psychiatry 2017; 174(8): 756-64.
[101] Pandey AK, Kunkulol RR. Cyber pornography addiction amongst medical students of western rural maharashtra Int J Clin Biomed Res 2017(8): 10-4. [Accessed: Sep. 30, 2019. [Online].]; Available: https://www.sumathipublications.com/index.php/ijcbr/article/view/139
[102] Cooper A, Putnam DE, Planchon LA, Boies SC. Online sexual compulsivity: Getting tangled in the net. Sex Addict Compulsivity 1999; 6(2): 79-104.
[103] Vaillancourt-Morel M-P, Blais-Lecours S, Labadie C, Bergeron S, Sabourin S, Godbout N. Profiles of cyberpornography use and sexual well-being in adults. J Sex Med 2017; 14(1): 78-85.
[104] Kafka MP. Hypersexual disorder: a proposed diagnosis for DSM-V. Arch Sex Behav 2010; 39(2): 377-400.
[105] Kraus SW, Meshberg-Cohen S, Martino S, Quinones LJ, Potenza MN. Treatment of compulsive pornography use with naltrexone: A case report. Am J Psychiatry 2015; 172(12): 1260-1.
[106] Eleuteri S, Tripodi F, Petruccelli I, Rossi R. Simonelli, “Questionnaires and scales for Cyberpsychology: the evaluation of the online sexual activities: A review of 20 years of research. J Psychosoc Res Cybersp 2014; 8(1): 2014.
[107] Delmonico D. Internet Sex Screening Test [Retrieved May 15, 2003.];http://www.sexhelp.com
[108] Delmonico D, Miller J. The internet sex screening test: A comparison of sexual compulsives versus non-sexual compulsives. Sex Relationship Ther 2003; 18(3): 261-76.
[109] Bostwick JM, Bucci JA. Internet sex addiction treated with naltrexone. Mayo Clin Proc 2008; 83(2): 226-30.
[110] Capurso NA. Naltrexone for the treatment of comorbid tobacco and pornography addiction. Am J Addict 2017; 26(2): 115-7.
[111] Gola M, Potenza MN. Paroxetine treatment of problematic pornography use: A case series. J Behav Addict 2016; 5(3): 529-32.
[112] Sniewski L, Farvid P, Carter P. The assessment and treatment of adult heterosexual men with self-perceived problematic pornography use: A review. Addict Behav 2018; 77: 217-24.
[113] Patchin JW, Hinduja S. Bullies move beyond the schoolyard: A preliminary look at cyberbullying. Youth Violence Juv Justice 2006; 4(2): 148-69.
[114] Schneider SK, O’Donnell L, Stueve A, Coulter RWS. Cyberbullying, school bullying, and psychological distress: a regional census of high school students. Am J Public Health 2012; 102(1): 171-7.
[115] Smith PK, Mahdavi J, Carvalho M, Fisher S, Russell S, Tippett N. Cyberbullying: its nature and impact in secondary school pupils. J Child Psychol Psychiatry 2008; 49(4): 376-85.
[116] Bottino S M B, Bottino C M C, Regina C G, Correia A V L, Ribeiro W S. Cyberbullying e saúde mental dos adolescentes: Revisão sistemática 2015.
[117] Elipe P, Mora-Merchán JA, Nacimiento L. Development and validation of an instrument to assess the impact of cyberbullying: The cybervictimization emotional impact scale. Cyberpsychol Behav Soc Netw 2017; 20(8): 479-85.
[118] Garaigordobil M. Psychometric properties of the cyberbullying test, a screening instrument to measure cybervictimization, cyberaggression and cyberobservation. J Interpers Violence 2017; 32(23): 3556-76.
[119] Hutson E, Kelly S, Militello LK. Systematic review of cyberbullying interventions for youth and parents with implications for evidence-based practice. Worldviews Evid Based Nurs 2018; 15(1): 72-9.
[120] Ortega-Barón J, Buelga S, Ayllón E, Martínez-Ferrer B, Cava M-J. Effects of intervention program prev@cib on traditional bullying and cyberbullying. Int J Environ Res Public Health 2019; 16(4): 527.
[121] Brand M, Laier C, Young KS. Internet addiction: coping styles, expectancies, and treatment implications. Front Psychol 2014; 5: 1256.
[122] Griffiths MD, Szabo A. Is excessive online usage a function of medium or activity? An empirical pilot study. J Behav Addict 2014; 3(1): 74-7.
[123] Laconi S, Tricard N, Chabrol H. Differences between specific and generalized problematic Internet uses according to gender, age, time spent online and psychopathological symptoms. Comput Human Behav 2015; 48(C): 236-44.
