Technological Addictions

Dr. Laura Roberts (00:08):

Hi, I'm Dr. Laura Roberts Editor-in-Chief for the books portfolio of the American Psychiatric Association, and welcome to the APA Books podcast.

Dr. Laura Roberts (00:25):

Well, welcome everybody to another edition of Psychiatry Unbound. Today our guest is a wonderful colleague and professor and chair of the Department of Psychiatry and associate Dean for professional development at Rutgers New Jersey Medical School. He's one of the deputy editors for APA Publishing, and we work really closely together. Petros is also the chief of the service of psychiatry at University Hospital in Newark, New Jersey. Dr. Levounis came to Rutgers from Columbia University where he served as the director of the Addiction Institute of New York from 2002 to 2013.

Dr. Laura Roberts (01:05):

And that's really relevant to the topic today. We're going to talk about Petros's wonderful book with James Sherer on technological addictions. But just to give a little bit more background, Petros is way smart. He was the Phi Beta Kappa honorary society graduate from Stanford University years ago, where he studied chemistry and biophysics before receiving his medical education also at Stanford. And then his training at Medical College of Pennsylvania. Today, he's here to talk with us about his newest book for APA Publishing on technological addictions. And I'm really happy to see you Petros virtually by zoom as we're recording this podcast and welcome to Unbound.

Dr. Petros Levounis(01:50):

Thank you so much Laura. Thank you for having me. Being invited is one thing, but being invited back, that's a big honor.

Dr. Laura Roberts (02:00):

Well it's because you keep on doing great books for us. I'm so glad and thank you. You were mentioning that James Sherer is a fellow. Tell me a little bit about him and how he was your partner in developing this book.

Dr. Petros Levounis (02:14):

He's an absolutely amazing human being and a wonderful psychiatrist and he was our chief resident here at Rutgers New Jersey Medical School. And he is now doing his fellowship in addiction psychiatry at NYU. He's the first one to admit and be proud of being a big gamer. He goes to the conventions and he plays video games quite frequently. He knows the culture in and out much better than I do. And he had a special interest in technological addictions with emphasis on internet gaming. So he and I got together and said, okay, this is the new frontier in addiction psychiatry really and let's put our folks together. Let's put the resources together. We don't have that much evidence, we don't have that much data, but we do have some, especially for internet gaming. And so we put that together in our technological addictions book.

Dr. Laura Roberts (03:20):

Yeah, that's wonderful. Technology is ubiquitous at this point. How do you discern when it crosses the line into an addiction?

Dr. Petros Levounis (03:30):

Most of our work reflects what we know about the substance use disorders. And luckily in a way, the more we study technological addictions, the more we appreciate the common themes that we see between the substance use disorders and the technological addictions. We go by pretty much the same criteria as we would for cocaine addiction, and heroin addiction and so on. We do have a physiological component to it with tolerance and withdrawal, we do have the internal pre occupation criteria that we use for substance use disorders. We also see those in the technological addiction and of course the external consequences.

Dr. Petros Levounis (04:29):

Somebody's relationships going south, getting in trouble with their work and their family and so on. That's how we see that line. It's not quite as crisp as we see it let's say in tobacco use disorder, you're either a smoker or you're not. And there are some people in between, but for the vast majority of people either you're a smoker or you're not. And we don't have that kind of crispness with the technological addictions, but we borrow from what we already know. To me out of all these 11 criteria that everybody knows from the DSM, the one that stands out is continued use despite knowledge of adverse consequences. That one rings particularly true for the technological addictions when people say, I know that this is getting too much, but I cannot really stop it.

Dr. Laura Roberts (05:27):

You commented to me in some other documents about how there might be some resistance to seeing this as a legitimate diagnosis, or maybe it's simply that people just don't know how to work with this as a newly emerging form of addiction. But what resistance are you encountering, if any, and what are you doing to overcome that resistance to the idea that this is a legitimate diagnosis?

Dr. Petros Levounis (05:54):

Interestingly, we don't get as much resistance from patients themselves and from the general public. I think it's one of the situations where the general public may be ahead of the professionals because they do see the problems and they come to us and say, Hey, is there something that they can do here? But we do see resistance from our own professionals, from our own colleagues.

