Two Cases of Excessive Internet Use with Comorbid Family Relationship Problems

Abstract

Although the internet is used effectively and beneficially in every aspect of life, several users have been experiencing some problems due to excessive and uncontrolled use. While the term “internet addiction” still remains controversial, disturbed family relationships are considered to be a diagnostic criterion. The use of the internet, even in non-excessive levels, is associated with disturbance in family and social life. As considering from systemic point of view; while family relationships may be disturbed with internet addiction, people who have problems with their family relationships also may use internet excessively. This case report is composed of both the cases with excessive internet usage and those who had problems in complying with the changes in their family systems following the decrease in duration of internet usage during the treatment process.

Introduction

Although the internet is used effectively and beneficially in every aspect of life, several users have been experiencing some problems due to excessive and uncontrolled use. While the term “internet addiction” still remains controversial, disturbed family relationships are considered to be a diagnostic criterion (1,2,3).

In an observational study in families who were without any previous computer experience and were given a computer and software and free access to the internet, it was found that greater use of the internet was associated with disturbance in family relationships and decline in the size of the social circle. Even non-excessive use of the internet was associated with increased loneliness and depression, especially in adolescents (4).

Excessive use of the internet causes disturbed family relationships, however, people with disturbed family relationships may also develop internet addiction. Therefore, making a causal relationship between excessive internet usage and disturbed family relationships may not be appropriate (5). In this paper, we present two cases of patients with internet addiction who were admitted to Bakırkoy Mental Health and Neurological Diseases Training and Research Hospital Internet Addiction Outpatient Clinic.

Case 1: Porn Viewing Addiction

US is a 30-year-old, divorced, primary school graduate male who works as a labor and has one child. He lives with his parents and six-year-old child. The patient complains of watching online porn movies. He spends incessant amounts of time to watch various types of internet porn from 8:00 am to 5:00 pm, at least 4 days of a week. In addition, he has a chronic neck pain because of internet over use. The patient was watching porn only in a cyber café. He engaged in excessive internet usage for eight years. In the meantime, he changed more than twenty jobs, because he did not go to work for several times or left his job in working hours due to the intensive impulse to internet use. Approximately one and a half years ago, his wife left home after seven years of marriage because of irretrievable breakdown of their marriage. He reported sexual aversion and dissatisfaction with his wife, especially after the he started excessive porn watching. He participated in almost no social activity with his family. He was spending all his time viewing on-line porn. Psychiatric examination revealed depressed affect. He felt intense guilt and had suicidal thoughts. The scores on the Beck Depression Inventory and the Beck Anxiety Inventory were 60 and 37, respectively. The Roschach test showed neurotic protocol with significant obsessive and paranoid characteristics. The Minnesota Multiphasic Personality Inventory (MMPI) showed low ego strength, paranoid features and inappropriate defensive behaviors. It was also noted that thought disorder might be detected. Treatment motivation of the patient was high and treatment targeting total abstinence of internet use was started in the first session. Cognitive behavioral therapy sessions were conducted in every two weeks. Medical treatment was started with naltrexone 50 mg daily in the first session. After the first session, fluvoxamine was initiated and titrated to 300 mg daily.

Case 2: The Case of Generalized Internet Addiction

VO is a forty-nine-year-old, married for twenty years, high school graduate male who works as a civil servant and has three children. He lives with his wife and children. Although his professional life was regular, he was spending his all spare time with entertaining internet games (rummikub, etc.), chatting with women whom he met on the internet, spending long times on various web sites without any certain aim, watching online porn movies and uploading files. After work, he was spending 1 to 2 hours in a cyber café and he was using the internet at home for 4 to 5 hours without having any conversation with his wife or children. The patient told that he had spent his last 5 years doing so and he wanted to share more time with his wife and children. The Rorschach test showed a high level of anxiety, low self-confidence personality traits. Depressive symptoms were also present, but there were no active psychotic symptoms. The MMPI showed worry and hopelessness. He had not any psychiatric comorbidity. No medication was prescribed. Cognitive behavioral therapy with predominantly behavioral techniques was given to the patient, who was highly motivated for the treatment. The patient could control the use of the internet after the end of the third session. However, the patient reported another problem after the end of the third session. When he reduced his time on internet he had much time and wanted to share this time with his wife. Although his wife was encouraging him for the treatment at the beginning, she refused to spend time with the patient and said “I do not want to see you, just stay on the internet”, “stay at your room alone”.

