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Risk taking adolescents: When and how to intervene
Boys will be boys” and other platitudes may condone adolescent reckless driving, substance use, or sexual promiscuity—but to write off dangerous behavior as normal would be a mistake. Because adolescent impulsivity and sensation-seeking may have physiologic as well as emotional causes,1,2 excessive risk taking may be treatable.
This article discusses the neurobiology of adolescent risk taking, suggests how to determine when such behavior may be pathologic, and offers a treatment approach for at-risk teens and their parents.
CASE: ‘WHAT’S WRONG WITH OUR SON?’
Josh, age 17, is brought to the adolescent psychiatry clinic by his distraught parents, who report their son has undergone a “personality change” over the past 2 years. They recall that he was respectful, studious, and soft-spoken until age 15. Since then, he has been skipping school, staying out late at night with his friends, and “obsessed” with TV poker games.
His parents recently discovered he has been gambling for money, which greatly upsets them. They also found a pack of cigarettes in their son’s car and are concerned that he might be using other substances. What finally prompted the psychiatric visit was Josh’s recent traffic citation for driving 25 miles over the speed limit.
CAUSES OF RISK TAKING
Normal development. In the absence of psychopathology, adolescent risk taking appears to be a normal development stage that is vital to successful transition to adulthood. This assumes that adolescents such as Josh learn to moderate their behavior and avoid long-term negative consequences.
Impulsivity and sensation seeking are recognized as key factors in adolescent risk taking Box 1.1-4 Apparently, these traits result primarily from incomplete neural circuit maturation. Adolescent brain regions involved in impulsivity and risk taking are also involved in reward, and these centers exhibit an exaggerated response to stimuli.5 This amplified response may help explain an adolescent’s propensity for risky behavior.
Despite potential hazards, adolescent risk taking may confer benefits. In taking risks, adolescents:
- explore adult behavior
- learn to accomplish increasingly difficult developmental tasks
- reinforce their self-esteem.
Adolescent risk-takers have been found to be more self-confident, to feel more accepted, and to be better liked than their more-cautious peers.6
Psychiatric comorbidity. Excessive risk taking can be associated with psychiatric illness, including bipolar mania, psychosis, substance abuse, and impulse control disorders. Individuals with borderline personality and other cluster B disorders have marked impulsivity and thus are prone to risky behavior.
Teens with attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional-defiant disorder (ODD) also tend to exhibit high impulsivity.
Alcohol. 40% of adult alcoholics report having had their first alcoholism-related symptoms between ages 15 and 19.1
Gambling. 10% to 14% of adolescents engage in problem or pathologic gambling, and gambling typically begins at age 12.2
Automobile crashes are the leading cause of death among North American adolescents; both sexes ages 16 to 20 are at least twice as likely to be in a motor vehicle accident as are drivers ages 20 to 50.3
STDs. Each year, 3 million U.S. adolescents contract a sexually transmitted disease (STD). HIV infection is the seventh leading cause of death for Americans ages 13 to 24.4
Sexual activity. Adolescents are more likely than adults to engage in impulsive sexual behavior, to have multiple partners, and to fail to use contraceptives. Younger teens (ages 12 to 14) are more likely to engage in risky sexual practices than older teens (ages 16 to 19).4
CASE CONTINUED: JUST ‘HAVING FUN’
When interviewed alone, Josh admits to “occasional” truancy, which he attributes to being “bored” with school and wanting to spend time with his friends “doing fun stuff, like going to the beach.” He admits to gambling for money and smoking a half-pack of cigarettes daily, as well as drinking beer and smoking marijuana “a few times a week.”
Josh says he engages in these activities “because they’re fun,” and states he is annoyed by his parents’ concern. He blames the speeding ticket on “not paying attention.” He admits to drinking and driving but claims he always feels “in control.”
He also reports he has been sexually active since age 16 and often has had unprotected intercourse. When asked if he is concerned that he might contract a sexually transmitted disease or impregnate his partner, Josh appears ambivalent.
IMPULSIVITY IN ADOLESCENCE
Josh is engaging in numerous impulsive behaviors. Adolescents generally are more impulsive than adults, as demonstrated by their significantly higher impulsivity scores on standardized tests.7 Furthermore, as measured by improved response inhibition (go/no go tasks), the level of adolescent impulsivity is inversely related to age.8
Problem behavior syndrome. High impulsivity is predictive of problem gambling, drug use, and risky driving and sexual practices later in life.1,2,9-11 Adolescents with what some authors describe as a “problem behavior syndrome” engage in behaviors—such as substance use, risky sexual behavior,12 gambling,13 and reckless driving14—that share a common trend toward impulsivity.
Impaired data processing. Decision making has been proposed as a three-part cognitive process:
- accumulating sensory input
- processing this input and formulating a behavioral response appropriate to the situation
- planning and implementing the resultant motor output.2
Impulsivity is believed to result from impaired ability of the brain to process accumulated information or to formulate a response to it—or both. Impulsive individuals thus experience impaired data processing, in which they:
- misjudge the likely risk of a given action or overestimate their ability to accomplish a task
- show impaired response inhibition and thus find it difficult to resist an impulse to participate in a given activity.
Sensation seeking. Adolescents who exhibit risk-taking behavior may wish to experience the thrill of the behavior (sensation or novelty seeking). Alcoholic or drug-dependent individuals and those who engage in pathologic gambling or take chances while driving also demonstrate significantly impaired decision making.15-17 Adolescents who engage in these and other problem behaviors have similarly scored high on sensation-seeking scales.10,18
DECISION-MAKING BIOLOGY
At least four neural circuits process decisions, weighing the risks and benefits of a given situation and formulating a response. These circuits are:
- prefrontal cortices, including orbitofrontal, dorsolateral, and ventromedial
- ventral striatum, including the nucleus accumbens
- thalamus
- monoaminergic brainstem nuclei (ventral tegmental area [VTA] and raphe nuclei).19
Functional imaging studies—including MRI and PET, EEG, and electrophysiology—have confirmed that these four brain regions are integral to response inhibition and show abnormal activity in impulsive individuals.20,21 Indeed, prefrontal cortex damage has been extensively documented to cause marked impulsivity, poor decision making, and an increased propensity for substance abuse and dependency.1
Functional imaging studies also have shown that adolescents appear to use these neural regions inefficiently during decision making. Extensive areas of the involved brain regions are activated in individuals ages 8 to 20, whereas only focal activation occurs in adults.22
Dopamine. The nuclear accumbens (NA) plays an important role in processing afferent excitatory glutamatergic projections and then instigating the given response.23 Dopamine is released in the NA in response to a long list of stimuli, including:
- exposure to substances
- natural rewards such as food or sex
- stimulating situations, such as playing video games, gambling, or thrill seeking.2
Novel experiences and rewards that are delivered erratically cause an elevated dopamine release in the NA. This may explain, in part, the excitement one gains from activities with unpredictable outcomes, such as gambling, bungee jumping, parachuting, white-water rafting, or taking risks while driving.
As rewarding stimuli are re-experienced, dopamine response accelerates in magnitude, and the reward becomes progressively stronger as the experience is repeated. This repeated dopamine release in the NA changes the cellular proteins involved in signaling pathways thought to be associated with the transition from impulsive to compulsive behavior.2 Therefore, addiction may be caused by neurocircuitry changes induced by repeated dopamine release. Similarly, persons who engage in impulsive behavior may have hypersensitive dopamine-related reward circuitry, which may, in part, explain their predisposition to addictive behavior.
Serotonin. Serotonergic projections originate mainly in the midbrain’s raphe nuclei and are transmitted to the ventral tegmental area, NA, prefrontal cortex, amygdala, and hippocampus.1 Abnormal serotonin levels have been implicated in impaired impulse control2 and decreased CNS serotonin in impulsive behavior.24
Functional brain imaging studies have shown reduced serotonin neurotransmission in highly impulsive individuals, compared with normal controls.25 Administering serotonergic agents seems to markedly decrease impulsive behavior.26
Activity within this network is modulated by excitatory glutamatergic transmission and inhibitory GABAergic transmission within the cortices and by dopaminergic and serotonergic transmission within the VTA and raphe nuclei, respectively.2,20 Although all of these neurotransmitters have been implicated in impulsivity, dopamine and serotonin have been studied most extensively (box 2).1,2,23-26
CASE CONTINUED: PSYCHIATRIC WORKUP
Josh clearly is engaged in worrisome behavior with potential long-term consequences. To evaluate him for underlying psychopathology, the psychiatrist used a structured psychiatric exam, Minnesota Multi-phasic Personality Inventory (MMPI), and SNAP-IV Rating Scale for ADHD (see Related resources). Josh endorsed some depressive symptoms—which were also evident on the MMPI—but did not meet DSM-IVTR criteria for major depressive disorder. Neither were his symptoms diagnostic for any other Axis I or Axis II disorder.
Given the risk of harm and likelihood of worsening behavior over time, the psychiatrist schedules Josh for weekly psychotherapy and possible medication.
Psychosocial interventions are discussed with Josh’s parents, including monitoring his activities, restricting access to peers who have been a poor influence, reinforcing good behavior, and enlisting help from teachers and his friends’ parents. The effect of these interventions is to be explored in follow-up visits.
After months or years of conflict with their child, the parents of an adolescent with severe risk-taking behavior are often distraught and frustrated. You can comfort them by explaining:
- the biology of adolescent risk taking
- how you will treat such behavior in their adolescent
- and their role in the treatment plan.
Often the child’s behaviors have weakened their marriage, given adolescents’ tendency to divide and manipulate their parents. To help them set and maintain limits in the face of their child’s hostility:
Educate them to communicate with each other, to maintain a united front, and to set firm limits for their adolescent. For example, recommend that they:
- forbid cell phone use while the adolescent is driving
- limit the number of passengers allowed in the adolescent’s car to reduce distractions
- reduce the amount of money and free time available to the adolescent.
Counsel them that they are unlikely to receive the child’s respect or affection in the short term. Reassure them, however, that the child will thank them for their firm guidance after he or she matures to adulthood.
DEFINING DEGREES OF RISK
Although no criteria differentiate “normal” from “pathologic” risk taking, the definition of taking a risk implies potential adverse consequences. In evaluating the impulsive adolescent, it is important to determine which behaviors:
- can be instructive and promote maturation
- fall outside normal adolescent behavior and/or carry potentially severe outcomes.
