Parkinsonism and Related Disorders 20 (2014) 482e487
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Problematic Internet use in Parkinson’s disease Kit Wu a, *, Marios Politis a, d, Sean S. O’Sullivan a, b,1, Andrew D. Lawrence c,1, Sarah Warsi a, Andrew Lees b, Paola Piccini a a
Division of Brain Sciences, Department of Medicine, Hammersmith Hospital, Imperial College London, London W12 0NN, UK Reta Lila Weston Institute of Neurological Studies, University College London, WC1N 1PJ, UK c School of Psychology, Cardiff University, CF10 3AT, UK d Neurodegeneration Imaging Group, Department of Clinical Neuroscience, King’s College London, De Crespigny Park, London SE5 8AF, UK b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 June 2013 Received in revised form 5 December 2013 Accepted 15 January 2014
Background: Problematic Internet use (PIU) has been associated with impulse control disorders (ICDs), and postulated to share characteristics of a behavioral addiction with both impulsive and compulsive features. However, Internet use has not been previously systematically studied in Parkinson’s disease. Aim: We explore Internet use in PD patients with and without ICDs and matched healthy controls. We hypothesize that the PD-ICD patients will spend more time on the Internet, accessing websites related to their ICDs, compared with PD patients without ICDs and healthy volunteers. Methods: Our study is the first to systematically explore problematic Internet use in patients with PD, with and without ICDs. Twenty-nine PD patients with ICDs, twenty PD patients without ICDs and nineteen healthy controls were recruited. All participants endorsed using the Internet for non-essential purposes. They underwent a semi-structured interview and completed questionnaires including the Yale-Brown Obsessive Compulsive Scale adapted for Internet use (Y-BOCS-Internet). Results: PD-ICD patients scored significantly higher on the Y-BOCS-Internet than the PD-control and HV groups (PD-ICD: 13.69; PD-control: 5.42; HV: 4.70; p < 0.0001). Compared to PD controls and HV groups, the PD-ICD group spent more time on the Internet (p ¼ 0.0001), described significantly more effort to resist Internet use (p ¼ 0.0002), thoughts about Internet use (p < 0.0001) and its interference with their life functioning (p ¼ 0.0025). Discussion: Our results suggest that PD patients with ICDs have a relative increased tendency towards excessive Internet use compared to those without ICDs and healthy controls. Clinicians should actively screen for excessive Internet use in patients with ICDs. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Computer use Internet addiction Impulse control disorder Parkinson’s disease Problematic Internet use Yale-Brown Obsessive Compulsive Scale
1. Introduction The popularity of the Internet has grown immensely over the last decade, so much so that it has become an important tool in our daily lives. Its benefits have given people with limited mobility, such as those with Parkinson’s disease (PD), greater independence and better quality of life [1]. More recently, there has been mounting interest in the concept of Problematic Internet Use (PIU), also known as Internet addiction disorder, or pathological computer use. Currently there is no consensus for the diagnostic classification of PIU, which has been conceptualized as a behavioral addiction, an impulse control disorder or an obsessive-compulsive spectrum disorder [2,3]. The * Corresponding author. Tel.: þ44 020 8383 3754; fax: þ44 020 8383 1783. E-mail addresses: [email protected], [email protected] (K. Wu). 1 These two authors contributed equally. 1353-8020/$ e see front matter Ó 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.parkreldis.2014.01.019
prevalence of PIU in the general population in North America and Europe has been estimated, depending upon the assessment tools used and the population studied, at 1.5%e8.2% [4]. People with PIU spend excessive amounts of time on the Internet at the expense of and to the detriment of other aspects of their lives. The behavior tends to target particular activities, for example online gambling; multi-user gaming; cybersex or viewing online pornography. Anyone with Internet access can become dependent upon it regardless of gender and age, but research conducted to date has focused on young people and college students. High rates of co-morbidity have been reported between PIU and ICDs. Gambling disorder (GD) and compulsive sexual behavior (CSB) have been most strongly linked to PIU, relative to other ICDs, such as compulsive buying (CB) or binge eating (BE) [5]. The occurrence of ICDs, such as PG and CSB, is a recognized iatrogenic side effect of the continued use of dopaminergic medication [6]. The estimated prevalence of the four most commonly
K. Wu et al. / Parkinsonism and Related Disorders 20 (2014) 482e487
reported ICDs (gambling disorder, compulsive sexual behavior, binge eating and compulsive buying) in PD patients on dopaminergic medication is 13% [7]. However, inappropriate use of the Internet in Parkinson’s patients has not been systematically investigated. To date in the literature, there are only a handful of reported cases of compulsive Internet use in Parkinson’s disease, and mainly in association with GD. Fan and colleagues reported one case of compulsive internet browsing in a group of 400 Chinese PD patients [8]; Larner reported another of using the Internet for gambling purposes [9] and a case series of eight patients with PG, four of whom were reported to use the Internet as a medium for gambling [10]. These cases are all linked to the use of dopaminergic medication (particularly dopamine agonists). However, currently there is no study specifically comparing Internet use in PD with ICDs to a PD control group, nor to healthy age-matched controls. Here, we examined patients with PD and healthy controls for excessive Internet use, and adapted the 10-item Y-BOCS [2,11] as a tool to explore problematic levels of Internet use in PD patients with and without ICDs and healthy controls, adapting the questions for Internet use (e-Supplementary File: 1). PIU has been postulated to have both impulsive and compulsive components, with impulsive tendencies initiating the behavior, eventually leading to a compulsion that causes the behavior to persist over time [5,12]. The Y-BOCS has previously been adapted for use in non-PD individuals with PIU [13]. We hypothesized that the PD-ICD group will spend more time on the Internet, particularly accessing websites related to their ICDs (e.g. gambling, pornography) relative to both the PD control and healthy volunteer (HV) groups. In this article, ‘ICDs’ refer specifically to gambling disorder, compulsive sexual behavior, binge eating and compulsive buying.
