An
estimated 15% of the American population experiences Posttraumatic
Stress Disorder (PTSD) in their lifetime. Those with PTSD have a higher
probability of developing an addictive behavior as a means to cope with
symptoms associated with this diagnosis. Behavioral addictions, such as
Internet usage, need to be considered while working with PTSD clients.
An overview of Internet addictions will be provided, along with a brief
explanation of how behavioral addictions can affect the behavioral,
neurobiological, and psychological aspects of the individual. Some
suggestions for treatment will be provided.
Audio Introduction
School shootings, terrorism, and military
conflict have become more publicized over the last decade. Due to the
increased awareness of violent acts in society, it is logical that
posttraumatic stress disorder (PTSD)
is poised to be one of the most prevalent mental health issues today. A
study by
Kessler, Sonnega, Bromet, Hughes and Nelson (1995) showed that
over their lifespan, 10 % of women and 5% of men in the United States
will experience PTSD. Clients diagnosed with PTSD have a lower
resistance to stressors and are ill equipped to cope with the symptoms
of flashbacks, emotional restriction, and need for isolation from the
external world (American
Psychiatric Association, 2000). In need of
coping mechanisms, clients will resort to dangerous behaviors, such as
excessive drug use, to get relief from their suffering (Brady, Back, &
Coffey, 2004). As a result, there is a high co-morbidity rate of PTSD
clients using addictive behaviors such as drugs and alcohol as a means
of coping with symptoms (Keane, Gerardi, Lyons, & Wolfe, 1988;
Kofoed,
Freidman, & Peck, 1993). These substances offer an element of escapism
and isolation that the client seeks to assuage conflict with others,
avoid unwanted emotions, and mitigate the discomfort of flashbacks
(Brown & Ouimette, 1999). However, Internet addiction as a tool for
escape has not been considered as a coping mechanism for PTSD before.
The Internet has become a common
companion for people across the world, and it is estimated that there
may be one billion users by 2005 (ET
Forecasts.com, 2001). Since its increase in popularity, the Internet
has gained momentum due to the attractive nature of its accessibility,
affordability, and anonymity (Cooper, 1998a). For twenty-four hours a
day, it can be accessed as a tool to seek pleasure and instant
gratification for a relatively low cost. Moreover, the ease of meeting
one’s needs in the safety of the home is a seductive notion. As the
popularity of the Internet increases, excessive use has been labeled a
behavioral addiction (Griffiths, 2003). By coupling the gratification of
the Internet with the PTSD sufferer’s inclination for addictive
behaviors and isolation, the Internet marries two great needs into one
perfect addiction.
The purpose of this article is to describe
Internet addiction as a possible substitute addiction for PTSD clients.
The article will (a) discuss the prevalence of comorbidity of addiction
among PTSD clients, (b) provide an overview of Internet addictions, and
(c) describe the implications of PTSD clients using Internet addiction
as a possible substitute for substance abuse.
Comorbidity of Addiction among PTSD
Clients
Over the years the co-occurrence
of addictive behaviors and PTSD has become a more recognized
complication for mental health clients. Previous studies have shown that
substance abuse among clients with PTSD can be as high as 60-80% (Keane, Gerardi, Lyons & Wolfe, 1988;
Kofoed, Freidman, & Peck, 1993). These
high numbers show that PTSD clients are apt to need some type of coping
mechanisms, which allow for relief from the symptoms that they
experience. Engaging in addictive behaviors can create neurobiological,
behavioral, and psychological changes in the individual that mimic
substance addictions (Bradley, 1990;
Holden, 2001).
Clients who have a co-occurrence
of addictive behaviors and PTSD have a high rate of relapse (Ouimette,
Finney, & Moos, 1999). It can be difficult to determine whether the
addiction or the PTSD should be the focus of treatment because the
client’s low-functioning social skills and difficulty in relating to
others exacerbate their need to engage in addictive behaviors (Jordan, Marmar, Fairbank, Schlenger, Kulka, Hough, & Weiss, 1992).
