Digital Escape: Internet Addiction as a Coping Mechanism and Prodrome of Psychosis in an Adolescent

INTRODUCTION

The COVID-19 pandemic has exacerbated mental health challenges among adolescents, particularly those in unstable home environments. This case explores the mental health deterioration of an adolescent boy who turned to internet addiction to escape the abusive behavior of his alcoholic father and the emergence of prodromal symptoms. Internet gaming disorder is an emerging behavioral addiction, particularly affecting adolescents. It has been linked to emotional dysregulation, social withdrawal, academic decline, and self-harm. Vulnerable individuals may also develop or experience worsening of mental health.

CASE REPORT

The report is about a 16-year-old male with no significant medical or psychiatric history who presented to the Psychiatry Outpatient Department (OPD) in May, 2024. His problems started when he was 13 years old, during the peak of COVID-19 in 2021, mainly due to his father's daily alcohol use and aggressive behavior. Before the pandemic, his father’s outbursts were less frequent because he was usually away for work, but the lockdown forced the family to stay together, which led to frequent fights at home. The patient tried to distract himself by gaming and using the computer. Initially, he started using the internet for around 1-2 hours per day. Over the subsequent three years, his screen time increased to more than 15 hours per day. He started playing multiplayer online games and made new online friends, gradually replacing real-life social interactions. His symptoms further increased after his mother was diagnosed with meningioma in 2022. He had completely withdrawn from school and social activities and could keep his head straight only when using the Internet. He was frequently absent from school and avoided any extracurricular activities. He would lock himself in his room and remain busy with his computer. Due to continued abusive behavior by the father, the mother started living separately from him in January 2023. A few days after living separately from his father, he reported hearing his father's voice when he was not around.

During this period, He felt as if his father would come and abuse him at any time. He felt all his classmates and the people outside kept talking about him and might harm him. He engaged in repeated self-harming behaviors using blades, stating it was a way to convert “mental pain into physical pain”. He also reported an episode in which he attempted to immerse his face in a bucket of water with the intention of harming himself.

His academic performance declined, and he developed an inferiority complex while dealing with his peers and teachers. He progressively started to stay alone and socially withdrawn. He became more isolated and found comfort in talking with his online friends. His academic performance declined significantly, and he eventually discontinued school for approximately 10 months before presenting to our OPD.

Additionally, he was found to be very philosophical, discussing life with an intelligence and depth not commonly seen in his age group, and demonstrated an impressive understanding of computer programming. Multiple hesitation cuts were observed on both forearms.

Mental status examination revealed poor eye contact, irritable mood, restricted affect, paranoid ideation, ideas of reference, suicidal ideation, and impaired judgment. He was preoccupied with internet gaming and his father's behavior. On evaluation sentence completion test revealed confusion regarding his sexual orientation. He mentioned that he does not want to identify himself as a boy, as he did not want to grow up to be like his father. His score on the internet addiction scale was 81 (severe addiction). The patient showed partial improvement with fluoxetine 40mg/day and risperidone 1mg per day, along with psychosocial interventions like supportive counselling, family psychoeducation, and sex education. He was on follow-up for 3 months, after which he presented to the emergency department with a very brief psychotic episode of 1 day, following which he was admitted again, and the risperidone dose was increased to 4mg/day.

Although symptoms fluctuated, a noticeable improvement in emotional stability and better treatment adherence were observed after his father was admitted for alcohol dependence, and motivational enhancement therapy was initiated. Addressing the father’s substance use led to a more supportive home environment, which positively impacted the patient’s clinical course.

DISCUSSION

This case highlights the profound impact that family dynamics can have on adolescent mental health. While internet use initially served as a coping mechanism, it ultimately became a maladaptive escape that increased the patient's psychological distress.

The COVID-19 lockdown acted as a precipitating factor by increasing exposure to family conflict while reducing social interaction and structured activities, contributing to excessive screen use and psychological distress.^[1]

Carli et al. found a significant association between internet use and suicidal ideation in adolescents, which aligns with our patient’s experience of self-harm and suicidal thoughts.^[2] An important feature of this case was the presence of subthreshold psychotic symptoms, including paranoid ideation, perceptual disturbances, and a brief psychotic episode. Excessive internet use has been linked to psychotic-like experiences through mechanisms such as social isolation, sleep disruption, and emotional dysregulation.^[3]

This case underscores the complex interplay between environmental stressors, behavioral addiction, and subthreshold psychotic symptoms in adolescents. According to the diathesis–stress model, individuals with a higher genetic or familial vulnerability are more likely to manifest psychopathology when exposed to significant psychosocial stressors, as stress may activate underlying predispositions.^[4] A study by Long et al. mentioned that A combination of additive genetic and shared environmental risk factors explained the familial aggregation in the frequency of internet use.^[5] In the present case, paternal alcohol dependence may represent a source of familial vulnerability, reflecting both possible genetic susceptibility and adverse environmental conditions, thereby acting as a predisposing factor for the development of gaming addiction in the adolescent.

Early recognition and integrated intervention are crucial to prevent further deterioration and support long-term recovery.

Individuals with internet gaming disorder display obsessive characteristics related to computer/internet use, and obsessive-compulsive disorder tends to respond well to selective serotonin reuptake inhibitors.^[6] A study by Murphy et al. further supports the association between obsessive– compulsive traits and problematic internet use.^[7] Fluoxetine was also preferred, keeping in view the relationship and its efficacy for suicidal ideations. Risperidone was added to address his subthreshold psychotic symptoms.

CONCLUSION

Excessive internet use was associated with significant functional decline, self-harm, and the emergence of subthreshold psychotic symptoms. Importantly, improvement was observed not only with pharmacological and psychosocial interventions for the patient but also following treatment of the father’s alcohol dependence, emphasizing the role of family-based management. Early recognition of problematic internet use and comprehensive interventions addressing individual and family factors are essential to prevent further psychological deterioration and support recovery in vulnerable adolescents.