Treatments

As with other addictions or dependencies, the most effective treatments are a combination of psychopharmacology and psychotherapy. Twelve-step programs have also shown promise.

The role of the neurotransmitters norepinephrine and dopamine in addiction to substances is widely accepted. When the addiction is a behavior and not a drug, research has shown dopamine and serotonin involvement. Selective serotonin reuptake inhibitors and atypical antipsychotic medications alone and in combination have therapeutic effects in published clinical trials and case studies. Other treatment options studied for impulse control disorders include lithium and mood stabilizers, opioid antagonists, tricyclic antidepressants, selective serotonin and norepinephrine reuptake inhibitors, benzodiazepines, the norepinephrine dopamine reuptake inhibitor bupropion, and β-blockers. Although not necessarily related to all MMORPGs, the sexual nature of some games was noted. Cybersex has been called the “crack cocaine of sex addiction,” and the addiction model of treatment is applied therapeutically. The function of the monoamine neurotransmitters, serotonin, norepinephrine, and dopamine, are used as the model for treating addictions and other compulsive behaviors. This area of research appears to be the future of all pharmacologic psychiatric treatment and is developing rapidly.

Implications for practice
Wieland provides recommendations for nurse practitioner psychotherapists, including cognitive behavioral therapy (CBT) and other therapies that increase insight into a person’s behaviors. She also recommends psychopharmacology, the use of 12-step support groups, and other available addictions treatments. The aforementioned recent American Psychiatric Association news release describes the need for research in this area to revise the DSM-V. Perhaps the most difficult to understand issue about any type of addiction is the apparent indifference of the addict toward how his or her behavior affects those around him or her. It is easy to develop a countertransference toward the addict, and this attitude can never be therapeutic. Understanding the chronic nature of addiction or dependence to substances or behaviors is paramount in treatment. All practitioners need to be able to recognize persons affected and guide them in effective treatment.

Patient updates

The following are the brief updates discussed earlier. For some patients other medication regimens were tried unsuccessfully before establishing the effective, therapeutic regimen. Not all cases are “cut and dry,” and not all cases are success stories, because patients are at times noncompliant with medications or psychotherapy. Addictions are many times difficult to treat. Countertransference issues make dealing with this population difficult for many practitioners. Understanding of the chronic nature and psychopathology of addictions and dependence can help clinicians be more therapeutic.

Bill has required inpatient treatment in a psychiatric facility on two occasions, resulting from severe depression with suicidal ideation and auditory hallucinations. His condition was diagnosed as bipolar disorder. He is currently stable on duloxetine, aripiprazole, and zolpidem. Family relationships have improved, and he is doing well in his studies. He has enrolled in two college classes on video game technology and creation. Although CBT was recommended, Bill has never shown an interest in pursuing this option.

Jim has filed for divorce and moved into his own apartment. He appears to have resolved most of his issues, although he continues individual Cognitive behavioral therapy (CBT). He is considering filing for custody of his three children. He reports that his wife continues to engage in online game activity and doubts he can trust her again. He was treated with escitalopram for 1 year, at which time he elected to stop medication and appears to be doing well.

Michelle is medication compliant in dealing with her bipolar disorder and remains with her fiance’. Her medications are oxcarbazepine and citalopram. Her fiance’ has decreased the amount of time he spends playing online games because he is now working full time and has agreed that he will no longer play while she is in the home. Couples therapy was recommended; however, they have not attempted to find a therapist.

George remains unemployed. He denies any illegal drug use. He continues to abuse alcohol periodically. The amount of time he spends playing online games has decreased because his mother no longer has Internet connections in the home. He is intermittently compliant with citalopram, bupropion, and divalproex. George also has never shown an interest in the CBT option.

References

1. I Goldberg, Internet addiction Available at: http://www.psycom.net/iasg.html (1995) Accessed February 20, 2007..
2. Young KS: Internet addiction: the emergence of a new clinical disorder. Paper presented at: 104th annual meeting of the American Psychological Association; August 11, 1996; Toronto, Canada.
3. American Psychiatric Association, Statement of the American Psychiatric Association on “Video Game Addiction.”
4. BD Ng and P Wiemer-Hastings, Addiction to the internet and online gaming, Cyberpsychol Behav 8 (2) (2005), pp. 110–113.
5. KS Young, Internet addiction: a new clinical phenomenon and its consequences, Am Behav Sci 48 (4) (2004), pp. 402–415.
6. SE Allison, L von Wahlde, T Shockley and GO Gabbard, The development of the self in the era of the internet and role-playing fantasy games, Am J Psychiatry 163 (3) (2006), pp. 381–385.
7. YM Bai, CC Lin and JY Chen, Internet addiction among clients of a virtual clinic [lsqb]letter[rsqb], Psychiatr Serv 52 (10) (2001), p. 1397.
8. D Chappell, V Eatough, MO Davies and MD Griffiths, Everquest—it’s just a computer game right? An interpretative phenomenological analysis of online gaming addiction, Int J Ment Health Addict 4 (3) (2006), pp. 205–216.
9. E Aboujaoude, LM Koran, N Gamel, MD Large and RT Serpe, Potential markers for problematic internet use: a telephone survey of 2,513 adults, CNS Spectr 11 (10) (2006), pp. 750–755.
10.   KW Beard and EM Wolf, Modification in the proposed diagnostic criteria for internet addiction, Cyberpsychol Behav 4 (3) (2001), pp. 377–383.

Cindy Burkhardt Freeman
The Journal for Nurse Practitioners
Volume 4, Issue 1, January 2008, Pages 42-47