Overview of Internet Addictions
Before delving deeper into the
issues of PTSD clients and their vulnerability to addictions, it is
important to have a better understanding of
Internet addictions. Gender attitudes towards Internet usage will be
explored as well as the sexual orientation and occupation of said users.
To further the readers’ understanding, the implications of over-usage to
the individual and their family systems will also be briefly discussed.
Technology addiction
(specifically Internet addiction) is a relatively new phenomenon that
has been shelved under the larger category of behavioral addictions
(Griffiths, 2003). The Internet affords its users the same experiences
that more tangible addictions, such as substance abuse, can provide.
These experiences can include feelings of euphoria and escapism,
withdrawal from the outside world, and increasing interpersonal conflict
due to the users heightened levels of anxiety or depression (Martin & Petry, 2005). However, it is important to differentiate between the
distinctive subtypes of the “Internet addiction” label.
Cyber sexual addictions: compulsive use of
adult websites for sexual gratification and internet pornography
Internet-relationship addictions:
Over-involvement in online relationships, chat rooms, relationships
sustained via email
Net compulsions: Over usage or obsessive
online gambling, shopping or day-trading
Information overload: compulsive web
surfing or database searches
Computer addiction: obsessive computer
game playing (e.g., Sims, Doom, Solitaire)
Whether the Internet is a means to have
certain addictive needs met or is an addiction with multiple avenues of
gratification is still up to debate. However, the basic fact remains
that the Internet can help people to get their needs met in a
potentially unhealthy manner.
Gender.
Gender attitudes diverge in
Internet usage. Women will use the Internet as a means to cultivate
connectedness with the world around them, to create attachments that may
be lacking in their everyday interactions with others, while men use the
internet to “hunt” for subjects that interest them (Gonyea, 2004;
Whitty, 2003). Women who engage in Internet usage and over-usage are
often testing out their emotional range in an anonymous environment (Maheu,
1999). A hypothesis for this phenomenon is that these women perceive
that society restricts their emotional range to purposefully avoid
emotions such as anger and aggression. Emotional restriction coupled
with society’s narrow view of female attractiveness and desirability,
deems it logical that women will use the anonymous chat-room environment
to engage long-term friendships and intimate relationships (Maheu, 1999;
Whitty, 2003).
Men are more likely to use the
Internet for basic gratification (Gonyea, 2004). While women use the
Internet to form connections with others, men are more likely to engage
in online sexual activity as a distraction from daily life, a means to
cope with stress, and for meeting sexual partners (Cooper, Morahan-Martin,
Mathy, & Maheu, 2002;
Gonyea, 2004). However, men can be
under-represented in studies concerning on-line addictions, because they
may be less likely than their female counterparts to recognize their
internet usage as problematic (Cooper, Delmonico, & Burg, 2000).
Sexual orientation.
Studies on the sexual
orientation of Internet users show that women and homosexuals are more
likely to engage in online sexual activities and chat rooms than are
heterosexual males and lesbians (Cooper et al., 2000;
Cooper et al.,
2002). The supposition is that disenfranchised groups, such as women and
homosexuals, may feel more comfortable engaging in chat-rooms and sexual
activities online due to the anonymous nature of the activity. However,
heterosexual males and lesbians may experience greater levels of
acceptance in their overall lifestyles and may not need to use the
Internet as a coping mechanism (Cooper et al., 2000).
Occupations.
College students are more likely to engage in Internet addiction
than their professional counterparts (Cooper et al., 2000;
Young, 2004).
Students’ vulnerability to Internet addiction is attributed mainly to
their unlimited free access to the internet, large amounts unstructured
of time on campus, newly found freedom from parental control,
unrestricted access to do or say what they wish online and academia’s
encouragement to use the internet as a means of research (Young, 2004).
Those who work at home are also vulnerable to Internet addictions due to
their unrestricted access to the Internet with relatively large amounts
of private time at home. Interestingly, those whose jobs involve
computers exclusively are much less likely to engage in excessive
amounts of inappropriate Internet usage (Cooper et al., 2002).