[124] Montag C, Bey K, Sha P, et al. Is it meaningful to distinguish between generalized and specific Internet addiction? Evidence from a cross-cultural study from Germany, Sweden, Taiwan and China. Asia-Pac Psychiatry 2015; 7(1): 20-6.
[125] Pontes HM, Szabo A, Griffiths MD. The impact of Internet-based specific activities on the perceptions of Internet addiction, quality of life, and excessive usage: A cross-sectional study. Addict Behav Rep 2015; 1: 19-25.
[126] Zhao H, Tian W, Xin T. The development and validation of the online shopping addiction scale. Front Psychol 2017; 8(MAY): 735.
[127] Dittmar H, Long K, Bond R. When a better self is only a button click away: Associations between materialistic values, emotional and identity–related buying motives, and compulsive buying tendency online. J Soc Clin Psychol 2007; 26(3): 334-61.
[128] Kukar-Kinney M, Ridgway NM, Monroe KB. The relationship between consumers’ tendencies to buy compulsively and their motivations to shop and buy on the internet. J Retailing 2009; 85(3): 298-307.
[129] McElroy SL, Keck PE, Pope HG, Smith JM, Strakowski SM. Compulsive buying: a report of 20 cases 2019.http://www.ncbi.nlm.nih.gov/pubmed/8071278
[130] Neuner M, Raab G, Reisch LA. Compulsive buying in maturing consumer societies: An empirical re-inquiry. J Econ Psychol 2005; 26(4): 509-22.
[131] Trotzke P, Starcke K, Müller A, Brand M. Pathological buying online as a specific form of internet addiction: A model-based experimental investigation. PLoS One 2015; 10(10): e0140296.
[132] Müller A, Steins-Loeber S, Trotzke P, Vogel B, Georgiadou E, de Zwaan M. Online shopping in treatment-seeking patients with buying-shopping disorder. Compr Psychiatry 2019; 94152120
[133] Griffiths MD. Griffiths, M.D. Behavioural addictions: An issue for everybody? J Work Learn 1996; 8(3): 19-25.
[134] Dell’Osso B, Allen A, Altamura AC, Buoli M, Hollander E. Impulsive-compulsive buying disorder: clinical overview. Aust N Z J Psychiatry 2008; 42(4): 259-66.
[135] Soares C, Fernandes N, Morgado P. A review of pharmacologic treatment for compulsive buying disorder. CNS Drugs 2016; 30(4): 281-91.
[136] Lourenço Leite P, Pereira VM, Nardi AE, Silva AC. Psychotherapy for compulsive buying disorder: a systematic review. Psychiatry Res 2014; 219(3): 411-9.
[137] King DL, Delfabbro PH, Doh YY, et al. Policy and prevention approaches for disordered and hazardous gaming and internet use: An international perspective. Prev Sci 2018; 19(2): 233-49.
[138] Vondráčková P, Gabrhelík R. Prevention of internet addiction: A systematic review. J Behav Addict 2016; 5(4): 568-79.
[139] Throuvala MA, Griffiths MD, Rennoldson M, Kuss DJ. School-based prevention for adolescent internet addiction: Prevention is the key. A systematic literature review. Curr Neuropharmacol 2019; 17(6): 507-25.
[140] Ang RP, Chong WH, Chye S, Huan VS. Loneliness and generalized problematic Internet use: Parents’ perceived knowledge of adolescents’ online activities as a moderator. Comput Human Behav 2012; 28(4): 1342-7.
[141] Busch V, De Leeuw RJJ, Schrijvers AJP. Results of a multibehavioral health-promoting school pilot intervention in a Dutch secondary school. J Adolesc Health 2013; 52(4): 400-6.
[142] Jang MH, Ji ES. Gender differences in associations between parental problem drinking and early adolescents’ internet addiction. J Spec Pediatr Nurs 2012; 17(4): 288-300.
[143] Lan CM, Lee YH. The predictors of internet addiction behaviours for Taiwanese elementary school students. Sch Psychol Int 2013; 34(6): 648-57.
[144] Lee S-Y, Kim MS, Lee HK. Prevention strategies and interventions for internet use disorders due to addictive behaviors based on an integrative conceptual model. Curr Addict Rep 2019; 6(3): 303-12.
[145] Lin M-P, Ko H-C, Wu JY-W. Prevalence and psychosocial risk factors associated with internet addiction in a nationally representative sample of college students in Taiwan. Cyberpsychol Behav Soc Netw 2011; 14(12): 741-6.