483
for problematic Internet use and presence of ICDs. Twenty-nine patients were identified as having problematic Internet use based on their report of maladaptive behavior that causes functional impairment, as according to proposed diagnostic criteria [2,13]. These patients also satisfied the diagnostic criteria for one of the four major ICDs reported in PD using the following [1]: DSM-V diagnostic criteria for gambling disorder [14,2]; DSM-V proposed criteria for binge eating [14]; proposed criteria for [3] compulsive sexual behavior [6]; and [4] compulsive buying [6]. Nineteen patients with PD free from any symptoms of ICDs or other neurological and psychological co-morbidities were recruited as controls. All patients with PD satisfied the Queen Square Brain Bank for Neurological Disorders clinical criteria [15]. None of the participants in this study has been diagnosed with PIU prior to the use of PD medication, and none had a diagnosis of obsessive-compulsive disorder. Twenty non-PD healthy volunteers matched for age and sex were recruited from individuals who responded to a local newspaper advert and acted as a comparison group. All participants endorsed using the Internet for ‘non-essential’ purposes. All participants underwent a semi-structured face-to-face interview with the first author (Table 1). 2.2. Additional measures
2.1. Participants
All participants were screened using the Mini-Mental State Examination (MMSE); any below 26 was excluded because of the requirement to complete self-administered questionnaires. Participants with PD completed a clinical assessment to record their medical history, dopaminergic medication use and a physical examination to include the Unified Parkinson Disease Rating Scale (UPDRS) motor score part III. The calculation of a daily L-dopa equivalent daily dose (LEDD) for each patient was based on theoretical equivalence to L-dopa as previously described [16]. All participants completed the following assessments during the semi-structured interview:
Informed consent was obtained from all participants in accordance with the Declaration of Helsinki and approval was obtained from the Hammersmith & Queen Charlotte’s Hospitals Research Ethics Committee. Patients with idiopathic PD attending specialist movement disorder clinics at the National Hospital for Neurology and Neurosurgery and Imperial College Hospitals NHS Trusts were screened
1. Yale-Brown Obsessive Compulsive Scale e a 10-item questionnaire, which measures obsessions and compulsive elements separately [11], adapted for Internet use [13]. The Y-BOCS is a suitable tool for our target group, as it is used widely in the general population, among those with OCD and/or ICD with good validity and reliability [17]; the questionnaire has an equal number of questions on obsessions and compulsions, without
2. Participants and methods
Table 1 Demographic and clinical details of participants.
