Dr. Y.A. Matcheswalla
Dr. Avinash De Sousa
Dr. Deepak Goel
Dr. Mansi Jain
Dr. Deepa Nair
Dr. Siddhika Ayyer
Psychologists – Counseling centre
A 43 year old Punjabi housewife educated
upto Std XII and had no knowledge of
computers till 6 months back.
 Her husband was a businessman and
daughter studying 2nd yr BDS.
 She had learnt basic e-mail, chatting and
skype since 6 months ago as her son was
going abroad.
 As she started using the chat with her son she
also started spending time chatting with
Overtime she began to like chatting and using
the internet and was happy she had
something to do all day long.
Gradually her time spent chatting online
chatting increased to 3-4 hrs a day and she
was chatting late in the night and even at
times right upto 4-5am in the morning.
She made around 100 friends on chat (mostly
Problem aggravated when
she stopped taking interest in
house hold work, was not
cooking regularly and even
stopped attending phone
calls while chatting.
On confrontation by family
members, she refused to
accept her internet use as a
In fact she kept telling them
it’s a nice way of
communication and they
should also use it more
She started sharing her personal details with
total strangers online including her phone
numbers on chat rooms.
There was never a love affair or any sexual
content but just chatting in general.
She refused to go to a Psychiatrist.
Her daughter then decided to stay in hostel
fed up of this situation.
Her husband went to his brother’s house to
stay and to discuss a solution to this dilemma.
After a week of their going she realized
her loneliness and called them up and
accepted to visit a Psychiatrist.
She denied loneliness and said that it was
nice to have so many friends all over the
There was no family h/o mental illness.
No interpersonal stressor before starting of
this problem.
On MSE she accepted having
some sadness but attributed it
to husband and daughter
leaving her one week back.
Clinical Diagnosis of “Internet
Addiction “ was made.
She was treated by us using Flouxetine 20mg per
day which was increased to 60mg per day.
Advised 3 months of abstinence from using
internet / computers.
Was allowed to contact her son on the phone
under supervision.
Patient followed up well. After 3 months she
was using internet 1 hour daily to chat with her
son under supervision.
Computer was shifted from her room to the
main hall they had.
Mr. X, 17 year old boy, studying in 11th std
 Brought by parents with complaints of
excessive time spent on internet via
computer and mobile phones
 Deterioriation in academic performance.
He would visit social
networking sites such as
facebook, twitter or chat
groups, indulge in online
gaming and would visit
pornographic sites 1-2 times
a week.
He would also surf aimlessly
about 8-9 hours a day,
started bunking lectures
would come back home
early from college to be on
the internet.
He would lie that there are
no lectures happening in
Difficulty in focusing on studies, showed
restlessness, became irritable and aggressive if
refused internet access and showed decreased
social interaction.
 Problem brought to parents notice by college
teachers due to poor attendance.
 No h/o substance use.
 Past h/o ADHD and conduct traits, treated
with methylphenidate with good response.
 FTND, no postnatal complications,
milestones normal, no siblings.
Family history s/o ADHD in father,
interpersonal stressor between parents
On examination- vitals stable
MSE- Patient appeared defensive.
Rapport was established with difficulty.
He thought that time he spent online was
normal and did not regret his actions
He rationalized academic deterioration. No
motivation for studies.
Professionally he wanted to be an ethical
Restarted on Methylphenidate for attentional
 Fluoxetine 20mg per day increased to 40mg.
 Restricted time of internet use under
Concept that was introduced in 1995.
Established as a disorder in 1996.
Internet not always perceived as addictive.
Not in keeping with basic premise of
(Goldberg 1995, Young 1996, Griffiths 1996, Levy, 1996, Winn, 1983)
How has internet addiction been measured
and is there a valid definition.
What aspects of internet addiction have
been investigated.
Internet addiction and student life.
Cause and effect studies on internet
Internet addiction and gender
Why is the internet addictive in nature.
Internet addiction and attitudes towards
The Online Disinhibition Effect
(Suler 1999, Tsai and Lin, 2010, Chen, 2005)
Subtypes of Internet Addiction
 Cybersex Addictions
 Cyber Relationship Addictions
 Net compulsions
 Information Overload
 Computer Game addiction
 Facebook Addiction
 Twitter and Messenger Addiction
(Young, 1996; 2000; 2005)
Needs leading to Internet Addiction
 Sexual Needs
 Altered states of consciousness
 Achievement Needs
 Need for Belonging
 Relationship Needs
 Self actualization needs
(Suler, 1999; Brian and Hastings, 2005)
Why we must bother
about internet addiction
The future of the
Importance of internet
related psychiatric
disorders and its influence
on comorbidity.