Acceptable. Risk taking is acceptable if the potential adverse outcome is relatively benign and the adolescent is likely to learn from the experience. For example, driving 10 miles over the speed limit and receiving a ticket can lead to stricter observance of the speed limit.
Pathologic. Josh clearly exhibits risky behaviors that one would reasonably consider “pathologic,” as they carry potentially severe consequences that exceed any possible developmental gain. For example, drinking and driving can result in a DUI citation and/or a motor vehicle accident with physical injuries or death.
TREATMENT OPTIONS
Psychiatric comorbidity. When you evaluate an adolescent engaged in excessive risk taking, consider Axis I and II disorders characterized by marked impulsivity. If the patient meets diagnostic criteria for a psychopathology such as bipolar disorder or ADHD, treating the underlying condition will likely improve impulsivity.
Recommended approach. Even without an Axis I or Axis II disorder, adolescents who engage in pathologic risky behavior may benefit from psychosocial interventions (Box 3), psychotherapy, and perhaps medication.
Because very little evidence supports using psychotropics to treat pathologically impulsive adolescents, we recommend that you:
- first try psychosocial interventions and psychotherapy
- reserve medications for patients who do not respond adequately to nondrug approaches and engage in impulsive behaviors that pose a high risk for grave consequences.
Psychotherapy can be effective once the adolescent and clinician form a therapeutic alliance. Because Josh—like other such teens—will likely view his psychiatrist as “just another adult lecturing me on what to do,” focus first on establishing rapport by:
- getting to know him
- helping him feel at ease
- showing interest in his thoughts and empathy towards his concerns and complaints
- discussing anything but the reason his parents brought him to your office.
After you establish an alliance, focus therapy on helping the adolescent gain insight into his or her dangerous behaviors and their consequences. To illustrate to Josh the potential consequences of his behaviors, for example, you might introduce him to:
- someone disabled in a motor vehicle accident
- an HIV-positive activist
- a recovering alcoholic
- a long-time smoker with severe chronic obstructive pulmonary disease.
At-risk adolescents also could be encouraged to complete an educational program that teaches alternate activities for sensation seeking (such as skiing instead of high-speed driving).
Medication. Although the monoaminergic systems are known to modulate impulsive behavior, few studies have examined using medications to treat risk-taking adolescents, and no drugs are FDA-approved for this indication.
SSRIs. Selective serotonin reuptake inhibitors such as fluoxetine, sertraline, or escitalopram might be useful for treating excessive adolescent risk taking. A preliminary study with paroxetine—an SSRI not recommended for children and adolescents—suggests this class of antidepressants may help reduce impulsivity.26 In the absence of data specific to risk-taking behavior, we recommend using SSRI dosages similar to those used to treat mood disorders in adolescents.
Clomipramine acts mainly on the serotonin receptor, preventing serotonin reuptake in a manner similar to an SSRI. Because it has the greatest serotonergic effect in its drug class, clomipramine is the only tricyclic proven effective in obsessive-compulsive disorder.27 Although no data have shown that clomipramine affects impulsivity, it theoretically could be effective because of its effect on serotonin.
Divalproex sodium has been shown to effectively treat impulsivity, particularly in patients with autism spectrum disorders, intermittent explosive disorder, schizophrenia, borderline personality disorder, and bipolar disorder.27-30 As an off-label use, one could consider trying this agent in an adolescent with pathologic risk-taking behavior. Use the same dosages and obtain routine labs as indicated for adolescents with other disorders.
Adherence. Like Josh, adolescents who engage in high-risk behaviors often do not recognize their pathology and resist psychiatric intervention. Getting them to take medication or participate in psychotherapy can be quite difficult.
Adolescents are far more likely to adhere to treatment if you develop a rapport with them and they trust you. As psychotherapy and psychosocial interventions progress, patients become more likely to gain insight into their conditions and become more adherent.
Other options to encourage adherence include having the parent:
- administer the medication and ensure that the patient swallows it
- use rewards to reinforce the adolescent’s good behavior and adherence to treatment.
Follow up weekly with patients such as Josh who exhibit high-risk behaviors and require psychotherapy and medication. Follow less-acute patients 2 weeks after the initial evaluation, then monthly if they are responding to medication.
- Strauch B. The primal teen: what the new discoveries about the teenage brain tell us about our kids. New York: Doubleday, 2004.
- SNAP-IV Rating Scale to screen for attention-deficit/hyperactivity disorder. Is your child really ADD/ADHD? www.drbiofeedback.com. Accessed Sept. 8, 2004.
- Focus Adolescent Services. Resources and information for families with adolescent behavior problems, including high-risk behavior. http://www.focusas.com/BehavioralDisorders.html. Accessed Aug. 26, 2004.
Drug brand names
- Clomipramine • Anafranil
- Divalproex sodium • Depakote
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Paroxetine • Paxil
- Sertraline • Zoloft
Disclosure
Dr. Husted reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr Shapira receives grant or research support from Abbott Laboratories, Janssen Pharmaceutica, Ortho-McNeil Pharmaceutical, Bristol-Myers Squibb Co., Eli Lilly and Co., and Pfizer Inc. He is a speaker for AstraZeneca Pharmaceuticals, Forest Laboratories, and Ortho-McNeil Pharmaceutical, Inc.
1. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry 2003;160:1041-52.
2. Chambers RA, Potenza MN. Neurodevelopment, impulsivity, and adolescent gambling. J Gambl Stud 2003;19:53-84.
3. Turner C, McClure R. Age and gender differences in risk taking behavior as an explanation for high incidence of motor vehicle crashes as a driver in young males. Inj Control Saf Promot 2003;10:123-30.
4. Bachanas PJ, Morris MK, Lewis-Gess JK, et al. Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: developmental differences during adolescence. J Pediatr Psych 2002;27:373-84.
5. Goldstein RZ, Volkow ND. Drug addiction and its underlying neuro- biological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 2002;159:1642-52.
6. Spear LP. The adolescent brain and age-related behavioral manifestations. Neurosci Biobehav Rev 2000;24:417-63.
7. Clayton R. Transitions in drug use: risk and protective factors. In: Glantz M, Pickens R (eds). Vulnerability to drug abuse. Washington, DC: American Psychological Association, 1992;15-52.
8. Tamm L, Menon V, Reiss AL. Maturation of brain function associated with response inhibition. J Am Acad Child Adolesc Psychiatry 2002;41:1231-8.
9. Jonah BA. Sensation seeking and risky driving: a review and synthesis of the literature. Accid Anal Prev 1997;29:651-6.
10. Vitaro F, Arseneault L, Tremblay RE. Dispositional predictors of problem gambling in male adolescents. Am J Psychiatry 1997;154:1769-70.
11. Malow RM, Devieux JG, Jennings T, et al. Substance-abusing adolescents at varying levels of HIV risk: psychosocial characteristics, drug use, and sexual behavior. J Subst Abuse 2001;13:103-17.
12. Donovan JE, Jessor R, Costa FM. Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol 1988;56:762-5.
13. Vitaro F, Brendgen M, Ladouceur R, Tremblay RE. Gambling, delinquency, and drug use during adolescence: mutual influences and common risk factors. J Gambl Stud 2001;17:171-90.
14. Shope JT, Bingham CR. Drinking-driving as a component of problem driving and problem behavior in young adults. J Stud Alcohol 2002;63(1):24-33.
15. Potenza MN. The neurobiology of pathological gambling. Semin Clin Neuropsychiatry 2001;6:217-26.
16. Petry NM. Substance abuse, pathological gambling, and impulsiveness. Drug Alcohol Depend 2001;63:29-38.
17. Bechara A. Neurobiology of decision-making: risk and reward. Semin Clin Neuropsychiatry 2001;6:205-16.
18. Zuckerman M. Sensation seeking: the balance between risk and reward. In: Lipsitt LP, Mitnick LL (eds). Self-regulatory behavior and risk taking. Norwood, NJ: Ablex Publishing; 1992;143-52.
19. Masterman DL, Cummings JL. Frontal-subcortical circuits: the anatomical basis of executive, social and motivational behaviors. J Psychopharmacol 1997;11:107-14.
20. Horn NR, Dolan M, Elliot R, et al. Response inhibition and impulsivity: an fMRI study. Neuropsychologia 2003;41:1959-66.
21. Fallgatter AJ, Herrmann MJ. Electrophysiological assessment of impulsive behavior in healthy subjects. Neuropsychologia 2001;39:328-33.
22. Booth JR, Burman DD, Meyer JR, et al. Neural development of selective attention and response inhibition. Neuroimage 2003;20:737-51.
23. O’Donnell P, Greene J, Pabello N, et al. Modulation of cell firing in the nucleus accumbens. Ann NY Acad Sci 1999;877:157-75.
24. Nordin C, Eklundh T. Altered CSF 5-HIAA disposition in pathologic male gamblers. CNS Spectrums 1999;4:25-33.
25. Leyton M, Okazawa H, Diksic M, et al. Brain regional alpha-[11C] methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001;158:775-82.
26. Cherek DR, Lane SD, Pietras CJ, Steinberg JL. Effects of chronic paroxetine administration on measures of aggressive and impulsive responses of adult males with a history of conduct disorder. Psychopharmacology (Berl) 2002;159:266-74.
27. Geller DA, Biederman J, Stewart SE, et al. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Am J Psychiatry 2003;160:1919-28.
28. Hollander E, Allen A, Lopez RP, et al. A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62(3):199-203.
29. Swann AC. Treatment of aggression in patients with bipolar disorder. J Clin Psychiatry 1999;60(suppl 15):25-8.
30. Hollander E, Dolgoff-Kaspar R, Cartwright C, et al. An open trial of divalproex sodium in autism spectrum disorders. J Clin Psychiatry 2001;62:530-4.
Boys will be boys” and other platitudes may condone adolescent reckless driving, substance use, or sexual promiscuity—but to write off dangerous behavior as normal would be a mistake. Because adolescent impulsivity and sensation-seeking may have physiologic as well as emotional causes,1,2 excessive risk taking may be treatable.
This article discusses the neurobiology of adolescent risk taking, suggests how to determine when such behavior may be pathologic, and offers a treatment approach for at-risk teens and their parents.
CASE: ‘WHAT’S WRONG WITH OUR SON?’
Josh, age 17, is brought to the adolescent psychiatry clinic by his distraught parents, who report their son has undergone a “personality change” over the past 2 years. They recall that he was respectful, studious, and soft-spoken until age 15. Since then, he has been skipping school, staying out late at night with his friends, and “obsessed” with TV poker games.
