Digital drugs. From the real world to the virtual one
SUMMARY Introduction. Technology has become an important part of our lives, being present more and more in learning and teaching processes, at work and in our free time as a recreational activity. Besides the advantages that it offers to us, the negative effects are not to be neglected, especially regarding the mental health of children and adolescents. Material and methods. Patient aged 13 years and 7 months, at first assessment at the Child and Adolescent Psychiatry and Addiction Clinic Cluj-Napoca, is presented in emergency accompanied by his mother for a psychopathological tableau characterized by psychomotor restlessness, disorganization in behavior, anxiety, visual, auditory and tactile hallucinations. The symptomatology started a day before the presentation, the mother being requested at school because of the adolescent’s disorganized behavior. Affirmative, it started a conflict between them on the topic of phone usage after the sleeping hour set by her. Results. The case was interpreted with the diagnosis of Acute psychotic episode with symptoms of schizophrenia, therapy was initiated with an antipsychotic and anxiolytic, with the interdiction of digital technology usage, with a favorable evolution over the symptomatology both during the admission and after the returning to the family environment. Conclusions. Radical prohibition of technology usage by children and adolescents is unrealistic. Digital technology addiction among them can be avoided by the parents who closely monitor and decide if, when and how much they can have technology access. Children can use the technology moderately with their parents, teaching them to use it responsible and with a purpose, to prevent the addiction in adolescence. Keywords: psychotic episode, technology, addiction, mental health
INTRODUCTION Technology has become an important part of our lives, being present more and more in learning and teaching processes, at work and in our free time as a recreational activity. Besides the advantages that it offers to us, the negative effects are not to be neglected, especially regarding the mental health of children and adolescents. MATERIALS AND METHODS We want to present you the case of an adolescent, aged 13 years and 7 months, at first assessment at the Child and Adolescent Psychiatry and Addiction Clinic Cluj-Napoca, without documented psychiatric history. He is presented in emergency accompanied by his mother at the beginning of October 2018 for a psychopathological tableau characterized by psychomotor restlessness, disorganization in behavior, anxiety, visual, auditory and tactile hallucinations. The symptomatology started a day before the presentation, when his mother caught him playing on the phone after the sleeping hour set by her. The adolescent had an age-appropriate development, with no significant physiological and pathological personal history and no family history of documented psychiatric pathology. At the presentation the patient is a little restless, with a cooperative attitude, eye contact easy established and maintained, but with a slightly anxious look. His psychopathological picture is characterized by disorders of perception which
started about 12 hours before the presentation, with visual and auditory hallucinations related to the alien games he plays on his smartphone, kinesthetic hallucinations (the sensation that ”I don’t have my bones anymore”, “My hands are not at their place”, “My blood is not flowing as it should”, he is touching his body as he was looking for something of as something is bothering him). The adolescent has a labile and fatigued attention, easily distracted by irrelevant stimuli from the environment, fixation and evocation hypomnesia, partially oriented temporal and spatial (he knows where he is, but he cannot place the events in time). The cognitive level of development corresponds to the chronological age, with a disorganized ideational rhythm, he doesn’t finish and repeats his ideas, he avoids some of the answers (he avoids telling what happened the night before admission and he repeats what happened that morning). The adolescent says that he did not take the minibus to school and walked because he had the feeling that somebody might kill him. Before classes he smoked a cigarette from a colleague, afterwards he was feeling ill, he fell asleep during classes and the teacher called his parents because of his disorganized behavior. Affectivity is marked by a thymic background mood with episodes of irritability, impulsivity and low frustration tolerance in the context of family conflicts related to his entourage, tobacco and alcohol consumption, and anxiety, the adolescent saying that he is scared because of the games with aliens that he plays on his smartphone and because of the horror movies that he has watched in recent days, he is afraid that something bad might happen to him or somebody might hurt him. Adolescent’s socialization is appropriate, he claims that he has many friends, but in the opinion of his mother some of them are not a positive influence for him, he has been smoking for a year and he spends 5-6 hours a day playing various games on his smartphone, affirmative of the mother, violent games. At the moment of assessment, the patient is a 7th grade student with average school results and low motivation for sustained cognitive effort. The circadian rhythm is altered, his sleep is restless, with poor quality, especially in the last few days. During the hospitalization the patient has disorganized thoughts, he does not present the facts in a coherent way, he is spatial oriented, but not temporal (he says that he has been admitted in the clinic a week ago and a day before he did not go to school), there are visual and auditory hallucinations during the night in relation with the game that he has been playing for almost a year on his smartphone, kinesthetic hallucinations (“Adam’s apple has moved below it’s place”, he touches his body as he is looking for something), he is anxious and says that “I swallow with difficulty”. The case was