Mr. A, 23 year old Muslim boy, studying in
TYBCom brought by parents with complaints of
spending time daily on pornographic sites
between 5 to 8 pm and engaging in online
sexual chat.
 Avoiding tuitions, sports and social interaction
 He would download pornographic movies,
watch videos or else chat sexually online with
any one.
 Associated with masturbation most of the time
and would even pose himself as opposite sex at
times during chatting.
He would also watch pornography related
to homosexuality, sexual perversions like
fetishism, sodomy etc which made him feel
that these acts were normal.
He would get upset and irritable, craving
for pornography during the time, he was
Developed symptoms of Dhat syndrome
and complained of night falls.
Though he was regular in college but he
used to fantasize excessively about sex and
this would affect his concentration and his
academic performance deteriorated
He was caught in a hotel once viewing
pornography during a family vacation
when others were out but he managed to
avoid confrontation.
The matter came out into the open finally
when he was caught at his cousin’s home
while accessing these sites by his uncle and
then confronted by parents.
No h/o surfing other sites excessively, No
h/o compulsive masturbation, or any form
of sexual exposure.
No h/o any other psychiatric abnormality,
physical or sexual abuse in the past.
Vitals stable.
On MSE- patient appeared to be guarded.
Feelings of guilt were present.
Worries about future relationships and
Was desperate for sexual attention online
so did not mind even posing as female.
SSRI- Escitalopram 15mg in divided doses
per day.
Sex education.
Shifting internet connection from his room
to hall.
Checking the sites regularly by parents.
Psycho-education for parents.
Educating about rational use of internet.
Subtypes of Online Sexual
 Pornography
 Sexual chatting
 Sexual Display with Chatting
 Online leading to real life.
 Sexual Net Binges
Sexual deviant behaviour
 Triple A factor in online sex
“Given the widespread availability of
sexually explicit materials online, Internet
sex addiction is the most common form of
problem online behavior among users.”
Young, K. S. (2008). Internet sex addiction:
Risk factors, stages of development, and
treatment. American Behavioral Scientist,
52, 21-37.
Recommended Reading
© 2010
Download the workbook for FREE
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Cyber-sexuality and sex
 Need for parents to be
 Cyber-sexuality as a
spectrum of other
psychiatric disorders
Psychotherapy and
behavioral interventions
Dual sex therapy
18 year male, Hindu, studying in F.Y.BA,
single, r/o urban area
C/C: posing online as a terminally ill
patient with end stage stomach cancer
Posted regularly on a support group
Since 3-4 months
~1 hour per day
Garnered support, concern, sympathy
Patient interacted with members and
Exchange of personal information
Was asked to meet in person
Patient seemed reluctant
Started ignoring messages, left the support
group site
Group members reached his home and
contacted family
Parents shocked
Confronted their son
The patient was callous, laughed at the
members for believing him
 Dismissed incident as a joke
 No remorse/ guilt
 Informed parents about similar instances in
the past
 Stubborn, oppositional behavior in childhood
 h/o physical abuse by parents and uncle
 h/o sexual abuse by uncle
 Separation from parents in childhood
 Aloof from parents
 Unstable personal relationships
h/o suicidal attempts twice in the past
Family history:
 Interpersonal conflicts among parents
 Father was dominating, hot-tempered
 Mother had h/o borderline traits with one
suicidal attempt; no psychiatric treatment
Personal history:
 No siblings
 Birth and developmental history: WNL
 Average at studies
 Patient was conscious, cooperative,
oriented to time, place, person
 Rapport was established with dificulty
 ETEC: Initiated; not sustained
 Mood: Happy
 Affect: Cheerful; unconcerned
 Felt parents did not care for him or understand
 Could not share his feelings with others
 Believed ill people got a lot of care and attention
from others
 Lying on internet sites made him feel wanted
 Believed it was a harmless way of getting attention
 Fantasized about group members replacing his
Social judgement: Impaired
Insight: III/VI
Borderline personality
with Cyber Munchausen
Mood stabilizer:
Oxcarbazepine 150 mg BD
Family counseling and
group therapy
Supportive psychotherapy
Parental monitoring of
Internet use
Limited internet use
What is Cyber Munchausen syndrome?