His parents recently discovered he has been gambling for money, which greatly upsets them. They also found a pack of cigarettes in their son’s car and are concerned that he might be using other substances. What finally prompted the psychiatric visit was Josh’s recent traffic citation for driving 25 miles over the speed limit.
CAUSES OF RISK TAKING
Normal development. In the absence of psychopathology, adolescent risk taking appears to be a normal development stage that is vital to successful transition to adulthood. This assumes that adolescents such as Josh learn to moderate their behavior and avoid long-term negative consequences.
Impulsivity and sensation seeking are recognized as key factors in adolescent risk taking Box 1.1-4 Apparently, these traits result primarily from incomplete neural circuit maturation. Adolescent brain regions involved in impulsivity and risk taking are also involved in reward, and these centers exhibit an exaggerated response to stimuli.5 This amplified response may help explain an adolescent’s propensity for risky behavior.
Despite potential hazards, adolescent risk taking may confer benefits. In taking risks, adolescents:
- explore adult behavior
- learn to accomplish increasingly difficult developmental tasks
- reinforce their self-esteem.
Adolescent risk-takers have been found to be more self-confident, to feel more accepted, and to be better liked than their more-cautious peers.6
Psychiatric comorbidity. Excessive risk taking can be associated with psychiatric illness, including bipolar mania, psychosis, substance abuse, and impulse control disorders. Individuals with borderline personality and other cluster B disorders have marked impulsivity and thus are prone to risky behavior.
Teens with attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional-defiant disorder (ODD) also tend to exhibit high impulsivity.
Alcohol. 40% of adult alcoholics report having had their first alcoholism-related symptoms between ages 15 and 19.1
Gambling. 10% to 14% of adolescents engage in problem or pathologic gambling, and gambling typically begins at age 12.2
Automobile crashes are the leading cause of death among North American adolescents; both sexes ages 16 to 20 are at least twice as likely to be in a motor vehicle accident as are drivers ages 20 to 50.3
STDs. Each year, 3 million U.S. adolescents contract a sexually transmitted disease (STD). HIV infection is the seventh leading cause of death for Americans ages 13 to 24.4
Sexual activity. Adolescents are more likely than adults to engage in impulsive sexual behavior, to have multiple partners, and to fail to use contraceptives. Younger teens (ages 12 to 14) are more likely to engage in risky sexual practices than older teens (ages 16 to 19).4
CASE CONTINUED: JUST ‘HAVING FUN’
When interviewed alone, Josh admits to “occasional” truancy, which he attributes to being “bored” with school and wanting to spend time with his friends “doing fun stuff, like going to the beach.” He admits to gambling for money and smoking a half-pack of cigarettes daily, as well as drinking beer and smoking marijuana “a few times a week.”
Josh says he engages in these activities “because they’re fun,” and states he is annoyed by his parents’ concern. He blames the speeding ticket on “not paying attention.” He admits to drinking and driving but claims he always feels “in control.”
He also reports he has been sexually active since age 16 and often has had unprotected intercourse. When asked if he is concerned that he might contract a sexually transmitted disease or impregnate his partner, Josh appears ambivalent.
IMPULSIVITY IN ADOLESCENCE
Josh is engaging in numerous impulsive behaviors. Adolescents generally are more impulsive than adults, as demonstrated by their significantly higher impulsivity scores on standardized tests.7 Furthermore, as measured by improved response inhibition (go/no go tasks), the level of adolescent impulsivity is inversely related to age.8
Problem behavior syndrome. High impulsivity is predictive of problem gambling, drug use, and risky driving and sexual practices later in life.1,2,9-11 Adolescents with what some authors describe as a “problem behavior syndrome” engage in behaviors—such as substance use, risky sexual behavior,12 gambling,13 and reckless driving14—that share a common trend toward impulsivity.
Impaired data processing. Decision making has been proposed as a three-part cognitive process:
- accumulating sensory input
- processing this input and formulating a behavioral response appropriate to the situation
- planning and implementing the resultant motor output.2
Impulsivity is believed to result from impaired ability of the brain to process accumulated information or to formulate a response to it—or both. Impulsive individuals thus experience impaired data processing, in which they:
- misjudge the likely risk of a given action or overestimate their ability to accomplish a task
- show impaired response inhibition and thus find it difficult to resist an impulse to participate in a given activity.
Sensation seeking. Adolescents who exhibit risk-taking behavior may wish to experience the thrill of the behavior (sensation or novelty seeking). Alcoholic or drug-dependent individuals and those who engage in pathologic gambling or take chances while driving also demonstrate significantly impaired decision making.15-17 Adolescents who engage in these and other problem behaviors have similarly scored high on sensation-seeking scales.10,18
DECISION-MAKING BIOLOGY
At least four neural circuits process decisions, weighing the risks and benefits of a given situation and formulating a response. These circuits are:
- prefrontal cortices, including orbitofrontal, dorsolateral, and ventromedial
- ventral striatum, including the nucleus accumbens
- thalamus
- monoaminergic brainstem nuclei (ventral tegmental area [VTA] and raphe nuclei).19
Functional imaging studies—including MRI and PET, EEG, and electrophysiology—have confirmed that these four brain regions are integral to response inhibition and show abnormal activity in impulsive individuals.20,21 Indeed, prefrontal cortex damage has been extensively documented to cause marked impulsivity, poor decision making, and an increased propensity for substance abuse and dependency.1
Functional imaging studies also have shown that adolescents appear to use these neural regions inefficiently during decision making. Extensive areas of the involved brain regions are activated in individuals ages 8 to 20, whereas only focal activation occurs in adults.22
Dopamine. The nuclear accumbens (NA) plays an important role in processing afferent excitatory glutamatergic projections and then instigating the given response.23 Dopamine is released in the NA in response to a long list of stimuli, including:
- exposure to substances
- natural rewards such as food or sex
- stimulating situations, such as playing video games, gambling, or thrill seeking.2
Novel experiences and rewards that are delivered erratically cause an elevated dopamine release in the NA. This may explain, in part, the excitement one gains from activities with unpredictable outcomes, such as gambling, bungee jumping, parachuting, white-water rafting, or taking risks while driving.
As rewarding stimuli are re-experienced, dopamine response accelerates in magnitude, and the reward becomes progressively stronger as the experience is repeated. This repeated dopamine release in the NA changes the cellular proteins involved in signaling pathways thought to be associated with the transition from impulsive to compulsive behavior.2 Therefore, addiction may be caused by neurocircuitry changes induced by repeated dopamine release. Similarly, persons who engage in impulsive behavior may have hypersensitive dopamine-related reward circuitry, which may, in part, explain their predisposition to addictive behavior.
Serotonin. Serotonergic projections originate mainly in the midbrain’s raphe nuclei and are transmitted to the ventral tegmental area, NA, prefrontal cortex, amygdala, and hippocampus.1 Abnormal serotonin levels have been implicated in impaired impulse control2 and decreased CNS serotonin in impulsive behavior.24
Functional brain imaging studies have shown reduced serotonin neurotransmission in highly impulsive individuals, compared with normal controls.25 Administering serotonergic agents seems to markedly decrease impulsive behavior.26
Activity within this network is modulated by excitatory glutamatergic transmission and inhibitory GABAergic transmission within the cortices and by dopaminergic and serotonergic transmission within the VTA and raphe nuclei, respectively.2,20 Although all of these neurotransmitters have been implicated in impulsivity, dopamine and serotonin have been studied most extensively (box 2).1,2,23-26
CASE CONTINUED: PSYCHIATRIC WORKUP
Josh clearly is engaged in worrisome behavior with potential long-term consequences. To evaluate him for underlying psychopathology, the psychiatrist used a structured psychiatric exam, Minnesota Multi-phasic Personality Inventory (MMPI), and SNAP-IV Rating Scale for ADHD (see Related resources). Josh endorsed some depressive symptoms—which were also evident on the MMPI—but did not meet DSM-IVTR criteria for major depressive disorder. Neither were his symptoms diagnostic for any other Axis I or Axis II disorder.
Given the risk of harm and likelihood of worsening behavior over time, the psychiatrist schedules Josh for weekly psychotherapy and possible medication.
Psychosocial interventions are discussed with Josh’s parents, including monitoring his activities, restricting access to peers who have been a poor influence, reinforcing good behavior, and enlisting help from teachers and his friends’ parents. The effect of these interventions is to be explored in follow-up visits.
After months or years of conflict with their child, the parents of an adolescent with severe risk-taking behavior are often distraught and frustrated. You can comfort them by explaining:
- the biology of adolescent risk taking
- how you will treat such behavior in their adolescent
- and their role in the treatment plan.
Often the child’s behaviors have weakened their marriage, given adolescents’ tendency to divide and manipulate their parents. To help them set and maintain limits in the face of their child’s hostility:
Educate them to communicate with each other, to maintain a united front, and to set firm limits for their adolescent. For example, recommend that they:
- forbid cell phone use while the adolescent is driving
- limit the number of passengers allowed in the adolescent’s car to reduce distractions
- reduce the amount of money and free time available to the adolescent.
Counsel them that they are unlikely to receive the child’s respect or affection in the short term. Reassure them, however, that the child will thank them for their firm guidance after he or she matures to adulthood.
DEFINING DEGREES OF RISK
Although no criteria differentiate “normal” from “pathologic” risk taking, the definition of taking a risk implies potential adverse consequences. In evaluating the impulsive adolescent, it is important to determine which behaviors:
- can be instructive and promote maturation
- fall outside normal adolescent behavior and/or carry potentially severe outcomes.
Acceptable. Risk taking is acceptable if the potential adverse outcome is relatively benign and the adolescent is likely to learn from the experience. For example, driving 10 miles over the speed limit and receiving a ticket can lead to stricter observance of the speed limit.
Pathologic. Josh clearly exhibits risky behaviors that one would reasonably consider “pathologic,” as they carry potentially severe consequences that exceed any possible developmental gain. For example, drinking and driving can result in a DUI citation and/or a motor vehicle accident with physical injuries or death.
TREATMENT OPTIONS
Psychiatric comorbidity. When you evaluate an adolescent engaged in excessive risk taking, consider Axis I and II disorders characterized by marked impulsivity. If the patient meets diagnostic criteria for a psychopathology such as bipolar disorder or ADHD, treating the underlying condition will likely improve impulsivity.