Dr. Petros Levounis (06:23):

And I think it has to do mostly with the fact that we don't have the body of evidence. We don't have the studies, we don't have the books, we don't have the conferences, the things that psychiatrists are just so familiar with and so comfortable with when something new comes out. You come up with a new antipsychotic, you expect it to be unveiled at the APA in May, you expect to have the articles in the Green Journal and everywhere else. There's a sequence of events that has to happen for people to embrace a new diagnosis or a new treatment. And we don't have that machinery yet in place for the technological addictions.

Dr. Laura Roberts (07:10):

Do you have a sense of how widespread technological addictions are? If we don't have the evidence?

Dr. Petros Levounis (07:21):

When we think about behavioral addictions, we think about gambling. I know that you're going to be talking with Tim Fong at some point, if you haven't talked to him already. But I would guess here that it's somewhere 1%, 2%, 3% somewhere there. Not in the teens or higher. The majority of people who engage in technology will not have a problem with it. They may get the blues when you take a cell phone away from a 15 year old, but you're not going to develop a frank addiction.

Dr. Laura Roberts (08:04):

Yeah. Actually you've foreshadowed my next question. I'm wondering how early you feel like you can diagnose this condition?

Dr. Petros Levounis (08:13):

I'm not a child and adolescent psychiatrist, but it feels to me that adolescence is where it's at. I don't see it much with kids younger than 11 or 12, but certainly we do see it in adolescence.

Dr. Laura Roberts (08:32):

It's so funny. The other day I walked into our house and we have like this four generation family. And I walked in my 91 year old mother-in-law was on her phone, my 22 year old son was on his phone, my mother who's 86 was on her phone. My husband in the other room probably was on his phone. And it is interesting. I'll be very curious to see where it hits the along the age spectrum, because so many people, elders included are engaged with technology. And one of the things I've read about and learned about is isolated individuals who become very technology dependent. And actually begin to shop, do a lot of internet shopping. I'm assuming this is one of the consequences that you're thinking about. And that's a problem that's disproportionately affecting elders. So anyways, I wonder if we're going to learn a lot over this next 10 years, about how dependence on technology, use of technology and then these adverse consequences emerge and how difficult they're going to be to discern clinically.

Dr. Petros Levounis (09:42):

Yeah. I want to thank you Laura very specifically about the inclusion of older adults in our work. I do remember when we proposed the book and we had our initial meeting, and we had the whole list of texting and emailing, and infobesity, and cyber sex, and internet gambling, and internet gaming and all that. And we had a special chapter on children and adolescence. And I remember you saying "That's wonderful, that's great, great, great, but where are the older adults here?" And I went like, whoa, okay, Laura, you have a great point here.

Dr. Petros Levounis (10:22):

And we had a wonderful geriatrician who authored the chapter on older adults. And we learned so much by studying it and by seeing what other people have done. For example, the distinction between technology natives and technology immigrants, where I have an 11 year old niece and she's through and through a technology native. Everything is just so easy for her. And then there are technology immigrants. Probably my generation is somewhere in between. We had some technology, but nowhere near the technology that kids have now. And we had to learn the technologies and I consider myself to be pretty good at it, but it's not immediate. It's the native's appreciation and ability to connect with technology.

Dr. Laura Roberts (11:24):

So let me ask you then about other things that.... You've done several books for us. They're all really different actually, and uniquely valuable I think for the community. And I really want to thank you for all that. And I see you as being very inclusive and actually mentoring a lot of people through the process of developing books. I wanted to say that I admire that very much. Let me ask you about the harder part. What's hard about putting together a book, what was hard about maybe putting together this book and what advice might you have to someone who's thinking about tackling a book for us or for other publishers?

Dr. Petros Levounis (12:07):

That's an easy question here specifically about this book. Because when it came to technological addictions, the major obstacle was the lack of extensive literature, of extensive scientific studies. Yes we do know quite a few things about internet gaming, but for the rest of the technological addictions, we had to rely on the evidence. That was the major issue I would say with this book. Which is not the same with other books like Motivational Interviewing or LGBTQ Mental Health, where if anything we have too much information. And then you have to be careful not to get lost in the information overload. In terms of what would be challenging about putting a book together. Don't fret the time that we will spend planning about the book. That would be my major advice here.