interpreted with the following diagnoses: Acute polymorphic psychotic disorder with symptoms of schizophrenia and Tobacco use disorder according to DSM-5 and ICD-10 criteria, and drug treatment was initiated with an antipsychotic and an anxiolytic. During the hospitalization the patient presented a favorable evolution, his condition has improved, he was oriented temporal and spatial, without any visual, auditory or kinesthetic hallucinations, his sleep initially restless becomes quiet and restful. It was decided to carry out a MRI for the exclusion of an organic psychotic disorder, which is why he returns in our clinic 2 weeks later. At the admission the patient is calm, cooperative with a slightly anxiety regarding his MRI. A night before his MRI appointment the patient is agitated psychomotor, and his mother says that his sleep was restless. The MRI was realized with difficulty. When he returned in our clinic the adolescent is restless, anxious, with delayed responses, easily distracted by irrelevant stimuli from the environment, with disorganized ideational
rhythm, incoherent, he says that he feels old, but he knows that he is only 14 years old. He also touches his hands because “they are dirty”. Despite doctor’s recommendations the patient wants to go home, so he is discharged at the request of the mother. DISCUSSIONS Video games sessions, especially the ones that are carried out over a long period can lead to alterations of visual perceptions manifested as incorrect perceptions, distortions of real objects from the environment and multi-sensory pseudo-hallucinatory experiences and sensory experiences with video game’s content [1]. The question was whether video games are beneficial for their users. The studies have analyzed both positive and negative effects of the time spent in virtual reality mediated by screens. Thus, the researchers concluded that action video games improve a range of spatial orientation skills, educational games successfully teach specific knowledge and specific abilities, exercise games can improve physical activity, and pro social games increase empathy and the ability to offer help along with decreasing aggression. Among the negative effects of video games, the literature mentions the intensification of the thoughts, the experiences and the aggressive behaviors, the desensitization of the players to violence with the decrease of empathy, the decrease of school performances with the accentuation of the difficulties of concentration, until the appearance of the dependence related to video games [2]. Technology can be a great source of learning and entertainment for children, but it comes with implications for their health, which is a reason for parents to take it in consideration. The American Academy of Pediatrics (AAP) recommends that use between 3 and 5 years old should not exceed one hour per day [3]. In the case of children under 3 years old, experts recommend that they do not spend time in front of the screens at all [3] and consistent limits in the case of children over 6 years old [4]. Internet Gaming Disorder – DSM-5 In the 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Internet gaming disorder is included in Section III of the manual as a disorder that requires further clinical research to be included in the manual as a diagnostic.
The proposed criteria involve persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period: 1.
Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life). 2. Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.) 3.
Tolerance – the need to spend increasing amounts of time engaged in Internet games. 4.
Unsuccessful attempts to control the participation in Internet games. 5.
Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games. 6.
Continued excessive use of Internet games despite knowledge of psychosocial problems. 7.
Has deceived family members, therapists, or others regarding the amount of Internet gaming. 8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety). 9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games. This disorder is distinct from Internet gambling, which is included under gambling disorder [5]. Gaming Disorder – ICD-11 In the new edition of ICD-11 Gaming disorder is mentioned as a diagnosis, characterized by a pattern
of persistent or recurrent gaming behavior (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the internet) or offline, manifested by: 1. impaired control over gaming (e.g., onset, frequency, intensity, duration, termination, context); 2. increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and 3. continuation or escalation of gaming despite the occurrence of negative consequences. The behavior pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. The pattern of gaming behavior may be continuous or episodic and recurrent. The gaming behavior and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe [6]. RESULTS Under medication with an antipsychotic and anxiolytic, with the interdiction of digital technology usage, the symptomatology had a favorable evolution over both during the admission and after the returning to the family environment. CONCLUSIONS Radical prohibition of technology usage by children and adolescents is unrealistic. Digital technology addiction among them can be avoided by the parents who closely monitor and decide if, when and how much they can have technology access. Children can use the technology moderately with their parents, teaching them to use it responsible and with a purpose, to prevent the addiction in adolescence.
BIBLIOGRAPHY
1. Ortiz de Gortari AB, Griffiths MD. Altered Visual Perception in Game Transfer Phenomena: An Empirical Self-Report Study. Int. J. Hum. Comput. Interaction. 2013;30(2): 95-105.
2. Prot S, McDonald KA, Anderson CA, Gentile DA. Video games: good, bad, or other?. Pediatr Clin North Am. 2012 Jun;59(3):64758.
3. Media and Young Minds. Pediatrics. 2016;138(5).
4. Media Use in School-Aged Children and Adolescents. Pediatrics. 2016;138(5).
5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.
6. World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en