Marks Psychiatry

Clinically, health care providers consider heavy drinking to be more than 2 drinks a day totaling 14 or more drinks per week. But what is a drink? In general one drink is one 5oz glass of wine 1oz of liquor or 12oz of beer. Heavy alcohol use can have serious health consequences.

Let’s look at Larry

Larry comes to see me because he has been depressed and wants to take medication. As usual, I get new patient bloodwork and see that Larry has elevated liver enzymes indicating liver inflammation. When I see this, I usually think alcohol or overuse of Tylenol products.

When I first saw Larry he told me he drank 1-2 glasses of wine with dinner. With further questioning, he admits that he consistently drinks 2 glasses of wine each night. When I ask for details, he tells me his “glass” is a 10oz beverage glass that his wife calls his chalice.

So Larry was really having the equivalent of 4 drinks a night. Larry did not want to switch to a smaller glass as he felt the use of his special glass was part of his evening ritual. He reluctantly cut back to one glass that he filled to the lip, then he slurped down to a level that allowed him to pick it up without spilling. Clearly Larry is trying to maximize his one glass, but at least it’s one.

Larry was also concerned about a chronic cough he’d had for months and was afraid it was cancer. I suggested he see his internist for a medical work up.

Months later…
Larry’s liver enzymes return to normal. His chronic cough turned out to be a combination of gastric reflux and allergies. He was told to reduce his alcohol intake to help with the reflux. He cut back by filling the chalice to ¾ full and skipping a night here and there. After several weeks his cough nearly diminished.

Larry does not refer to a specific person, but real situations I have seen many times. He illustrates how people can unknowingly consume heavy quantities of alcohol putting themselves at risk to develop medical problems.

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Theresa H. M. Moore of the University of Bristol in England and her colleagues have conducted research which concluded that having used marijuana at any point in your life increases the risk of having a psychotic episode by 40%. This was more than twice the risk of those who have never smoked marijuana. The heavier the use, greater the chance of developing psychosis. Heavy use was defined as smoking more than 100 times in a lifetime or currently smoking marijuana weekly.There study does not definitively establish a causal relationship between marijuana and psychosis, but it’s about the best that it gets because the only way to establish causality would be to do a randomized, controlled study having some people smoke marijuana to see what happens later in life. This type of study would be unethical.

I found this study interesting because I often hear people say “there’s nothing wrong with marijuana” or “marijuana should be legal.” These findings illustrate the fact that marijuana is a drug that can have very negative effects on your life, for the rest of your life.

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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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