Dr. Petros Levounis (13:10):

That it feels like it takes so much time to figure out what chapters you want to have, what's the organization of the book, what each chapter should have in it, the format of the book, the format of each chapter to have some continuity, to have some consistency from chapter to chapter, spend as much time as you need to really nail down exactly how you envision the book, both in terms of the sequence of the chapters, as well as each chapter individually.

Dr. Petros Levounis (13:45):

Then when you write all this up in your instructions to the chapter authors, you make their lives much, much easier. And the final product is one that seems like it does have some internal consistency to it. I would say that's somewhat of a challenge to take your time upfront in a book and then the rest will just take its place. I've become pretty good at editing at this point. We used to split chapters with my co editor, let's say, we say, I'll do those chapters, you do those. We don't do that anymore. We added all chapters both of us. And it is such a better feeling because you know that you're not the end of the line and you can put your thoughts down and it becomes much more collaborative. Then at the end of the day, it's not that much more time.

Dr. Laura Roberts (14:43):

Yeah, I think building a book is really, really fun. Another issue that I've heard people struggle with and I myself have struggled with is identifying the right authors for individual chapters in an edited book. Do you have a...You probably just mostly know people in the field and can think through who might be a good person to comment on a particular domain, but do you have any tricks or special approaches to that challenge?

Dr. Petros Levounis (15:13):

Yeah. There are some people who are very well known in their area, and you want them to be part of your book because they have done a lot of work. They've done a lot of studies and they're very well respected. The challenge here is that some of these people do not really have the time to write a chapter for your book. But the good news is that quite a lot of them may have fellows, and post docs and junior faculty that work with them who need some publications and need some writing. So I very often ask them to be the senior author in a chapter and have one of their trainees be the first author in the chapter and ends up quite often, like a win-win situation.

Dr. Petros Levounis (16:05):

The most extreme example of that to me is for our LGBTQ Mental Health book, where the lead author for one of the chapters was a high school student. And it was a reflection both of her own quality because she's an amazing person. And she did a wonderful job with the chapter, but also the content of it was on asexuality, something that is really emerging as a major sexual orientation identity. Not really that common in my generation, but certainly quite common in young people.

Dr. Laura Roberts (16:48):

Yeah. That's great. Let's step back then to the big picture. We're living in the time of a pandemic, we had multiple really addiction-related epidemics in our world and in our country prior to the pandemic, the intersection of addiction and the pandemic. We could focus a little bit on technology because I think technology has helped us overcome or address isolation that's come with the pandemic. But addiction as a whole, I think has yet underappreciated the impact of the pandemic or living through a pandemic and how that's going to have interplay with addiction. Am I on the right track here? Are you worried as I am about what we're going to be seeing in the months and years to come certainly in mental health, but specifically in addiction?

Dr. Petros Levounis (17:45):

The way that I see it, I break it down in three groups. There are the people with the bona fide psychiatric disorder with the bona fide addictions. And for them the stress of the pandemic has been really bad. And we see relapse in their addiction. We see worsening of the addiction. Somebody who managed to curb his alcoholism for some years and now because of the stress of the pandemic, they're all back to being full blown alcoholics. People with a severe form of an addiction are really not doing well at all. Then there's another group of people with lighter forms of, let's say, a substance use disorder or a behavioral addiction. And the picture there is a little more complex. For example, with alcohol, we know that people drink less, there are less opportunities to go out and bars and socialize, with less opportunities to drink in secrecy at home, which is we know women often drink at home in secrecy because everybody's at home now, everything is virtual.

Dr. Petros Levounis (18:59):

We've seen actually relief of some of these middle ground disorders. And then there's the general public, that's the people who do not really qualify for any psychiatric disorder or at least so far for whom I think the news are pretty bad as well. I think that's the area where anxiety and depression is going up. It's only a matter of time before we see more and more addictions coming out with technological addictions included, substance use disorders and the like. So at the two ends of the spectrum the news are pretty bad and the middle ground, it's a little more complex and confusing at this time that's how I see it.

Dr. Laura Roberts (19:45):

Yeah. And I think the other great lesson of the pandemic, I'm glad that there's at least one group that might actually have a little bit of relief in this. But the other big news of the pandemic is that it's just made so obvious and so extraordinarily painful the health disparities. And the lack of adequate resources, especially for certain populations. And I don't know if you have any observations there or what we can do beyond awareness. I think people are increasingly aware, but we need action. And if you have guidance for us or for me, or for the field on that.