Implications to self and others.
Excessive Internet usage may
cause individuals to have difficulty in their social networks. Internet
addicts must work hard to maintain an illusion of normalcy to the
outside world. Addicts will hide their usage from others, changing their
behaviors in order to get the time that they need on the Internet. An
addict can spend up to 80 hours per week on the Internet. In order to
facilitate these prolonged hours, the user may forego sleep or begin
taking caffeine pills in order to stay awake. Loss of sleep can leave
users susceptible to fatigue and illness as well as impair their ability
to be effective in their daily life. Other health risks may include a
sedentary lifestyle and increased risk for carpal tunnel syndrome
(Young, 2004).
Eventually the addiction will
become noticeable to those who are close to the addict, no matter how
the user attempts to hide their usage. The individual will become
increasingly asocial, and when social encounters do occur, the user may
manifest tension and fatigue. These symptoms may occur due to the user’s
intense need to fulfill the craving to be on the Internet. The need to
be on the Internet becomes less about being on the computer and more
about using it as a tool to find a means of escape or to cope with life
stress (Young, 2004).
As the user’s behavior becomes
more erratic, and the need to use the computer becomes more pronounced,
the user’s family and friends will become increasingly aware that
something is wrong with the addict. The impact to the social network can
be that of concern, confusion, and withdrawal. The Internet can become a
means of virtual support and release for the user; thus making the
living system obsolete. The individual’s social networks may withdrawal
from the user and inadvertently increase the user’s need to cope with
the loss.
Implications of PTSD Client Using
Internet as a Substitute Addiction
Using the Internet as a means of
escape and coping is currently not as stigmatized as other addictive
behaviors. For example, there are ongoing campaigns and public service
announcements to educate the public about excessive drug and alcohol
abuse but no warnings about excessive Internet usage. Connectedness to
the outside world via the Internet is the norm, considering the public
is inundated with new and better technology such as cell phones and
personal digital assistants that allow people to get onto the Internet
virtually anywhere. Because the Internet has not been thought of as a
high threat, research around PTSD clients using the Internet is not well
researched.
Internet addiction is a behavioral
addiction and not a substance addiction and is not necessarily regarded
with the same amount of seriousness. Because of the previously held
belief that only a foreign substance could create chemical changes and
dependencies in the brain, substance addiction has been considered far
more harmful than behavioral addictions (Martin, & Petry, 2005).
However, both substance and behavioral addictions have the power to
create behavioral, neurobiological and psychological changes in the
individual, making all types of addictions detrimental (Bradley, 1990;
Holden, 2001;
Martin, & Petry, 2005).
Behavioral changes.
Behavioral addictions can transform basic
drives for survival, such as sleep, into actions that are
counterproductive to survival, such as spending four hours per night on
Internet gambling. Similar to the cocaine addict who foregoes sleep to
find the means for their next high, a behavioral addict will sacrifice
sleep in order to maintain the hours needed on the Internet to get their
cravings met. Individuals are identified as an “addict” when survival
instincts are interrupted to the point that the new behavior interferes
with quality of life (Martin, & Petry, 2005).
Neurobiological changes.
When the individual is occupied with
repetitive activity, such as Internet surfing, a dopamine reaction
begins to occur in the brain.
Dopamine, a chemical produced in the body, affects brain processes
that control movement, emotional response, and ability to experience
pleasure and pain (University of Texas at Austin, 2005). As the
individual uses the Internet, a certain level of dopamine will allow
them to experience pleasure and arousal (Holden, 2001). As the
individual builds up a resistance to the chemical, they need greater
amounts of time for the activity to get the same high.
Psychological changes.
Increased emotional arousal from
engaging in behavioral addictions is a prominent psychological change.
The individual will feel a high level of anticipation while engaging in
the act, and then experience a feeling of euphoria during and
immediately after the need has been fulfilled (Bradley, 1990). Feelings
of remorse and guilt will then replace the elation. Mood swings are
another emotion response that can occur when the individual is deprived
of their Internet cravings. A person can become hostile and angry as
they go into withdrawal (Bradley, 1990).
