1. Cyberspazio e psicopatologia Casi Clinici
Dipartimento di Scienze Farmaceutiche
Università di Catania
Cyberspazio e psicopatologia Casi Clinici
Filippo Caraci

2. Mr. A was a 42-year-old married man, an academic sociologist, who was seen with the chief complaint of a recurring depressed mood, despite ongoing treatment with an antidepressant agent. He indicated that although treatment with fluoxetine, 20 mg/day, had been successful in treating major depression in the past, in recent months, in parallel with new stressors in his life, his depressed mood had returned. This had been accompanied by irritability, anhedonia, decreased concentration, and changes in sleep and appetite. On further exploration, Mr. A also revealed that during this period he had increased his use of the Internet, spending several hours a day searching for particular pornographic images.

3. He clearly articulated distress at the loss of control this behavior represented for him and also noted that he was spending more money on Internet downloads than he could afford. His behavior had also led to a marked decline in research productivity……. He felt his marital relationship was unaffected, although when he masturbated to orgasm during the day he was often unable to achieve orgasm if he and his wife had sex that night.

4. On further inquiry, Mr. A indicated that the first time that he had had an episode of depression that required treatment with an antidepressant had occurred when he was an 18- year-old college student, in the context of the break-up of a relationship.
- Subsequent similar episodes of depression,(fluoxetine for 3 years).
No history of hypomanic or manic episodes nor of other axis I conditions.
Many of his depressive symptoms were atypical: when depressed he tended to eat more and sleep more.

5. His job required her to travel several weeks a year, and at these times he felt more lonely, had more time on his hands, and would masturbate more. Indeed, at times throughout his life he had relied on masturbation to obtain a sense of relief, sometimes regularly masturbating to orgasm three or more times a day. However, this had not interfered with his occupational or social function until he had gained ready access to Internet pornography.

6. The university had provided office access to the Internet to all faculty around 3 years previously. Initially, Mr. A had mostly used this for research purposes. On occasion, however, he spent time in Internet sex chat rooms.
Over time, however, the bulk of his use of the Internet had become devoted to searching for particular kinds of pornographic photographs; these involved a man who he felt was macho or dominant in some way having sex with a woman………. Once he had found a picture that was “just right,” he would masturbate to orgasm

7. At times he would recall the pictures that aroused him when he and his wife were making love, but by and large they had an apparently unvaried and unadventurous sexual relationship, which both experienced as adequate. A detailed sexual history revealed nothing out of the ordinary.
There was no history of childhood molestation.
Mr. A did, however, note having difficulty with assertiveness. He tended, for example, to follow the instructions of others, even when he disagreed with them. Eventually, feelings of anger would erupt, sometimes in inappropriate ways.

8. Mr. A initially declined psychotherapy referral by his psychiatrist, who did mostly psychopharmacological work, but agreed to an increase in fluoxetine to 40 mg/
day. Over the next several weeks this led to further improvement in mood symptoms but not to decreased libido or to any changes in his hypersexual behavior.
Some months later, Mr. A agreed to discuss his symptoms with a psychologist.
At the 1-year follow-up, he felt that the psychotherapy had been useful in helping with difficulties assertiveness. Indeed, he now felt that this issue had contributed to the stress he felt at work, together with feeling he had lost control over his sexual behavior

9. There had also been a decrease in his problematic Internet use, although at times of increased work stress or loneliness, he was still prone to excessive use of pornography and masturbation.
Significant use of Internet pornography was present even when his depression had responded to medication

10. Conclusioni degli autori:
disturbo autonomo (Internet addiction) o diversa espressione del disturbo depressivo maggiore ?
Insufficienti i dati nel 2001 per iniziare a vedere la IAD sia come disturbo autonomo che in comorbidità
Per gli autori l’uso maladattivo di Internet sembra aver slatentizzato condizioni psicopatologiche preesistenti (spettro ossessivo-compulsivo ??)
Il trattamento combinato tuttavia (SSRI+ psicoterapia) migliorava il quadro depressivo ma non i comportamenti sessuali compulsivi

11. CLASSIFICAZIONE INTERNAZIONALE World Health Organization (WHO) / American Psychiatric Association (APA) Disturbi del Controllo degli Impulsi Non Altrove Classificati
Internet addiction
Impulsive-compulsive sexual behaviour
Impulsive-compulsive shopping

