Marks Psychiatry

We used to believe that we were born with all of the new brain cells we would have for life. Once we reached adulthood, we can’t learn any more new tricks. Actually it’s not quite that way, but in general neural stem cells (undifferentiated brain cells, like fetal brain cells) were thought to only exist in fetal or neonatal brain. This is why brain injury to an adult has such a devastating affect.

But, new research conducted by Fred Gage PhD of the Salk Institute shows that neural stem cells exist in the adult brain and they can multiply, differentiate and join the rest of the mature brain cells. This process, called neurogenesis (think nerve beginning or nerve birth) can happen throughout our lives.

Aging slows neurogenesis, but Dr. Gage has also found that physical activity enhances the process. Chronic stress suppresses neurogenesis temporarily, possibly for months.

These findings have tremendous implications for finding ways to promote growth of damaged brain and spinal cord cells.

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Two studies published in the New England Journal of Medicine in June 2007 reported on the risks of birth defects when women took selective serotonin-reuptake inhibitors (SSRIs) during pregnancy (sources: Louik, C et. al NEJM Volume 356:2675-2683 June 28, 2007 Number 26 and Alwan S. et al. NEJM Volume 356:2684-2692 June 28, 2007 Number 26). Both articles conclude that SSRIs taken during the first trimester of pregnancy increase the risk of certain birth defects, but the increased risk was considered to be small. Given that untreated depression carries its own risks to the unborn baby, the researchers were said to have considered these finding reassuring in terms of weighing the risks and benefits of treating depressed women during pregnancy.

Further analysis of their data showed that women with a body mass index of 30 and greater showed an even further increase in risk defects. For example, obesity plus SSRI use resulted in 3.5 times greater chance of certain heart defects and 5.9 greater chance of certain cranial defects. These numbers were in comparison to non-obese women taking SSRIs.

We don’t know why having more body fat makes a difference, but we do know SSRIs are absorbed more quickly in fat. Thus, it would stand to reason that perhaps more drug is absorbed and/or retained and this may amplify the effects of the drugs.

Women taking antidepressants and considering getting pregnant should consult with their doctor about whether to continue on the medication during pregnancy.

Your body mass index is calculated based on you height and weight. Want to know yours? Get you BMI

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Some researchers still question whether problematic Internet use should be considered a disease. An argument against this is that the internet can be a means to satisfy other compulsive behaviors such as gambling, shopping, pornography use, etc. So it’s a medium of exchange to fuel other addictions and is not the source of the addiction. That is, if a person has a shopping compulsion and spends hours shopping on the Internet, they are “addicted” to shopping and not the Internet. Others will say that the Internet itself provides its own level of rewarding experience such that those addicted to the Internet use the internet simply for the experience of being online.

So, what’s wrong with enjoying being online? After all, there is a vast amount of information available over the Internet and it is easy to spend loads of time reading and surfing. How is this different from watching television? Although theoretically, the Internet could be seen as a better use of time than television because it can be a research tool providing useful information, it is the interactive nature of the Internet and the sheer volume of information available that makes it more dangerous to some than sitting in front of the television.

Unfortunately, we haven’t definitively established how much is too much. In a review article on problematic Internet use (source: Liu T, Potenza MN, CNS Spectr. Vol 12, No. 6, 2007), the author cites several studies where they used time as a measure of social and occupational impairment. In one study those considered to have an Internet addiction spent 38.5 hours/wk on the Internet for non-work related activities compared to 4.9 hours/wk for the non-problematic user.

How does one find 38 extra hours in the week to spend on the internet?

So how do you know if you spend too much time on the internet? Diagnostic criteria aside, I think the most practical way is to examine how much of an impact it has on your personal and work life. Are you less efficient at work, missing deadlines, being warned not to surf, being distracted in meetings because you’re thinking of what you’re going to surf next? Are you spending less time with friends, losing sleep because you’re up late on the Internet? Is your spouse or significant other threatening to throw away your Blackberry? Are you getting more headaches, neck pain or finger cramps because of too much time at your keyboard?

As for treatment, the Center for Internet Addiction Recovery is a web-based treatment that some have found to be very helpful (despite that it uses the Internet to treat an Internet problem). There are also some more traditional treatment centers that use an addiction model and 12 step recovery program. Some research has suggested antidepressants may be helpful.

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In Psychiatry we define addictions as habitual usage of something that creates physical and psychological dependence. Furthermore, when the activity is discontinued, the individual experiences withdrawal. Substances such as alcohol and drugs fall under this addiction model. When considering behaviors such as sexual activity, shopping, eating and more recently internet use, these behaviors don’t quite meet the biological model of addiction, but researchers have recognized that people can fall into a similar pattern of escalating the behavior while having trouble discontinuing it despite experiencing negative consequences. These behaviors can more broadly fall under impulse-control disorders.

The idea of a computer addiction first emerged in the 70’s and 80’s, however with the introduction of Broadband, it is now estimated that over 200 million people in the US use the internet. This equates to almost 70% of the population (source: Liu T, Potenza MN, CNS Spectr. Vol 12, No. 6, 2007). A few people have proposed criteria for diagnosing Internet Addiction as a disease entity.

The following is diagnostic criteria proposed by KS Young in an article published in Cyberpsychol Behav 1998; 11:237-244. A person must have 5 or more of these 8 criteria:

1. Is preoccupied with the internet (thinks about previous online activity or anticipates the next online session)
2. Needs to use the Internet with increased amounts of time in order to achieve satisfaction
3. Has made unsuccessful efforts to control, cut back or stop Internet use
4. Is restless, moody, depressed, or irritable when attempting to cut down or stop Internet use
5. Has stayed online longer than originally intended
6. Has jeopardized or risked the loss of significant relationship, job, educational, or career opportunity because of the internet
7. Has lied to family members, therapists, or others to conceal the extent of involvement with the Internet
8. Uses the Internet as a way to escape problems or to relieve a dysphoric mood (such as feelings of helplessness, guilt, anxiety, depression).

Young used the criteria for substance dependence as a model with some criticism as the behavior does not involve the physiological dependence I previously mentioned. Other researchers have developed more broad criteria, but Internet Addiction or Problematic Internet Use still has not been accepted into standard practice.

To be continued…

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