Treatment for PTSD Clients Manifesting an
Internet Addiction
Treatment for clients with both PTSD and an
Internet addiction should address the behavioral, neurobiological, and
psychological needs of the client. The goal for these clients should be
the lessening of symptoms of both diagnoses. Traditionally, clients with
PTSD and addiction diagnoses have been treated with individual therapy,
in therapeutic support groups and with pharmacotherapy (Brady et al.,
2004).
While established treatments may work for
clients with Internet addictions, the problem remains that the Internet
is a prominent fixture in today’s world. Therapists working with this
population need to be aware of the potential temptations that the client
will come into contact with daily. A client’s daily routine may involve
technology that will help them access the Internet. Some suggestions for
tailoring treatment to the Internet addicted client:
Encourage client to remove Internet
access from their home. Similar to a therapist suggesting that
alcoholics remove alcohol from their home, the therapist should contract
with the client to remove the temptation of internet access. The
intervention could utilize family members to facilitate the removal
process.
Crisis intervention and support services
should be made available to the client. Moments of weakness and
temptation will tempt the client to use the Internet. Providing the
client an opportunity to work through a crisis with some help can
circumvent a relapse. Because Internet addiction is relatively new,
crisis services may need to be provided in community agencies.
Maintaining new behaviors and preventing
relapses should be supported. After clients have concluded services
it is important that they feel comfortable accessing help when it is
necessary. Scheduling check-in visits at intermittent times, such as
every six months, can help to maintain new patterns of functioning. The
client should be encouraged to come back for services if they feel that
their overall functioning is not optimal.
Suggestions for the Counseling Profession
There are multiple resources for
people who manifest symptoms of PTSD and Internet addiction. These
resources come in the form of treatment facilities, counseling clinics,
and private therapists. When a client is seeking counseling services,
there are usually credentialing bodies that maintain certification for a
facility, such as the Commission on Accreditation of Rehabilitation
Facilities (CARF). In private practice, counselors display degrees that
signify they are legitimate and competent members of the profession.
As the worldwide web gets bigger
and more people seek information about various mental illnesses, there
is an increased need for trustworthy sources of information. One of the
ways that the counseling profession can meet this need is the creation
of a centralized website about mental illnesses. A website endorsed by a
professional organization, such as the American Counseling Association,
may be perceived as more trustworthy than a website that is maintained
by a private organization. (Example websites: Appendix A)
Conclusion
Clients with PTSD comprise 15%
of the overall American population (Kessler et al., 1995). Among these
clients, 60-80% engages in addictive behaviors that can further impede
overall functioning (Keane et al., 1988;
Kofoed, et al. 1993). Substance
addiction among PTSD clients has been documented but behavioral
addictions, specifically Internet addiction, have not.
The Internet has a prominent place in our
society today. It is projected that there are over one billion users in
2005 alone (ET Forecasts.com, 2001). Because it is so readily available,
people have developed ways to use the Internet in an unhealthy manner.
Misuse of the Internet can be categorized into five parts: cyber sexual
addictions, internet-relationship addictions, net compulsion,
information overload, and computer addiction (Griffiths, 2003;
Young,
1999).
Because Internet addiction is considered a
behavioral addiction, some question the level of danger it poses to the
individual. However, a behavioral addict can manifest behavioral,
neurobiological, and psychological impairment just as a substance abuse
addict can (Bradley, 1990;
Holden, 2001;
Martin, & Petry, 2005). While
traditional treatments can include individual therapy, pharmacotherapy,
and therapeutic support groups, modifications are required to meet the
specific needs of the PTSD client with an Internet addiction.
Elizabeth R. O’Brien
is a Doctoral Student in the Department of Child, Family, and Community
Sciences-Counselor Education at The University of Central Florida.
Correspondence can be directed to
erobrie@mailbox.sc.edu