[146] Young-Kwon Bae, and Seong-Sik Kim, “A learning system for internet addiction prevention IEEE International Conference on Advanced Learning Technologies 2004; 836-7.
[147] Yang MK, Oh WO, Yang MK, Oh WO. Effects of the internet game addiction prevention educational program on self-control and time spent on internet games by elementary school students. Child Health Nurs Research 2007; 13(3): 282-90.
[148] Kok G, Schaalma H, Ruiter RAC, van Empelen P, Brug J. Intervention mapping: protocol for applying health psychology theory to prevention programmes. J Health Psychol 2004; 9(1): 85-98.
[149] Alavi SS, Ferdosi M, Jannatifard F, Eslami M, Alaghemandan H, Setare M. Behavioral addiction versus substance addiction: Correspondence of psychiatric and psychological views. Int J Prev Med 2019; 3(4): 290-4. Available: http://www.ncbi.nlm.nih.gov/pubmed/22624087
[150] Truzoli R, Osborne LA, Romano M, Reed P. The relationship between schizotypal personality and internet addiction in university students. Comput Human Behav 2016; 63: 19-24.
[151] Reed P, Romano M, Re F, et al. Differential physiological changes following internet exposure in higher and lower problematic internet users. PLoS One 2017; 12(5)e0178480
[152] Reed P, Osborne LA, Romano M, Truzoli R. Higher impulsivity after exposure to the internet for individuals with high but not low levels of self-reported problematic internet behaviours. Comput Human Behav 2015; 49: 512-6.
[153] Kuss DJ, van Rooij AJ, Shorter GW, Griffiths MD, van de Mheen D. Internet addiction in adolescents: Prevalence and risk factors. Comput Human Behav 2013; 29(5): 1987-96.
[154] Dalbudak E, Evren C, Aldemir S, Taymur I, Evren B, Topcu M. The impact of sensation seeking on the relationship between attention deficit/hyperactivity symptoms and severity of Internet addiction risk. Psychiatry Res 2015; 228(1): 156-61.
[155] Donati MA, Chiesi F, Ammannato G, Primi C. Versatility and addiction in gaming: the number of video-game genres played is associated with pathological gaming in male adolescents. Cyberpsychol Behav Soc Netw 2015; 18(2): 129-32.
[156] Ha Y-M, Hwang WJ. Gender differences in internet addiction associated with psychological health indicators among adolescents using a national web-based survey. Int J Ment Health Addict 2014; 12(5): 660-9.
[157] Koo H-Y. Effects of a prevention program for media addiction on television addiction, internet addiction, cellular addiction, and impulsiveness in elementary school students. Child Health Nurs Res 2013; 19(4): 270.
[158] Shek DTL, Sun RCF. The Project P.A.T.H.S. in Hong Kong: development, training, implementation, and evaluation. J Pediatr Adolesc Gynecol 2013; 26(3)(Suppl.): S2-9.
[159] Busiol D, Lee TY. Prevention of Internet Addiction: The PATHS Program 2015; 185-93.
[160] Lee SJ. Parental restrictive mediation of children’s internet use: Effective for what and for whom? New Media Soc 2013; 15(4): 466-81.
[161] Espelage D L, Hong J S. Cyberbullying prevention and intervention efforts: current knowledge and future directions. Can J Psychiatry 2017; 62(6): 374-80.
[162] Da Zhan J, Chuan Chan H, Da J, Chuan H. Government regulation of online game addiction. Comm Assoc Inform Syst 2012; 30(13): 187-98.
[163] Gámez-Guadix M, Calvete E. Assessing the relationship between mindful awareness and problematic internet use among adolescents. Mindfulness (N Y) 2016; 7(6): 1281-8.
[164] Sapthiang S, Van Gordon W, Shonin E. Mindfulness in schools: A health promotion approach to improving adolescent mental health. Int J Ment Health Addict 2019; 17(1): 112-9.
[165] Łukawski K, Rusek M, Czuczwar SJ. Can pharmacotherapy play a role in treating internet addiction disorder? Expert Opin Pharmacother 2019; 20(11): 1299-301.
[166] Przepiorka AM, Blachnio A, Miziak B, Czuczwar SJ. Clinical approaches to treatment of Internet addiction. Pharmacol Rep 2014; 66(2): 187-91.
[167] Liu C, Liao M, Smith DC. An empirical review of internet addiction outcome studies in china. Res Soc Work Pract 2011; 22(3)
[168] Liu J, Nie J, Wang Y. Effects of group counseling programs, cognitive behavioral therapy and sports intervention on internet addiction in east Asia: A systematic review and meta-analysis. Int J Environ Res Public Health 2017; 14(12): E1470.