12. Impulso + compulsione = craving?
Gli impulsi sono pensieri o azioni stereotipati e ripetitivi NON legati all’ansia, ma ad uno stimolo provocativo di natura sensoriale o cognitiva, senza alcuna resistenza e la cui esecuzione è fonte di piacere (egosintonia).
Le compulsioni sono legate alla riduzione dell’ansia o all’evitamento di un evento temuto e contrastate da un certo grado di resistenza, con conseguente messa in pratica di un atto considerato spiacevole (egodistonico) e afinalistico.
DSM-III-R e seguenti sottolineano “la natura compulsiva dell’assunzione della sostanza”, associata ad un “inadeguato controllo sull’uso della sostanza stessa” (Skodol, 1989).
Tiffany (1990): da un livello inconscio ed automatico di craving basale (equivalente all’impulsività), emergerebbe il craving cosciente (simile alla compulsione se presente un desiderio di resistervi), determinando una coazione che tende a ripetersi.
Craving: dimensione comportamentale complessa (impulsiva-compulsiva) e generalizzabile ad altri disturbi di tipo additivo, NON legati a sostanze (dipendenze comportamentali).

13. Internet addiction e disturbi del controllo degli impulsi
Internet addiction come un Disturbo del Controllo degli Impulsi (DCI) perché l’individuo diviene progressivamente incapace di resistere all’impulso di usare internet
I DCI sono caratterizzati da:
1) incapacità o difficoltà nel resistere ad un impulso, spinta o tentazione di compiere un atto dannoso per sè o per gli altri;
2) aumento progressivo della tensione prima dell’atto;
3) piacere, sollievo o gratificazione quando l’atto viene compiuto (egosintonicità);
4) eventuali sentimenti negativi (senso di colpa, rimorso), dopo aver terminato l’atto.
Shaw & Black (2008): Internet addiction e DCI accomunati da fenomenologia e relazione con i Disturbi Affettivi, l’Abuso di Sostanze ed i Disturbi d’Ansia.
Disturbo autonomo ma in comorbidità con altri disturbi
o semplice modalità d’espressione di un disturbo d’asse I ?

14. Internet addiction Cybersexual addiction Net Information Compulsions
Overload
Internet addiction
Cyber-relational
addiction
Computer
addiction
Shaw & Black (2008)

15. Internet addiction: prevalence

16. Internet addiction appears to be a common disorder that merits inclusion in DSM-V.
It’s a compulsive-impulsive spectrum disorder that involves online and/or offline computer usage and consists of at least three subtypes:
Excessive gaming,
Sexual preoccupations
/text messaging

17. Internet addiction toward the DSM-V
All of the variants share the following four components:
1) excessive use, often associated with a loss of sense of time or a neglect of basic drives
2) withdrawal, including feelings of anger, tension, and/or depression when the computer is inaccessible
3) tolerance, including the need for better computer equipment, more software, or more hours of use
4) negative repercussions, including arguments, lying, poor achievement, social isolation, and fatigue

18. Internet addiction toward the DSM-V
There is no consensus on definition
About 86% of Internet addiction cases have some other DSM-IVdiagnosis present
Internet addiction is resistant to treatment, entails significant risks and has high relapse rates.
It also makes comorbid disorders less responsive to therapy
Main problem to propose new criteria: only a few clinical cases have been reported and published in literature

19. A male patient first presented to a psychiatrist (J. M. B
A male patient first presented to a psychiatrist (J.M.B.) at age 24, with the explanation, “I’m here for sexual addiction. It has consumed my entire life.”
He feared losing both marriage and job if he could not contain his burgeoning preoccupation with Internet pornography. He was spending many hours each day chatting online, engaging in extended masturbation sessions, and occasionally meeting cybercontacts in person for spontaneous, typically unprotected, sex.

20. From age 10, after discovering his grandfather’s cache of “dirty magazines,” the patient had had a strong appetite for pornography. In his late teens, he engaged in phone sex via credit cards and 900-series commercial telephone connections.
Describing himself as a compulsive masturbator, he also subscribed to conservative Christian beliefs. Morally troubled by his own behavior, he claimed his sexual actions emanated—at least in part—from “negative influences from the devil.”

21. After high school, he took an advertising sales job that included overnight travel. Both at work and on trips, he used his computer not only for business related activities but also for online “cruising” (ie, searching for sexually gratifying activity).
Business trips would feature hours of online masturbation and overwhelming urges to visit strip clubs. With 24-hour Internet access at his office, he frequently engaged in all-night online sessions.
He quickly developed tolerance.