Recommended approach. Even without an Axis I or Axis II disorder, adolescents who engage in pathologic risky behavior may benefit from psychosocial interventions (Box 3), psychotherapy, and perhaps medication.
Because very little evidence supports using psychotropics to treat pathologically impulsive adolescents, we recommend that you:
- first try psychosocial interventions and psychotherapy
- reserve medications for patients who do not respond adequately to nondrug approaches and engage in impulsive behaviors that pose a high risk for grave consequences.
Psychotherapy can be effective once the adolescent and clinician form a therapeutic alliance. Because Josh—like other such teens—will likely view his psychiatrist as “just another adult lecturing me on what to do,” focus first on establishing rapport by:
- getting to know him
- helping him feel at ease
- showing interest in his thoughts and empathy towards his concerns and complaints
- discussing anything but the reason his parents brought him to your office.
After you establish an alliance, focus therapy on helping the adolescent gain insight into his or her dangerous behaviors and their consequences. To illustrate to Josh the potential consequences of his behaviors, for example, you might introduce him to:
- someone disabled in a motor vehicle accident
- an HIV-positive activist
- a recovering alcoholic
- a long-time smoker with severe chronic obstructive pulmonary disease.
At-risk adolescents also could be encouraged to complete an educational program that teaches alternate activities for sensation seeking (such as skiing instead of high-speed driving).
Medication. Although the monoaminergic systems are known to modulate impulsive behavior, few studies have examined using medications to treat risk-taking adolescents, and no drugs are FDA-approved for this indication.
SSRIs. Selective serotonin reuptake inhibitors such as fluoxetine, sertraline, or escitalopram might be useful for treating excessive adolescent risk taking. A preliminary study with paroxetine—an SSRI not recommended for children and adolescents—suggests this class of antidepressants may help reduce impulsivity.26 In the absence of data specific to risk-taking behavior, we recommend using SSRI dosages similar to those used to treat mood disorders in adolescents.
Clomipramine acts mainly on the serotonin receptor, preventing serotonin reuptake in a manner similar to an SSRI. Because it has the greatest serotonergic effect in its drug class, clomipramine is the only tricyclic proven effective in obsessive-compulsive disorder.27 Although no data have shown that clomipramine affects impulsivity, it theoretically could be effective because of its effect on serotonin.
Divalproex sodium has been shown to effectively treat impulsivity, particularly in patients with autism spectrum disorders, intermittent explosive disorder, schizophrenia, borderline personality disorder, and bipolar disorder.27-30 As an off-label use, one could consider trying this agent in an adolescent with pathologic risk-taking behavior. Use the same dosages and obtain routine labs as indicated for adolescents with other disorders.
Adherence. Like Josh, adolescents who engage in high-risk behaviors often do not recognize their pathology and resist psychiatric intervention. Getting them to take medication or participate in psychotherapy can be quite difficult.
Adolescents are far more likely to adhere to treatment if you develop a rapport with them and they trust you. As psychotherapy and psychosocial interventions progress, patients become more likely to gain insight into their conditions and become more adherent.
Other options to encourage adherence include having the parent:
- administer the medication and ensure that the patient swallows it
- use rewards to reinforce the adolescent’s good behavior and adherence to treatment.
Follow up weekly with patients such as Josh who exhibit high-risk behaviors and require psychotherapy and medication. Follow less-acute patients 2 weeks after the initial evaluation, then monthly if they are responding to medication.
- Strauch B. The primal teen: what the new discoveries about the teenage brain tell us about our kids. New York: Doubleday, 2004.
- SNAP-IV Rating Scale to screen for attention-deficit/hyperactivity disorder. Is your child really ADD/ADHD? www.drbiofeedback.com. Accessed Sept. 8, 2004.
- Focus Adolescent Services. Resources and information for families with adolescent behavior problems, including high-risk behavior. http://www.focusas.com/BehavioralDisorders.html. Accessed Aug. 26, 2004.
Drug brand names
- Clomipramine • Anafranil
- Divalproex sodium • Depakote
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Paroxetine • Paxil
- Sertraline • Zoloft
Disclosure
Dr. Husted reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr Shapira receives grant or research support from Abbott Laboratories, Janssen Pharmaceutica, Ortho-McNeil Pharmaceutical, Bristol-Myers Squibb Co., Eli Lilly and Co., and Pfizer Inc. He is a speaker for AstraZeneca Pharmaceuticals, Forest Laboratories, and Ortho-McNeil Pharmaceutical, Inc.
Boys will be boys” and other platitudes may condone adolescent reckless driving, substance use, or sexual promiscuity—but to write off dangerous behavior as normal would be a mistake. Because adolescent impulsivity and sensation-seeking may have physiologic as well as emotional causes,1,2 excessive risk taking may be treatable.
This article discusses the neurobiology of adolescent risk taking, suggests how to determine when such behavior may be pathologic, and offers a treatment approach for at-risk teens and their parents.
CASE: ‘WHAT’S WRONG WITH OUR SON?’
Josh, age 17, is brought to the adolescent psychiatry clinic by his distraught parents, who report their son has undergone a “personality change” over the past 2 years. They recall that he was respectful, studious, and soft-spoken until age 15. Since then, he has been skipping school, staying out late at night with his friends, and “obsessed” with TV poker games.
His parents recently discovered he has been gambling for money, which greatly upsets them. They also found a pack of cigarettes in their son’s car and are concerned that he might be using other substances. What finally prompted the psychiatric visit was Josh’s recent traffic citation for driving 25 miles over the speed limit.
CAUSES OF RISK TAKING
Normal development. In the absence of psychopathology, adolescent risk taking appears to be a normal development stage that is vital to successful transition to adulthood. This assumes that adolescents such as Josh learn to moderate their behavior and avoid long-term negative consequences.
Impulsivity and sensation seeking are recognized as key factors in adolescent risk taking Box 1.1-4 Apparently, these traits result primarily from incomplete neural circuit maturation. Adolescent brain regions involved in impulsivity and risk taking are also involved in reward, and these centers exhibit an exaggerated response to stimuli.5 This amplified response may help explain an adolescent’s propensity for risky behavior.
Despite potential hazards, adolescent risk taking may confer benefits. In taking risks, adolescents:
- explore adult behavior
- learn to accomplish increasingly difficult developmental tasks
- reinforce their self-esteem.
Adolescent risk-takers have been found to be more self-confident, to feel more accepted, and to be better liked than their more-cautious peers.6
Psychiatric comorbidity. Excessive risk taking can be associated with psychiatric illness, including bipolar mania, psychosis, substance abuse, and impulse control disorders. Individuals with borderline personality and other cluster B disorders have marked impulsivity and thus are prone to risky behavior.
Teens with attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional-defiant disorder (ODD) also tend to exhibit high impulsivity.
Alcohol. 40% of adult alcoholics report having had their first alcoholism-related symptoms between ages 15 and 19.1
Gambling. 10% to 14% of adolescents engage in problem or pathologic gambling, and gambling typically begins at age 12.2
Automobile crashes are the leading cause of death among North American adolescents; both sexes ages 16 to 20 are at least twice as likely to be in a motor vehicle accident as are drivers ages 20 to 50.3
STDs. Each year, 3 million U.S. adolescents contract a sexually transmitted disease (STD). HIV infection is the seventh leading cause of death for Americans ages 13 to 24.4
Sexual activity. Adolescents are more likely than adults to engage in impulsive sexual behavior, to have multiple partners, and to fail to use contraceptives. Younger teens (ages 12 to 14) are more likely to engage in risky sexual practices than older teens (ages 16 to 19).4
CASE CONTINUED: JUST ‘HAVING FUN’
When interviewed alone, Josh admits to “occasional” truancy, which he attributes to being “bored” with school and wanting to spend time with his friends “doing fun stuff, like going to the beach.” He admits to gambling for money and smoking a half-pack of cigarettes daily, as well as drinking beer and smoking marijuana “a few times a week.”
Josh says he engages in these activities “because they’re fun,” and states he is annoyed by his parents’ concern. He blames the speeding ticket on “not paying attention.” He admits to drinking and driving but claims he always feels “in control.”
He also reports he has been sexually active since age 16 and often has had unprotected intercourse. When asked if he is concerned that he might contract a sexually transmitted disease or impregnate his partner, Josh appears ambivalent.
IMPULSIVITY IN ADOLESCENCE
Josh is engaging in numerous impulsive behaviors. Adolescents generally are more impulsive than adults, as demonstrated by their significantly higher impulsivity scores on standardized tests.7 Furthermore, as measured by improved response inhibition (go/no go tasks), the level of adolescent impulsivity is inversely related to age.8
Problem behavior syndrome. High impulsivity is predictive of problem gambling, drug use, and risky driving and sexual practices later in life.1,2,9-11 Adolescents with what some authors describe as a “problem behavior syndrome” engage in behaviors—such as substance use, risky sexual behavior,12 gambling,13 and reckless driving14—that share a common trend toward impulsivity.
Impaired data processing. Decision making has been proposed as a three-part cognitive process:
- accumulating sensory input
- processing this input and formulating a behavioral response appropriate to the situation
- planning and implementing the resultant motor output.2
Impulsivity is believed to result from impaired ability of the brain to process accumulated information or to formulate a response to it—or both. Impulsive individuals thus experience impaired data processing, in which they:
- misjudge the likely risk of a given action or overestimate their ability to accomplish a task
- show impaired response inhibition and thus find it difficult to resist an impulse to participate in a given activity.
Sensation seeking. Adolescents who exhibit risk-taking behavior may wish to experience the thrill of the behavior (sensation or novelty seeking). Alcoholic or drug-dependent individuals and those who engage in pathologic gambling or take chances while driving also demonstrate significantly impaired decision making.15-17 Adolescents who engage in these and other problem behaviors have similarly scored high on sensation-seeking scales.10,18
DECISION-MAKING BIOLOGY
At least four neural circuits process decisions, weighing the risks and benefits of a given situation and formulating a response. These circuits are:
- prefrontal cortices, including orbitofrontal, dorsolateral, and ventromedial
- ventral striatum, including the nucleus accumbens
- thalamus
- monoaminergic brainstem nuclei (ventral tegmental area [VTA] and raphe nuclei).19
Functional imaging studies—including MRI and PET, EEG, and electrophysiology—have confirmed that these four brain regions are integral to response inhibition and show abnormal activity in impulsive individuals.20,21 Indeed, prefrontal cortex damage has been extensively documented to cause marked impulsivity, poor decision making, and an increased propensity for substance abuse and dependency.1
Functional imaging studies also have shown that adolescents appear to use these neural regions inefficiently during decision making. Extensive areas of the involved brain regions are activated in individuals ages 8 to 20, whereas only focal activation occurs in adults.22
Dopamine. The nuclear accumbens (NA) plays an important role in processing afferent excitatory glutamatergic projections and then instigating the given response.23 Dopamine is released in the NA in response to a long list of stimuli, including:
- exposure to substances
- natural rewards such as food or sex
- stimulating situations, such as playing video games, gambling, or thrill seeking.2
Novel experiences and rewards that are delivered erratically cause an elevated dopamine release in the NA. This may explain, in part, the excitement one gains from activities with unpredictable outcomes, such as gambling, bungee jumping, parachuting, white-water rafting, or taking risks while driving.