Frequency (n¼) Age (yrs) Disease duration (yrs) Age of PD onset (yrs) UPDRS (III) ‘off’ medication Total LEDD (mg/day) L-dopa (mg/day) LEU DA (mg/day) Percentage of patients on DA (%) BDI (II) BIS/BAS BSS
PD ICD
PD controls
Healthy volunteers
p Value
29 (4F: 25M) 63.25 (9.28) 12.44 (8.01) 51.24 (11.96) 38.44 (11.34) 673.20 (309.82) 324.31 (202.94) 348.89 (307.72) 82 15.48 (8.80)** 56.89 (8.06) 6.96 (3.12)
19 (6F: 13M) 62.32 (9.06) 10.37 (6.26) 53.18 (9.64) 34.40 (11.13) 768.83 (321.67) 231.70 (84.72) 537.13 (329.28) 90 14.32 (9.76)** 55.37 (7.47) 7.211 (3.38)
20 (3F: 17M) 60.25 (10.33) e e e e e e e 6.35 (8.88) 55.80 (7.48) 10.35 (3.96)
e
Values represent mean (Standard deviation). Statistical significance value is
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Problematic Internet use in Parkinson’s disease Kit Wu a, *, Marios Politis a, d, Sean S. O’Sullivan a, b,1, Andrew D. Lawrence c,1, Sarah Warsi a, Andrew Lees b, Paola Piccini a a
Division of Brain Sciences, Department of Medicine, Hammersmith Hospital, Imperial College London, London W12 0NN, UK Reta Lila Weston Institute of Neurological Studies, University College London, WC1N 1PJ, UK c School of Psychology, Cardiff University, CF10 3AT, UK d Neurodegeneration Imaging Group, Department of Clinical Neuroscience, King’s College London, De Crespigny Park, London SE5 8AF, UK b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 June 2013 Received in revised form 5 December 2013 Accepted 15 January 2014
Background: Problematic Internet use (PIU) has been associated with impulse control disorders (ICDs), and postulated to share characteristics of a behavioral addiction with both impulsive and compulsive features. However, Internet use has not been previously systematically studied in Parkinson’s disease. Aim: We explore Internet use in PD patients with and without ICDs and matched healthy controls. We hypothesize that the PD-ICD patients will spend more time on the Internet, accessing websites related to their ICDs, compared with PD patients without ICDs and healthy volunteers. Methods: Our study is the first to systematically explore problematic Internet use in patients with PD, with and without ICDs. Twenty-nine PD patients with ICDs, twenty PD patients without ICDs and nineteen healthy controls were recruited. All participants endorsed using the Internet for non-essential purposes. They underwent a semi-structured interview and completed questionnaires including the Yale-Brown Obsessive Compulsive Scale adapted for Internet use (Y-BOCS-Internet). Results: PD-ICD patients scored significantly higher on the Y-BOCS-Internet than the PD-control and HV groups (PD-ICD: 13.69; PD-control: 5.42; HV: 4.70; p < 0.0001). Compared to PD controls and HV groups, the PD-ICD group spent more time on the Internet (p ¼ 0.0001), described significantly more effort to resist Internet use (p ¼ 0.0002), thoughts about Internet use (p < 0.0001) and its interference with their life functioning (p ¼ 0.0025). Discussion: Our results suggest that PD patients with ICDs have a relative increased tendency towards excessive Internet use compared to those without ICDs and healthy controls. Clinicians should actively screen for excessive Internet use in patients with ICDs. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Computer use Internet addiction Impulse control disorder Parkinson’s disease Problematic Internet use Yale-Brown Obsessive Compulsive Scale
1. Introduction The popularity of the Internet has grown immensely over the last decade, so much so that it has become an important tool in our daily lives. Its benefits have given people with limited mobility, such as those with Parkinson’s disease (PD), greater independence and better quality of life [1]. More recently, there has been mounting interest in the concept of Problematic Internet Use (PIU), also known as Internet addiction disorder, or pathological computer use. Currently there is no consensus for the diagnostic classification of PIU, which has been conceptualized as a behavioral addiction, an impulse control disorder or an obsessive-compulsive spectrum disorder [2,3]. The * Corresponding author. Tel.: þ44 020 8383 3754; fax: þ44 020 8383 1783. E-mail addresses: [email protected], [email protected] (K. Wu). 1 These two authors contributed equally. 1353-8020/$ e see front matter Ó 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.parkreldis.2014.01.019
prevalence of PIU in the general population in North America and Europe has been estimated, depending upon the assessment tools used and the population studied, at 1.5%e8.2% [4]. People with PIU spend excessive amounts of time on the Internet at the expense of and to the detriment of other aspects of their lives. The behavior tends to target particular activities, for example online gambling; multi-user gaming; cybersex or viewing online pornography. Anyone with Internet access can become dependent upon it regardless of gender and age, but research conducted to date has focused on young people and college students. High rates of co-morbidity have been reported between PIU and ICDs. Gambling disorder (GD) and compulsive sexual behavior (CSB) have been most strongly linked to PIU, relative to other ICDs, such as compulsive buying (CB) or binge eating (BE) [5]. The occurrence of ICDs, such as PG and CSB, is a recognized iatrogenic side effect of the continued use of dopaminergic medication [6]. The estimated prevalence of the four most commonly
K. Wu et al. / Parkinsonism and Related Disorders 20 (2014) 482e487
reported ICDs (gambling disorder, compulsive sexual behavior, binge eating and compulsive buying) in PD patients on dopaminergic medication is 13% [7]. However, inappropriate use of the Internet in Parkinson’s patients has not been systematically investigated. To date in the literature, there are only a handful of reported cases of compulsive Internet use in Parkinson’s disease, and mainly in association with GD. Fan and colleagues reported one case of compulsive internet browsing in a group of 400 Chinese PD patients [8]; Larner reported another of using the Internet for gambling purposes [9] and a case series of eight patients with PG, four of whom were reported to use the Internet as a medium for gambling [10]. These cases are all linked to the use of dopaminergic medication (particularly dopamine agonists). However, currently there is no study specifically comparing Internet use in PD with ICDs to a PD control group, nor to healthy age-matched controls. Here, we examined patients with PD and healthy controls for excessive Internet use, and adapted the 10-item Y-BOCS [2,11] as a tool to explore problematic levels of Internet use in PD patients with and without ICDs and healthy controls, adapting the questions for Internet use (e-Supplementary File: 1). PIU has been postulated to have both impulsive and compulsive components, with impulsive tendencies initiating the behavior, eventually leading to a compulsion that causes the behavior to persist over time [5,12]. The Y-BOCS has previously been adapted for use in non-PD individuals with PIU [13]. We hypothesized that the PD-ICD group will spend more time on the Internet, particularly accessing websites related to their ICDs (e.g. gambling, pornography) relative to both the PD control and healthy volunteer (HV) groups. In this article, ‘ICDs’ refer specifically to gambling disorder, compulsive sexual behavior, binge eating and compulsive buying.