 “virtual factitious disorder” or
Munchausen by internet
 Misuse of Internet based support groups
by offering false stories of personal illness
or crises for reasons such as getting
attention, sympathy, acting out anger or
sense of controlling others
37% Internet users access medicine-related
Online support groups are meant to assist
people by supporting their feelings, help in
finding facts about illness and treatment
Not usually reliable as facts not verified
and posts are anonymous
But of help to patients emotionally when
their doctors are time-constrained or
found intimidating
Groups for rare
conditions have
also been formed
including a group
for support of
people who have
been traumatised
by virtual
• Case reports indicate that some patients have
deliberately provided false information online
about their medical and personal histories
because it is emotionally gratifying
• Some patients have also pretended to be
caregivers of really sick/ dying people
• Like Munchausen’s syndrome/ Munchausen’s
by proxy in which a person willfully feigns/
induces illness in themselves or others with
the primary goal being emotional gratification
by assuming a ‘sick role’
• These patients may not seek care at hospitals
but may surf from one support group to
• Known to join multiple groups simultaneously
or have several identities on the same group
• They may fabricate victimization, assault, or
• Florid description about one’s life and
accomplishments termed pseudologia
fantastica may also be present
• When found out, may protest, accuse group
of ill-treatment, resist actual treatment or may
disappear (online death-pseuicide)
May have use information provided by
the patient to shape their own health care
May feel angry and betrayed
Lose faith in support groups and thus lose
their support system
Medical literature from websites or textbooks is
often duplicated
The length and severity of physical ailments
conflicts with user behaviour.
Symptoms may be exaggerated.
Grave situations and increasingly critical prognoses
are followed by "miraculous" recoveries.
A user's posts eventually reveal contradictory
information or claims that are implausible.
When attention and sympathy decreases to focus
on other members of the group, a user may
announce that other dire events have occurred,
such as the illness or death of a close family
When faced with insufficient attention or
sympathy from others, the person may claim this
as a cause for worsening of symptoms.
 A user resists contact beyond the Internet, by
telephone or personal visit, often claiming bizarre
reasons for not being able to accept such contact.
 Other forum members post on behalf of a user,
exhibiting identical writing styles, spelling errors,
and language idiosyncrasies, suggesting that the
user has created fictitious identities to move the
conversation in their direction.
What’s on your online profile?
Do you have an avatar?
What have you chosen for your e-mail addresses, screen
names, or nicknames on the Internet? Can you explain why
you chose them?
I’ve noticed that a lot of people have photographs of
themselves on their online. How did you choose the ones that
you posted
Are you more comfortable expressing yourself in person or
How would you feel if your computer crashed tomorrow and
you were unable to log on to the Internet?
Do you get any support from family, friends, or others online?
Do you use any Websites that you check regularly and how
How long does it take you to write an e-mail (or blog post
• Do you look up medical information online?
• Do you ever feel that what happens online is more real
than your life offline?
• Do you ever lose track of time or forget where you are
when you are playing a game or chatting online?
• Are you concerned about your privacy online?
• What do you do to protect your privacy online?
• Do you ever send e-mails to famous people, or to
people you don’t know very well? If yes: What kinds
of things do you say?
• Do you think your Internet use has caused any
problems for you in job, marriage, school, social life,
• Have you ever posted something or done something
on the Internet and regretted it later?
• Do you ever feel like you are online too much or can’t
stop when you want to?
Flaming and flame warsonline “fights” using
angry, vulgar language
Harassment – repeatedly
sending offensive, rude,
and insulting messages
Denigration – posting
information about
another that is derogatory
and untrue
Impersonation – breaking into an email
account and sending vicious and
embarrassing materials to others
Outing and trickery – sharing someone’s
secrets or embarrassing information, or
tricking someone into revealing such and
forwarding it
Exclusion/Ostracism – blocking someone
from buddy lists, chat rooms, etc.
Cyber stalking – repeatedly sending a
messages that include threats of harm or
of intimidating, or engaging in other
online activities that make someone fear
for their safety
Happy slapping – slapping someone
usually a stranger, recording it, and
posting the image online
What extent are
adolescents exposed to
Cyber-bullying and
academic achievement.
Cyber-bullying and
relation to internet
School bullying and
Safety strategies in the
school environment.
Gender age differences in cyber-bullying
Suicide in cyber-bullying.
School safety norms for cyber bullying