As rewarding stimuli are re-experienced, dopamine response accelerates in magnitude, and the reward becomes progressively stronger as the experience is repeated. This repeated dopamine release in the NA changes the cellular proteins involved in signaling pathways thought to be associated with the transition from impulsive to compulsive behavior.2 Therefore, addiction may be caused by neurocircuitry changes induced by repeated dopamine release. Similarly, persons who engage in impulsive behavior may have hypersensitive dopamine-related reward circuitry, which may, in part, explain their predisposition to addictive behavior.
Serotonin. Serotonergic projections originate mainly in the midbrain’s raphe nuclei and are transmitted to the ventral tegmental area, NA, prefrontal cortex, amygdala, and hippocampus.1 Abnormal serotonin levels have been implicated in impaired impulse control2 and decreased CNS serotonin in impulsive behavior.24
Functional brain imaging studies have shown reduced serotonin neurotransmission in highly impulsive individuals, compared with normal controls.25 Administering serotonergic agents seems to markedly decrease impulsive behavior.26
Activity within this network is modulated by excitatory glutamatergic transmission and inhibitory GABAergic transmission within the cortices and by dopaminergic and serotonergic transmission within the VTA and raphe nuclei, respectively.2,20 Although all of these neurotransmitters have been implicated in impulsivity, dopamine and serotonin have been studied most extensively (box 2).1,2,23-26
CASE CONTINUED: PSYCHIATRIC WORKUP
Josh clearly is engaged in worrisome behavior with potential long-term consequences. To evaluate him for underlying psychopathology, the psychiatrist used a structured psychiatric exam, Minnesota Multi-phasic Personality Inventory (MMPI), and SNAP-IV Rating Scale for ADHD (see Related resources). Josh endorsed some depressive symptoms—which were also evident on the MMPI—but did not meet DSM-IVTR criteria for major depressive disorder. Neither were his symptoms diagnostic for any other Axis I or Axis II disorder.
Given the risk of harm and likelihood of worsening behavior over time, the psychiatrist schedules Josh for weekly psychotherapy and possible medication.
Psychosocial interventions are discussed with Josh’s parents, including monitoring his activities, restricting access to peers who have been a poor influence, reinforcing good behavior, and enlisting help from teachers and his friends’ parents. The effect of these interventions is to be explored in follow-up visits.
After months or years of conflict with their child, the parents of an adolescent with severe risk-taking behavior are often distraught and frustrated. You can comfort them by explaining:
- the biology of adolescent risk taking
- how you will treat such behavior in their adolescent
- and their role in the treatment plan.
Often the child’s behaviors have weakened their marriage, given adolescents’ tendency to divide and manipulate their parents. To help them set and maintain limits in the face of their child’s hostility:
Educate them to communicate with each other, to maintain a united front, and to set firm limits for their adolescent. For example, recommend that they:
- forbid cell phone use while the adolescent is driving
- limit the number of passengers allowed in the adolescent’s car to reduce distractions
- reduce the amount of money and free time available to the adolescent.
Counsel them that they are unlikely to receive the child’s respect or affection in the short term. Reassure them, however, that the child will thank them for their firm guidance after he or she matures to adulthood.
DEFINING DEGREES OF RISK
Although no criteria differentiate “normal” from “pathologic” risk taking, the definition of taking a risk implies potential adverse consequences. In evaluating the impulsive adolescent, it is important to determine which behaviors:
- can be instructive and promote maturation
- fall outside normal adolescent behavior and/or carry potentially severe outcomes.
Acceptable. Risk taking is acceptable if the potential adverse outcome is relatively benign and the adolescent is likely to learn from the experience. For example, driving 10 miles over the speed limit and receiving a ticket can lead to stricter observance of the speed limit.
Pathologic. Josh clearly exhibits risky behaviors that one would reasonably consider “pathologic,” as they carry potentially severe consequences that exceed any possible developmental gain. For example, drinking and driving can result in a DUI citation and/or a motor vehicle accident with physical injuries or death.
TREATMENT OPTIONS
Psychiatric comorbidity. When you evaluate an adolescent engaged in excessive risk taking, consider Axis I and II disorders characterized by marked impulsivity. If the patient meets diagnostic criteria for a psychopathology such as bipolar disorder or ADHD, treating the underlying condition will likely improve impulsivity.
Recommended approach. Even without an Axis I or Axis II disorder, adolescents who engage in pathologic risky behavior may benefit from psychosocial interventions (Box 3), psychotherapy, and perhaps medication.
Because very little evidence supports using psychotropics to treat pathologically impulsive adolescents, we recommend that you:
- first try psychosocial interventions and psychotherapy
- reserve medications for patients who do not respond adequately to nondrug approaches and engage in impulsive behaviors that pose a high risk for grave consequences.
Psychotherapy can be effective once the adolescent and clinician form a therapeutic alliance. Because Josh—like other such teens—will likely view his psychiatrist as “just another adult lecturing me on what to do,” focus first on establishing rapport by:
- getting to know him
- helping him feel at ease
- showing interest in his thoughts and empathy towards his concerns and complaints
- discussing anything but the reason his parents brought him to your office.
After you establish an alliance, focus therapy on helping the adolescent gain insight into his or her dangerous behaviors and their consequences. To illustrate to Josh the potential consequences of his behaviors, for example, you might introduce him to:
- someone disabled in a motor vehicle accident
- an HIV-positive activist
- a recovering alcoholic
- a long-time smoker with severe chronic obstructive pulmonary disease.
At-risk adolescents also could be encouraged to complete an educational program that teaches alternate activities for sensation seeking (such as skiing instead of high-speed driving).
Medication. Although the monoaminergic systems are known to modulate impulsive behavior, few studies have examined using medications to treat risk-taking adolescents, and no drugs are FDA-approved for this indication.
SSRIs. Selective serotonin reuptake inhibitors such as fluoxetine, sertraline, or escitalopram might be useful for treating excessive adolescent risk taking. A preliminary study with paroxetine—an SSRI not recommended for children and adolescents—suggests this class of antidepressants may help reduce impulsivity.26 In the absence of data specific to risk-taking behavior, we recommend using SSRI dosages similar to those used to treat mood disorders in adolescents.
Clomipramine acts mainly on the serotonin receptor, preventing serotonin reuptake in a manner similar to an SSRI. Because it has the greatest serotonergic effect in its drug class, clomipramine is the only tricyclic proven effective in obsessive-compulsive disorder.27 Although no data have shown that clomipramine affects impulsivity, it theoretically could be effective because of its effect on serotonin.
Divalproex sodium has been shown to effectively treat impulsivity, particularly in patients with autism spectrum disorders, intermittent explosive disorder, schizophrenia, borderline personality disorder, and bipolar disorder.27-30 As an off-label use, one could consider trying this agent in an adolescent with pathologic risk-taking behavior. Use the same dosages and obtain routine labs as indicated for adolescents with other disorders.
Adherence. Like Josh, adolescents who engage in high-risk behaviors often do not recognize their pathology and resist psychiatric intervention. Getting them to take medication or participate in psychotherapy can be quite difficult.
Adolescents are far more likely to adhere to treatment if you develop a rapport with them and they trust you. As psychotherapy and psychosocial interventions progress, patients become more likely to gain insight into their conditions and become more adherent.
Other options to encourage adherence include having the parent:
- administer the medication and ensure that the patient swallows it
- use rewards to reinforce the adolescent’s good behavior and adherence to treatment.
Follow up weekly with patients such as Josh who exhibit high-risk behaviors and require psychotherapy and medication. Follow less-acute patients 2 weeks after the initial evaluation, then monthly if they are responding to medication.
- Strauch B. The primal teen: what the new discoveries about the teenage brain tell us about our kids. New York: Doubleday, 2004.
- SNAP-IV Rating Scale to screen for attention-deficit/hyperactivity disorder. Is your child really ADD/ADHD? www.drbiofeedback.com. Accessed Sept. 8, 2004.
- Focus Adolescent Services. Resources and information for families with adolescent behavior problems, including high-risk behavior. http://www.focusas.com/BehavioralDisorders.html. Accessed Aug. 26, 2004.
Drug brand names
- Clomipramine • Anafranil
- Divalproex sodium • Depakote
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Paroxetine • Paxil
- Sertraline • Zoloft
Disclosure
Dr. Husted reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr Shapira receives grant or research support from Abbott Laboratories, Janssen Pharmaceutica, Ortho-McNeil Pharmaceutical, Bristol-Myers Squibb Co., Eli Lilly and Co., and Pfizer Inc. He is a speaker for AstraZeneca Pharmaceuticals, Forest Laboratories, and Ortho-McNeil Pharmaceutical, Inc.
1. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry 2003;160:1041-52.
2. Chambers RA, Potenza MN. Neurodevelopment, impulsivity, and adolescent gambling. J Gambl Stud 2003;19:53-84.
3. Turner C, McClure R. Age and gender differences in risk taking behavior as an explanation for high incidence of motor vehicle crashes as a driver in young males. Inj Control Saf Promot 2003;10:123-30.
4. Bachanas PJ, Morris MK, Lewis-Gess JK, et al. Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: developmental differences during adolescence. J Pediatr Psych 2002;27:373-84.
5. Goldstein RZ, Volkow ND. Drug addiction and its underlying neuro- biological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 2002;159:1642-52.
6. Spear LP. The adolescent brain and age-related behavioral manifestations. Neurosci Biobehav Rev 2000;24:417-63.
7. Clayton R. Transitions in drug use: risk and protective factors. In: Glantz M, Pickens R (eds). Vulnerability to drug abuse. Washington, DC: American Psychological Association, 1992;15-52.