Discussion

Motivational interviews have a major role in the treatment of internet addiction, which is also a behavioral addiction (6). We used cognitive behavioral therapy with intensive behavioral techniques starting from the first session, as our patients were highly motivated for the treatment.

Case 1 was addicted to watching internet porn, instead of generalized use. Considering the role of dopamine in the addiction by affecting the brain reward center, treatment with opiate antagonist-naltrexone 50 mg daily was initiated in order to block opiates’ capacity to augment dopamine release (7).

After the analysis of advantages-disadvantages for our patient, we concluded on a treatment approach targeting complete abstinence from the internet. Although the patient did not receive antidepressant treatment, depressive symptoms were surprisingly resolved and the scores on the Beck Depression Inventory and the Beck Anxiety Inventory were 8 and 6, respectively after the avoidance of internet use. At subsequent sessions, due to the compulsive nature of the problem, fluvoxamine was initiated and titrated to 300 mg daily in order to treat intensive impulses for the use of the internet (8).

The patient had been followed up for ten months in our outpatient clinic. He had no relapses except only one day duration of porn viewing in the third month of the treatment. Naltrexone dosage was decreased to one in every other day after 3 months and then one in every three days after 5 months. He used naltrexone only when an intense impulse for porn viewing arised after 7 months. Fluvoxamine treatment was maintained at 300 mg daily.

Case 2 achieved to control the use of the internet after three cognitive behavioral therapy sessions that were held every two weeks. The patient had no comorbid disease, thus, no medical treatment was initiated. After the patient achieved to control the use of the internet, his wife was invited to attend the fourth session. At the end of the interview, it was discovered that the couple did not have effective communication skills and their problems that they postponed to talk on emerged after when they had ‘new’ regulated hours of internet use. The patient’s wife was repetitively talking about the sad moments she had in the previous years. With the treatment of internet addiction, as if their postponed problems came up, the patient started to spend his time in a disturbed mood alone in his bedroom or kitchen even if he did not use the internet. The patient and his wife were informed about the importance of improving communication skills for the maintenance of new internet use hours. After the patient and his wife accepted the rational of treatment, couple therapy was initiated.

In their case report, Rodrigues et al. (2004) noted that coping skills to deal with family issues were improved following cognitive-behavioral therapy (CBT) and CBT-related motivational interviews (9). In our cases, changes in family systems were also detected.

Especially in adult patients with treatment motivation, encouragement for public internet use should be attempted. Some of the basic and useful methods can be utilized, such as making patients to use internet in public places (with family and friends) instead of using it alone, restricting internet hours and days, determining locations for internet use, providing the computer screen visible to others (i. e. colleagues), setting the pictures of important people, (e. g. family members) as screen saver (10).

The internet is accepted as an indispensable part of modern life, therefore, problems may not be noticed by the relatives of patients. In their history, it is remarkable that changes in the attitudes of their relatives start after their uncontrolled use of the internet. In such cases, family members should be informed about healthy internet use and, patients’ adherence to therapy should be ensured with their family members (11).

In the treatment of patients with disturbed and affected family and marital relationships with internet addiction, involvement of family members may be needed. Educating the family about the addictive effects of the internet, encouraging the family members for supportive actions, such as reducing blame on the addict for their behaviors, improving communication on the family issues that drive the patients to use the internet in order to meet psychological demands, acquisition of new hobbies by the addict, having a long-term vacation, and paying attention to the feelings of the patient may be helpful in overcoming the addiction problem (1).

To establish a causal relationship between communication problems and uncontrolled use of the internet is difficult, however, internet addiction may lead to negative consequences for couple relationships and health status of the patients (11). Besides, from the systemic perspective of family system, there is no linear relationship but always a circular causality is held. Therefore, in couples therapy we insist to ask: “how does it work, how come that happens”.

Online communication with a third person about current relationship problems to obtain relief, expression of the negative feelings for the partner easily and gaining an appreciation from the other person, and monotony of sexual life among couples may drive a person to cybersex, pornography or unfaithfulness (12,13); or cybersex and unfaithfulness may occur as a result of internet addiction.

In conclusion, conflicts with family members (parents, partner) due to excessive internet use must be inquired in patients with suspected internet addiction. Regulation of sexual functions or disturbed sexual relationships between couples due to cyber chatting is crucial for the maintenance of positive results in patients treated for cybersex and online pornography addiction. For such cases, couples therapies given by physicians, who are specialized on couple and sexual therapies, may be required and useful.