483
for problematic Internet use and presence of ICDs. Twenty-nine patients were identified as having problematic Internet use based on their report of maladaptive behavior that causes functional impairment, as according to proposed diagnostic criteria [2,13]. These patients also satisfied the diagnostic criteria for one of the four major ICDs reported in PD using the following [1]: DSM-V diagnostic criteria for gambling disorder [14,2]; DSM-V proposed criteria for binge eating [14]; proposed criteria for [3] compulsive sexual behavior [6]; and [4] compulsive buying [6]. Nineteen patients with PD free from any symptoms of ICDs or other neurological and psychological co-morbidities were recruited as controls. All patients with PD satisfied the Queen Square Brain Bank for Neurological Disorders clinical criteria [15]. None of the participants in this study has been diagnosed with PIU prior to the use of PD medication, and none had a diagnosis of obsessive-compulsive disorder. Twenty non-PD healthy volunteers matched for age and sex were recruited from individuals who responded to a local newspaper advert and acted as a comparison group. All participants endorsed using the Internet for ‘non-essential’ purposes. All participants underwent a semi-structured face-to-face interview with the first author (Table 1). 2.2. Additional measures
2.1. Participants
All participants were screened using the Mini-Mental State Examination (MMSE); any below 26 was excluded because of the requirement to complete self-administered questionnaires. Participants with PD completed a clinical assessment to record their medical history, dopaminergic medication use and a physical examination to include the Unified Parkinson Disease Rating Scale (UPDRS) motor score part III. The calculation of a daily L-dopa equivalent daily dose (LEDD) for each patient was based on theoretical equivalence to L-dopa as previously described [16]. All participants completed the following assessments during the semi-structured interview:
Informed consent was obtained from all participants in accordance with the Declaration of Helsinki and approval was obtained from the Hammersmith & Queen Charlotte’s Hospitals Research Ethics Committee. Patients with idiopathic PD attending specialist movement disorder clinics at the National Hospital for Neurology and Neurosurgery and Imperial College Hospitals NHS Trusts were screened
1. Yale-Brown Obsessive Compulsive Scale e a 10-item questionnaire, which measures obsessions and compulsive elements separately [11], adapted for Internet use [13]. The Y-BOCS is a suitable tool for our target group, as it is used widely in the general population, among those with OCD and/or ICD with good validity and reliability [17]; the questionnaire has an equal number of questions on obsessions and compulsions, without
2. Participants and methods
Table 1 Demographic and clinical details of participants.
Frequency (n¼) Age (yrs) Disease duration (yrs) Age of PD onset (yrs) UPDRS (III) ‘off’ medication Total LEDD (mg/day) L-dopa (mg/day) LEU DA (mg/day) Percentage of patients on DA (%) BDI (II) BIS/BAS BSS
PD ICD
PD controls
Healthy volunteers
p Value
29 (4F: 25M) 63.25 (9.28) 12.44 (8.01) 51.24 (11.96) 38.44 (11.34) 673.20 (309.82) 324.31 (202.94) 348.89 (307.72) 82 15.48 (8.80)** 56.89 (8.06) 6.96 (3.12)
19 (6F: 13M) 62.32 (9.06) 10.37 (6.26) 53.18 (9.64) 34.40 (11.13) 768.83 (321.67) 231.70 (84.72) 537.13 (329.28) 90 14.32 (9.76)** 55.37 (7.47) 7.211 (3.38)
20 (3F: 17M) 60.25 (10.33) e e e e e e e 6.35 (8.88) 55.80 (7.48) 10.35 (3.96)
e
Values represent mean (Standard deviation). Statistical significance value is