8. Tamm L, Menon V, Reiss AL. Maturation of brain function associated with response inhibition. J Am Acad Child Adolesc Psychiatry 2002;41:1231-8.
9. Jonah BA. Sensation seeking and risky driving: a review and synthesis of the literature. Accid Anal Prev 1997;29:651-6.
10. Vitaro F, Arseneault L, Tremblay RE. Dispositional predictors of problem gambling in male adolescents. Am J Psychiatry 1997;154:1769-70.
11. Malow RM, Devieux JG, Jennings T, et al. Substance-abusing adolescents at varying levels of HIV risk: psychosocial characteristics, drug use, and sexual behavior. J Subst Abuse 2001;13:103-17.
12. Donovan JE, Jessor R, Costa FM. Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol 1988;56:762-5.
13. Vitaro F, Brendgen M, Ladouceur R, Tremblay RE. Gambling, delinquency, and drug use during adolescence: mutual influences and common risk factors. J Gambl Stud 2001;17:171-90.
14. Shope JT, Bingham CR. Drinking-driving as a component of problem driving and problem behavior in young adults. J Stud Alcohol 2002;63(1):24-33.
15. Potenza MN. The neurobiology of pathological gambling. Semin Clin Neuropsychiatry 2001;6:217-26.
16. Petry NM. Substance abuse, pathological gambling, and impulsiveness. Drug Alcohol Depend 2001;63:29-38.
17. Bechara A. Neurobiology of decision-making: risk and reward. Semin Clin Neuropsychiatry 2001;6:205-16.
18. Zuckerman M. Sensation seeking: the balance between risk and reward. In: Lipsitt LP, Mitnick LL (eds). Self-regulatory behavior and risk taking. Norwood, NJ: Ablex Publishing; 1992;143-52.
19. Masterman DL, Cummings JL. Frontal-subcortical circuits: the anatomical basis of executive, social and motivational behaviors. J Psychopharmacol 1997;11:107-14.
20. Horn NR, Dolan M, Elliot R, et al. Response inhibition and impulsivity: an fMRI study. Neuropsychologia 2003;41:1959-66.
21. Fallgatter AJ, Herrmann MJ. Electrophysiological assessment of impulsive behavior in healthy subjects. Neuropsychologia 2001;39:328-33.
22. Booth JR, Burman DD, Meyer JR, et al. Neural development of selective attention and response inhibition. Neuroimage 2003;20:737-51.
23. O’Donnell P, Greene J, Pabello N, et al. Modulation of cell firing in the nucleus accumbens. Ann NY Acad Sci 1999;877:157-75.
24. Nordin C, Eklundh T. Altered CSF 5-HIAA disposition in pathologic male gamblers. CNS Spectrums 1999;4:25-33.
25. Leyton M, Okazawa H, Diksic M, et al. Brain regional alpha-[11C] methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001;158:775-82.
26. Cherek DR, Lane SD, Pietras CJ, Steinberg JL. Effects of chronic paroxetine administration on measures of aggressive and impulsive responses of adult males with a history of conduct disorder. Psychopharmacology (Berl) 2002;159:266-74.
27. Geller DA, Biederman J, Stewart SE, et al. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Am J Psychiatry 2003;160:1919-28.
28. Hollander E, Allen A, Lopez RP, et al. A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62(3):199-203.
29. Swann AC. Treatment of aggression in patients with bipolar disorder. J Clin Psychiatry 1999;60(suppl 15):25-8.
30. Hollander E, Dolgoff-Kaspar R, Cartwright C, et al. An open trial of divalproex sodium in autism spectrum disorders. J Clin Psychiatry 2001;62:530-4.
1. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry 2003;160:1041-52.
2. Chambers RA, Potenza MN. Neurodevelopment, impulsivity, and adolescent gambling. J Gambl Stud 2003;19:53-84.
3. Turner C, McClure R. Age and gender differences in risk taking behavior as an explanation for high incidence of motor vehicle crashes as a driver in young males. Inj Control Saf Promot 2003;10:123-30.
4. Bachanas PJ, Morris MK, Lewis-Gess JK, et al. Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: developmental differences during adolescence. J Pediatr Psych 2002;27:373-84.
5. Goldstein RZ, Volkow ND. Drug addiction and its underlying neuro- biological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 2002;159:1642-52.
6. Spear LP. The adolescent brain and age-related behavioral manifestations. Neurosci Biobehav Rev 2000;24:417-63.
7. Clayton R. Transitions in drug use: risk and protective factors. In: Glantz M, Pickens R (eds). Vulnerability to drug abuse. Washington, DC: American Psychological Association, 1992;15-52.
8. Tamm L, Menon V, Reiss AL. Maturation of brain function associated with response inhibition. J Am Acad Child Adolesc Psychiatry 2002;41:1231-8.
9. Jonah BA. Sensation seeking and risky driving: a review and synthesis of the literature. Accid Anal Prev 1997;29:651-6.
10. Vitaro F, Arseneault L, Tremblay RE. Dispositional predictors of problem gambling in male adolescents. Am J Psychiatry 1997;154:1769-70.
11. Malow RM, Devieux JG, Jennings T, et al. Substance-abusing adolescents at varying levels of HIV risk: psychosocial characteristics, drug use, and sexual behavior. J Subst Abuse 2001;13:103-17.
12. Donovan JE, Jessor R, Costa FM. Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol 1988;56:762-5.
13. Vitaro F, Brendgen M, Ladouceur R, Tremblay RE. Gambling, delinquency, and drug use during adolescence: mutual influences and common risk factors. J Gambl Stud 2001;17:171-90.
14. Shope JT, Bingham CR. Drinking-driving as a component of problem driving and problem behavior in young adults. J Stud Alcohol 2002;63(1):24-33.
15. Potenza MN. The neurobiology of pathological gambling. Semin Clin Neuropsychiatry 2001;6:217-26.
16. Petry NM. Substance abuse, pathological gambling, and impulsiveness. Drug Alcohol Depend 2001;63:29-38.
17. Bechara A. Neurobiology of decision-making: risk and reward. Semin Clin Neuropsychiatry 2001;6:205-16.
18. Zuckerman M. Sensation seeking: the balance between risk and reward. In: Lipsitt LP, Mitnick LL (eds). Self-regulatory behavior and risk taking. Norwood, NJ: Ablex Publishing; 1992;143-52.
19. Masterman DL, Cummings JL. Frontal-subcortical circuits: the anatomical basis of executive, social and motivational behaviors. J Psychopharmacol 1997;11:107-14.
20. Horn NR, Dolan M, Elliot R, et al. Response inhibition and impulsivity: an fMRI study. Neuropsychologia 2003;41:1959-66.
21. Fallgatter AJ, Herrmann MJ. Electrophysiological assessment of impulsive behavior in healthy subjects. Neuropsychologia 2001;39:328-33.
22. Booth JR, Burman DD, Meyer JR, et al. Neural development of selective attention and response inhibition. Neuroimage 2003;20:737-51.
23. O’Donnell P, Greene J, Pabello N, et al. Modulation of cell firing in the nucleus accumbens. Ann NY Acad Sci 1999;877:157-75.
24. Nordin C, Eklundh T. Altered CSF 5-HIAA disposition in pathologic male gamblers. CNS Spectrums 1999;4:25-33.
25. Leyton M, Okazawa H, Diksic M, et al. Brain regional alpha-[11C] methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder. Am J Psychiatry 2001;158:775-82.
26. Cherek DR, Lane SD, Pietras CJ, Steinberg JL. Effects of chronic paroxetine administration on measures of aggressive and impulsive responses of adult males with a history of conduct disorder. Psychopharmacology (Berl) 2002;159:266-74.
27. Geller DA, Biederman J, Stewart SE, et al. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Am J Psychiatry 2003;160:1919-28.
28. Hollander E, Allen A, Lopez RP, et al. A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 2001;62(3):199-203.
29. Swann AC. Treatment of aggression in patients with bipolar disorder. J Clin Psychiatry 1999;60(suppl 15):25-8.
30. Hollander E, Dolgoff-Kaspar R, Cartwright C, et al. An open trial of divalproex sodium in autism spectrum disorders. J Clin Psychiatry 2001;62:530-4.
Time to log off: New diagnostic criteria for problematic Internet use
Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses.
We propose a screening tool called “MOUSE” and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:
- How does problematic Internet use present?
- Is it an addiction or an impulse control disorder?
- How can we help those afflicted with this problem?
When Internet use goes over the line
Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:
- an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function1
- and employment and relationships are jeopardized by the hours spent online2 (Box).
Relationships—particularly marriages but also parent-child relationships, dating relationships, and close friendships—appear to suffer the greatest harm. At least one-half of “Internet addicts” (53%) report that their Internet use has caused serious relationship problems.
School. Academic problems are common; one study showed 58% of students blamed Internet use for a drop in grades, missed classes, declining study habits, or being placed on probation.
Workplace. Many executives—55% in one study—complain that time spent on the Internet for non-business purposes reduces their employees’ effectiveness.
Health. Some users spend 40 to 80 hours per week online, and single sessions can last up to 20 hours. Lack of sleep results in fatigue, decreased exercise, and decreased immunity. Sitting in front of the computer for hours also increases the risk of carpal tunnel syndrome, eye strain, and back pain.
Other addictions. The more time spent on the Internet, the greater the user’s risk of exposure to other addictive activities, such as online gambling and sexual solicitations. This risk is particularly concerning in children and adolescents.
Source: Young KS. Innovations in Clin Pract 1999;17:19-31.
Case: Computer gamer out of control
Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.
He is taking no medications. The only clinically significant family history is his father’s apparent OCD, undiagnosed and untreated.
Mr. A’s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.
Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week—nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:
- 35% in chat forums, communicating with gaming partners he has never met
- 25% in multi-player, video/strategy games
- 15% using e-mail
- and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).
He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.
Internet overuse: An ‘addiction’?
Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke.3 He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.4,5
Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder.5-8 Shapira et al studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.1
As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.8
Diagnostic criteria. Although Mr. A’s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),9 which we define as:
- uncontrollable
- markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
- and not solely present during mania or hypomania.
Teasing out comorbid disorders
As in Mr. A’s case, Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.10-12
Although some researchers feel that the many comorbid and complicating factors cannot be teased out,13 most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.
A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.