22. Reasoning that the patient might suffer from an obsessive- compulsive disorder variant, his psychiatrist prescribed sertraline at an oral dose of 100 mg/d.
Whereas the patient’s mood and self-esteem improved and irritability decreased, an initial decline in sexual urges was not sustained.
He stopped taking the sertraline and discontinued his relationship with the psychiatrist for a year.
When the patient finally returned to treatment, he was spending up to 8 hours a day online, masturbating until tissue irritation or fatigue ended the sessions.

23. He had had several “hook-ups” with Internet contacts that included unprotected intercourse and was no longer intimate with his wife for fear of transmitting venereal disease to her.
He had lost several jobs as a result of poor productivity from time spent pursuing his compulsions at the expense of work. He described extreme pleasure from the sex itself but equally extreme remorse about his inability to control himself.
When sertraline therapy was reinstated, his mood improved, but he still felt “powerless to resist the urges” and again stopped treatment.

24. When the patient reappeared after another 2-year hiatus, more marital distress, and another lost job, the psychiatrist proposed adding naltrexone to the sertraline therapy. (The sertraline now seemed necessary for an ongoing depressive disorder.)
Within a week of treatment with 50 mg/d of oral naltrexone, the patient reported “a measurable difference in sexual urges. I wasn’t being triggered all the time. It was like paradise.” His sense Of “overwhelming pleasure” during Internet sessions was much diminished, and he discovered an ability to resist rather than submit to impulses. Not until the naltrexone dose reached 150 mg/d did he report complete control over his impulses.

25. When he tried on his own to taper the drug, he felt it lost its efficacy at 25mg/day. He went online to test himself, met a potential sexual contact, and reached his car before thinking better of an in-person rendezvous. This time, returning to 50 mg of naltrexone was enough to slake his sexual urges.
In the more than 3 years he has received sertraline and naltrexone, he has been in nearly complete remission from depressive symptoms and compulsive Internet use, as he himself has noted: “I occasionally slip, but I don’t carry it as far, and I have no desire to meet anyone.”
As an added benefit he has discovered that binge drinking has lost its charm.

26. The patient had problems stemming both from time wasted in compulsive online masturbatory cybersex and from potential consequences, such as unwanted pregnancy and sexually transmitted diseases, when his virtual activities were extended to extramarital in-person sexual contacts.
Adding naltrexone to a medication regimen that already included a selective serotonin reuptake inhibitor coincided with a precipitous decline in and eventual resolution of his addictive symptoms, with a resultant renaissance of his social, occupational, and personal function.

27. Il sistema meso-limbico proietta dall’area ventrale del
del tegmento mesencefalico al nucleus accumbens ed
ha un ruolo centrale nei meccanismi di reward

28. Neurobiologia delle dipendenze Funzioni del circuito del “reward”
(sistema meso-limbico)
Aspetti attivazionali della motivazione
Previsione dell’entità del reward in base agli
stimoli associati
Meccanismi di “wanting” (e non di “liking”)
Attribuzione della salienza agli stimoli
associati all’assunzione della sostanza

29. “Functional enhancement” Risoluzione astinenza Genetica
Euforia
Azione ansiolitica
“Functional enhancement”
Risoluzione astinenza
Genetica
Contesto sociale
Storia farmacologica
Storia comportamentale
Drug Seeking Behavior
Rinforzo positivo
Circuito nervoso che risponde ai
“Rewards” ed agli stimoli ambientali
Associati (salienza dello stimolo)

30. Analisi funzionale del sistema mesi-limbico mediante
la tecnica del bold fRMN

31. Neurobiology of Internet addiction Effects of naltrexone

32. Pharmacological treatment of Internet addiction Role of naltrexone
Other case reports have demonstrated its potential for treating
pathologic gambling, self-injury, kleptomania, and compulsive sexual behavior
Naltrexone is generally well tolerated but can cause mild gastrointestinal upset. Because of potential hepatic adverse effects, naltrexone treatment necessitates monitoring of liver function tests at baseline, and then at 2–4 week intervals during the first 3 months of treatment (No NSAIDS)
Naltrexone may be started at 25 mg/day and is to be taken with food in order to avoid possible nausea.
The dosage may be increased by 50 mg/day every 2 weeks, to a maximum dosage of 100–150 mg/day (?)
Yancu et al. 2008

33. Internet addiction e gioco d’azzardo patologico: possibili strategie per il trattamento farmacologico La