Shapira et al1,14 found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black11 found:
- 33% had a mood disorder
- 38% had a substance use disorder
- 19% had an anxiety disorder
- 52% met criteria for at least one personality disorder.
On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.1,11
Table 1
PROPOSED DIAGNOSTIC CRITERIA FOR PROBLEMATIC INTERNET USE
| Maladaptive preoccupation with Internet use, as indicated by at least one of the following: |
|
|
| Source: Reprinted with permission from an article by Shapira et al9 that has been accepted for publication in Depression and Anxiety. © Copyright 2003 John Wiley & Sons. |
Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al15 hypothesized that the Internet use caused the depression. Pratarelli et al16 noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.
In a survey of college students, individuals with “Internet addiction” were found to:
- have obsessive characteristics
- prefer online interactions to real-life interactions
- use the Internet “to feel better,” alleviate depression, and become sexually aroused.16
Personality traits. In another study, Orzack12 found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of “Internet addiction disorder:”
- boredom
- private self-consciousness
- loneliness
- social anxiety
- shyness
- and low self-esteem.
Table 2
5 SCREENING QUESTIONS FOR PROBLEMATIC INTERNET USE
| More than intended time spent online? |
| Other responsibilities or activities neglected? |
| Unsuccessful attempts to cut down? |
| Significant relationship discord due to use? |
| Excessive thoughts or anxiety when not online? |
Diagnosing Internet overuse
Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions—easily recalled by the mnemonic MOUSE—can help you screen for problematic Internet use (Table 2).
History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.17 Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.
To determine how the Internet may alter the patient’s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the patient sort through his or her emotions.17
Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.17 They tend to take pride in their computer skills2 and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use (“I’m using it for work, academics, travel, research, etc.”).
Chomorbidities. Given the high incidence of psychiatric comorbidity,1 it is important to complete a thorough psychiatric evaluation and treat any underlying illness. Whether the illness is primary or comorbid, it is likely exacerbating the symptoms of problematic Internet use.
Changing problematic behaviors
Psychotherapy. Once you find the motives and possible causes of Internet overuse, what is the best form of treatment? This question warrants further study, but cognitive-behavioral therapy (CBT) is the primary treatment at this time.
The goal of CBT is for patients to disrupt their problematic computer use and reconstruct their routines with other activities. They can:
- use external timers to keep track of time online
- set goals of brief, frequent sessions online
- carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected.17
Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use.12 Support groups and family therapy can help repair damaged relationships and engage friends and family in the treatment plan.
Drug therapy. No studies have looked at drug therapy for problematic Internet use, beyond treating comorbid psychiatric illnesses.
Treatment declined. Mr. A declined treatment for his problematic Internet use. As in many other psychiatric illnesses, insight into impulse control disorders tends to be limited. We can address the problem directly and offer to help patients change their online behaviors, but we cannot force them into treatment if they are not endangering themselves or others.
Related resources
- Computer Addiction Services. Maressa Hecht Orzack, PhD. www.computeraddiction.com; (617) 855-2908.
- Center for Online Addiction. Kimberly S. Young, PhD. www.netaddiction.com; (877) 292-3737.
1. Shapira NA, Goldsmith TG, Keck PE, Jr, Khosla UM, McElroy SL. Psychiatric features of individuals with problematic Internet use. J Affect Disord 2000;57:267-72.
2. Beard KW, Wolf EM. Modification in the proposed diagnostic criteria for Internet addiction. Cyberpsychol Behav 2001;4:377-83.
3. Goldberg I. Internet addiction. Available at http://www.cybernothing.org/jdfalk/media-coverage/archive/msg01305.html. Accessed Feb. 26, 2003.
4. Griffiths MD. Internet addiction: an issue for clinical psychology? Clin Psychol Forum 1996;97:32-6.
5. Young KS. Psychology of computer use: XL. Addictive use of the Internet: a case that breaks the stereotype. Psychol Rep 1996;79:899-902.
6. Treuer T, Fábián Z, Füredi J. Internet addiction associated with features of impulse control disorder: is it a real psychiatric disorder? J Affect Disord 2001;66:283.-
7. Young KS. Caught in the net: how to recognize the signs of Internet addiction-and a winning strategy for recovery. New York: John Wiley & Sons, Inc. 1998;8.-
8. Young KS, Rogers RC. The relationship between depression and Internet addiction. Cyberpsychol Behav 1998;1:25-8.
9. Shapira NA, Lessig MC, Goldsmith TD, et al. Problematic Internet use: proposed classification and diagnostic criteria. Depress Anxiety (in press).
10. Griffiths MD. Internet addiction: Fact or fiction? Psychologist 1999;12:246-50.
11. Black DW, Belsare G, Schlosser S. Clinical features, psychiatric comorbidity, and health-related quality of life in persons reporting compulsive computer use behavior. J Clin Psychiatry 1999;60:839-44.
12. Orzack MH. How to recognize and treat computer.com addictions. Directions in Mental Health Counseling 1999;9:13-20.
13. Stein DJ. Internet addiction, Internet psychotherapy (letter; comment). Am J Psychiatry 1997;154(6):890.-
14. Shapira NA. Unpublished data, 2000.
15. Kraut R, Lundmark V, Patterson M, Kiesler S, Mukopadhyay T, Scherlis W. Internet paradox: A social technology that reduces social involvement and psychological wellbeing? Am Psychol 1998;53:1017-31.
16. Pratarelli ME, Browne BL. Confirmatory factor analysis of Internet use and addiction. Cyberpsychol Behav 2002;5:53-64.
17. Young KS. Internet addiction: symptoms, evaluation and treatment. Innovations in Clin Pract 1999;17:19-31.
Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses.
We propose a screening tool called “MOUSE” and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:
- How does problematic Internet use present?
- Is it an addiction or an impulse control disorder?
- How can we help those afflicted with this problem?
When Internet use goes over the line
Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:
- an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function1
- and employment and relationships are jeopardized by the hours spent online2 (Box).
Relationships—particularly marriages but also parent-child relationships, dating relationships, and close friendships—appear to suffer the greatest harm. At least one-half of “Internet addicts” (53%) report that their Internet use has caused serious relationship problems.
School. Academic problems are common; one study showed 58% of students blamed Internet use for a drop in grades, missed classes, declining study habits, or being placed on probation.
Workplace. Many executives—55% in one study—complain that time spent on the Internet for non-business purposes reduces their employees’ effectiveness.
Health. Some users spend 40 to 80 hours per week online, and single sessions can last up to 20 hours. Lack of sleep results in fatigue, decreased exercise, and decreased immunity. Sitting in front of the computer for hours also increases the risk of carpal tunnel syndrome, eye strain, and back pain.
Other addictions. The more time spent on the Internet, the greater the user’s risk of exposure to other addictive activities, such as online gambling and sexual solicitations. This risk is particularly concerning in children and adolescents.
Source: Young KS. Innovations in Clin Pract 1999;17:19-31.
Case: Computer gamer out of control
Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.
He is taking no medications. The only clinically significant family history is his father’s apparent OCD, undiagnosed and untreated.
Mr. A’s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.
Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week—nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:
- 35% in chat forums, communicating with gaming partners he has never met
- 25% in multi-player, video/strategy games
- 15% using e-mail
- and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).
He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.
Internet overuse: An ‘addiction’?
Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke.3 He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.4,5
Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder.5-8 Shapira et al studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.1
As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.8
Diagnostic criteria. Although Mr. A’s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),9 which we define as:
- uncontrollable
- markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
- and not solely present during mania or hypomania.
Teasing out comorbid disorders
As in Mr. A’s case, Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.10-12
Although some researchers feel that the many comorbid and complicating factors cannot be teased out,13 most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.
A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.
Shapira et al1,14 found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black11 found:
- 33% had a mood disorder
- 38% had a substance use disorder
- 19% had an anxiety disorder
- 52% met criteria for at least one personality disorder.
On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.1,11
Table 1
PROPOSED DIAGNOSTIC CRITERIA FOR PROBLEMATIC INTERNET USE
| Maladaptive preoccupation with Internet use, as indicated by at least one of the following: |
|
|
| Source: Reprinted with permission from an article by Shapira et al9 that has been accepted for publication in Depression and Anxiety. © Copyright 2003 John Wiley & Sons. |
Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al15 hypothesized that the Internet use caused the depression. Pratarelli et al16 noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.
In a survey of college students, individuals with “Internet addiction” were found to:
- have obsessive characteristics
- prefer online interactions to real-life interactions
- use the Internet “to feel better,” alleviate depression, and become sexually aroused.16
Personality traits. In another study, Orzack12 found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of “Internet addiction disorder:”
- boredom
- private self-consciousness
- loneliness
- social anxiety
- shyness
- and low self-esteem.
Table 2
5 SCREENING QUESTIONS FOR PROBLEMATIC INTERNET USE
| More than intended time spent online? |
| Other responsibilities or activities neglected? |
| Unsuccessful attempts to cut down? |
| Significant relationship discord due to use? |
| Excessive thoughts or anxiety when not online? |
Diagnosing Internet overuse
Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions—easily recalled by the mnemonic MOUSE—can help you screen for problematic Internet use (Table 2).
History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.17 Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.
To determine how the Internet may alter the patient’s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the patient sort through his or her emotions.17
Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.17 They tend to take pride in their computer skills2 and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use (“I’m using it for work, academics, travel, research, etc.”).
Chomorbidities. Given the high incidence of psychiatric comorbidity,1 it is important to complete a thorough psychiatric evaluation and treat any underlying illness. Whether the illness is primary or comorbid, it is likely exacerbating the symptoms of problematic Internet use.
Changing problematic behaviors
Psychotherapy. Once you find the motives and possible causes of Internet overuse, what is the best form of treatment? This question warrants further study, but cognitive-behavioral therapy (CBT) is the primary treatment at this time.
The goal of CBT is for patients to disrupt their problematic computer use and reconstruct their routines with other activities. They can:
- use external timers to keep track of time online
- set goals of brief, frequent sessions online
- carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected.17
Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use.12 Support groups and family therapy can help repair damaged relationships and engage friends and family in the treatment plan.
Drug therapy. No studies have looked at drug therapy for problematic Internet use, beyond treating comorbid psychiatric illnesses.
Treatment declined. Mr. A declined treatment for his problematic Internet use. As in many other psychiatric illnesses, insight into impulse control disorders tends to be limited. We can address the problem directly and offer to help patients change their online behaviors, but we cannot force them into treatment if they are not endangering themselves or others.
Related resources
- Computer Addiction Services. Maressa Hecht Orzack, PhD. www.computeraddiction.com; (617) 855-2908.
- Center for Online Addiction. Kimberly S. Young, PhD. www.netaddiction.com; (877) 292-3737.
Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses.
We propose a screening tool called “MOUSE” and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:
- How does problematic Internet use present?
- Is it an addiction or an impulse control disorder?
- How can we help those afflicted with this problem?
When Internet use goes over the line
Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:
- an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function1
- and employment and relationships are jeopardized by the hours spent online2 (Box).
Relationships—particularly marriages but also parent-child relationships, dating relationships, and close friendships—appear to suffer the greatest harm. At least one-half of “Internet addicts” (53%) report that their Internet use has caused serious relationship problems.
School. Academic problems are common; one study showed 58% of students blamed Internet use for a drop in grades, missed classes, declining study habits, or being placed on probation.
Workplace. Many executives—55% in one study—complain that time spent on the Internet for non-business purposes reduces their employees’ effectiveness.
Health. Some users spend 40 to 80 hours per week online, and single sessions can last up to 20 hours. Lack of sleep results in fatigue, decreased exercise, and decreased immunity. Sitting in front of the computer for hours also increases the risk of carpal tunnel syndrome, eye strain, and back pain.
Other addictions. The more time spent on the Internet, the greater the user’s risk of exposure to other addictive activities, such as online gambling and sexual solicitations. This risk is particularly concerning in children and adolescents.
Source: Young KS. Innovations in Clin Pract 1999;17:19-31.
Case: Computer gamer out of control
Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.
He is taking no medications. The only clinically significant family history is his father’s apparent OCD, undiagnosed and untreated.
Mr. A’s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.
Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week—nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:
- 35% in chat forums, communicating with gaming partners he has never met
- 25% in multi-player, video/strategy games
- 15% using e-mail
- and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).
He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.
Internet overuse: An ‘addiction’?
Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke.3 He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.4,5
Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder.5-8 Shapira et al studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.1
As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.8
Diagnostic criteria. Although Mr. A’s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),9 which we define as:
- uncontrollable
- markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
- and not solely present during mania or hypomania.
Teasing out comorbid disorders
As in Mr. A’s case, Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.10-12
Although some researchers feel that the many comorbid and complicating factors cannot be teased out,13 most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.
A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.
Shapira et al1,14 found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black11 found:
- 33% had a mood disorder
- 38% had a substance use disorder
- 19% had an anxiety disorder
- 52% met criteria for at least one personality disorder.
On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.1,11
Table 1
PROPOSED DIAGNOSTIC CRITERIA FOR PROBLEMATIC INTERNET USE
| Maladaptive preoccupation with Internet use, as indicated by at least one of the following: |
|
|
| Source: Reprinted with permission from an article by Shapira et al9 that has been accepted for publication in Depression and Anxiety. © Copyright 2003 John Wiley & Sons. |
Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al15 hypothesized that the Internet use caused the depression. Pratarelli et al16 noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.
In a survey of college students, individuals with “Internet addiction” were found to:
- have obsessive characteristics
- prefer online interactions to real-life interactions
- use the Internet “to feel better,” alleviate depression, and become sexually aroused.16
Personality traits. In another study, Orzack12 found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of “Internet addiction disorder:”
- boredom
- private self-consciousness
- loneliness
- social anxiety
- shyness
- and low self-esteem.
Table 2
5 SCREENING QUESTIONS FOR PROBLEMATIC INTERNET USE
| More than intended time spent online? |
| Other responsibilities or activities neglected? |
| Unsuccessful attempts to cut down? |
| Significant relationship discord due to use? |
| Excessive thoughts or anxiety when not online? |
Diagnosing Internet overuse
Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions—easily recalled by the mnemonic MOUSE—can help you screen for problematic Internet use (Table 2).
History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.17 Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.
To determine how the Internet may alter the patient’s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the patient sort through his or her emotions.17
Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.17 They tend to take pride in their computer skills2 and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use (“I’m using it for work, academics, travel, research, etc.”).
Chomorbidities. Given the high incidence of psychiatric comorbidity,1 it is important to complete a thorough psychiatric evaluation and treat any underlying illness. Whether the illness is primary or comorbid, it is likely exacerbating the symptoms of problematic Internet use.
Changing problematic behaviors
Psychotherapy. Once you find the motives and possible causes of Internet overuse, what is the best form of treatment? This question warrants further study, but cognitive-behavioral therapy (CBT) is the primary treatment at this time.
The goal of CBT is for patients to disrupt their problematic computer use and reconstruct their routines with other activities. They can:
- use external timers to keep track of time online
- set goals of brief, frequent sessions online
- carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected.17
Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use.12 Support groups and family therapy can help repair damaged relationships and engage friends and family in the treatment plan.
Drug therapy. No studies have looked at drug therapy for problematic Internet use, beyond treating comorbid psychiatric illnesses.
Treatment declined. Mr. A declined treatment for his problematic Internet use. As in many other psychiatric illnesses, insight into impulse control disorders tends to be limited. We can address the problem directly and offer to help patients change their online behaviors, but we cannot force them into treatment if they are not endangering themselves or others.
Related resources
- Computer Addiction Services. Maressa Hecht Orzack, PhD. www.computeraddiction.com; (617) 855-2908.
- Center for Online Addiction. Kimberly S. Young, PhD. www.netaddiction.com; (877) 292-3737.
1. Shapira NA, Goldsmith TG, Keck PE, Jr, Khosla UM, McElroy SL. Psychiatric features of individuals with problematic Internet use. J Affect Disord 2000;57:267-72.
2. Beard KW, Wolf EM. Modification in the proposed diagnostic criteria for Internet addiction. Cyberpsychol Behav 2001;4:377-83.
3. Goldberg I. Internet addiction. Available at http://www.cybernothing.org/jdfalk/media-coverage/archive/msg01305.html. Accessed Feb. 26, 2003.
4. Griffiths MD. Internet addiction: an issue for clinical psychology? Clin Psychol Forum 1996;97:32-6.
5. Young KS. Psychology of computer use: XL. Addictive use of the Internet: a case that breaks the stereotype. Psychol Rep 1996;79:899-902.
6. Treuer T, Fábián Z, Füredi J. Internet addiction associated with features of impulse control disorder: is it a real psychiatric disorder? J Affect Disord 2001;66:283.-
7. Young KS. Caught in the net: how to recognize the signs of Internet addiction-and a winning strategy for recovery. New York: John Wiley & Sons, Inc. 1998;8.-
8. Young KS, Rogers RC. The relationship between depression and Internet addiction. Cyberpsychol Behav 1998;1:25-8.
9. Shapira NA, Lessig MC, Goldsmith TD, et al. Problematic Internet use: proposed classification and diagnostic criteria. Depress Anxiety (in press).
10. Griffiths MD. Internet addiction: Fact or fiction? Psychologist 1999;12:246-50.
11. Black DW, Belsare G, Schlosser S. Clinical features, psychiatric comorbidity, and health-related quality of life in persons reporting compulsive computer use behavior. J Clin Psychiatry 1999;60:839-44.
12. Orzack MH. How to recognize and treat computer.com addictions. Directions in Mental Health Counseling 1999;9:13-20.
13. Stein DJ. Internet addiction, Internet psychotherapy (letter; comment). Am J Psychiatry 1997;154(6):890.-
14. Shapira NA. Unpublished data, 2000.
15. Kraut R, Lundmark V, Patterson M, Kiesler S, Mukopadhyay T, Scherlis W. Internet paradox: A social technology that reduces social involvement and psychological wellbeing? Am Psychol 1998;53:1017-31.
16. Pratarelli ME, Browne BL. Confirmatory factor analysis of Internet use and addiction. Cyberpsychol Behav 2002;5:53-64.
17. Young KS. Internet addiction: symptoms, evaluation and treatment. Innovations in Clin Pract 1999;17:19-31.
1. Shapira NA, Goldsmith TG, Keck PE, Jr, Khosla UM, McElroy SL. Psychiatric features of individuals with problematic Internet use. J Affect Disord 2000;57:267-72.
2. Beard KW, Wolf EM. Modification in the proposed diagnostic criteria for Internet addiction. Cyberpsychol Behav 2001;4:377-83.
3. Goldberg I. Internet addiction. Available at http://www.cybernothing.org/jdfalk/media-coverage/archive/msg01305.html. Accessed Feb. 26, 2003.
4. Griffiths MD. Internet addiction: an issue for clinical psychology? Clin Psychol Forum 1996;97:32-6.
5. Young KS. Psychology of computer use: XL. Addictive use of the Internet: a case that breaks the stereotype. Psychol Rep 1996;79:899-902.
6. Treuer T, Fábián Z, Füredi J. Internet addiction associated with features of impulse control disorder: is it a real psychiatric disorder? J Affect Disord 2001;66:283.-
7. Young KS. Caught in the net: how to recognize the signs of Internet addiction-and a winning strategy for recovery. New York: John Wiley & Sons, Inc. 1998;8.-
8. Young KS, Rogers RC. The relationship between depression and Internet addiction. Cyberpsychol Behav 1998;1:25-8.
9. Shapira NA, Lessig MC, Goldsmith TD, et al. Problematic Internet use: proposed classification and diagnostic criteria. Depress Anxiety (in press).
10. Griffiths MD. Internet addiction: Fact or fiction? Psychologist 1999;12:246-50.
11. Black DW, Belsare G, Schlosser S. Clinical features, psychiatric comorbidity, and health-related quality of life in persons reporting compulsive computer use behavior. J Clin Psychiatry 1999;60:839-44.
12. Orzack MH. How to recognize and treat computer.com addictions. Directions in Mental Health Counseling 1999;9:13-20.
13. Stein DJ. Internet addiction, Internet psychotherapy (letter; comment). Am J Psychiatry 1997;154(6):890.-
14. Shapira NA. Unpublished data, 2000.
15. Kraut R, Lundmark V, Patterson M, Kiesler S, Mukopadhyay T, Scherlis W. Internet paradox: A social technology that reduces social involvement and psychological wellbeing? Am Psychol 1998;53:1017-31.
16. Pratarelli ME, Browne BL. Confirmatory factor analysis of Internet use and addiction. Cyberpsychol Behav 2002;5:53-64.
17. Young KS. Internet addiction: symptoms, evaluation and treatment. Innovations in Clin Pract 1999;17:19-31.