Dr. Petros Levounis (20:27):

For some addictions, I'm thinking about the opioids and tobacco more specifically, we do have wonderful medications and we can make them available to quite a few people. And we have seen, even in the midst of the pandemic, we're able through phone calls and so on, even with the most economically depressed populations we serve to do quite well. There is some hope there. But for a lot of other addictions where 12 step programs are not available, or 12 step programs are not really very acceptable to a patient we have wonderful psychotherapies, truly wonderful psychotherapies. Contingency management, cognitive behavioral therapy, motivational interviewing, mindfulness, wonderful interventions that are just not accessible. They're not available to our patients.

Dr. Petros Levounis (21:27):

They're expensive, they're time consuming, they're not culturally ingrained in a lot of our populations. And so we do have the tools, but we don't have really the ability to reach the patients who probably need it the most. And these health disparities are only exaggerated now with the pandemic. You brought the technological addictions, so the topic of the day today for the technological addictions outside of treating co-care psychiatric disorders, the main treatments are psychotherapy. Psychotherapy and counseling.

Dr. Laura Roberts (22:08):

The idea of treating a person with say an internet addiction or another kind of technological addiction may feel very outside of the skillset of many psychiatrists and even psychotherapists in general, and probably means that we have to pick up new knowledge and new competency and new skills. Tell us what you think about that and how you would advise people who want to really meet the patients where they are in terms of this emerging addiction set of issues.

Dr. Petros Levounis (22:45):

Wonderful question. Yes the patient will teach you some of it. Because Sherer, he knows about these technologies, knows about these issues has played animal crossing and knows all about loot boxes and micro transactions and everything else. But part of the responsibility in 2021 is also for the therapist to be somewhat aware of the subcultures of these micro environments. And it's not really all that hard. You just before a session, just Google it. And the information is going to come up right away. Patient tells you that they use teledildonics. You can imagine what teledildonics would be like, but if you don't know about it, just Google it and the information will just come right there.

Dr. Laura Roberts (23:39):

Okay. People shouldn't be afraid to learn about these things and to take it on. And you could Google it, you could rely on your wonderful book. Maybe you could comment on a few patients where you were surprised or you encountered something new and you had to make maybe yourself go and learn some more about this space.

Dr. Petros Levounis (24:04):

Absolutely. The kink culture I wasn't aware of how... Of course, I knew that there was kinky sex, both virtual and in person, but I had no clue how organized that subculture is with their meetings, with having special trainings for the police. So if the police comes in and finds a situation that seems to be very dangerous and yet this could be just simply a scene of consenting adults involved in kinky sex. And this whole world that I wasn't aware of and I heard to learn from one of my patients really opened my eyes.

Dr. Laura Roberts (25:06):

Well, it's immediately making me nervous. Tell me about counter transference and how you... I know such a huge issue in the care of people living with addiction is remaining compassionate and appreciative of the lived experience of people with addiction. And encountering something that is really new or different, or frankly, very different from one's own life experience or values always gets us. I don't know, a little bit uncomfortable. Right? How do you think about that? Or again, what advice would you have for people is they're bumping up against things that feel very new and maybe a little scary and uncomfortable.

Dr. Petros Levounis (25:58):

The dance that we have to do is to allow ourselves to engage with our patients, to get in there, to try to see the world from their own eyes, to genuinely feel their anxieties, and their pain, and their fears when they engage, let's say, in this subcultures that I'm aware of. I do let myself connect with the patient in these matters, but always, always, always keeping my own sanity the best I can.

Dr. Petros Levounis (26:34):

My own husband, my own friends, my own world, that I can extract myself back. In terms of counter transference, the major issue in all of addiction, but certainly technological addictions as well is the disappointment that we sometimes feel when a patient relapses. Patient does so well and everything is great, great, great and they come to see you and it's such a kumbaya situation and you feel very good about your treatment. And then of course there is a relapse. Analogies with cancer and other chronic relapsing illnesses are very helpful to me that the illness is just much bigger than anything that I can do. And unfortunately, anything that my patient can do and it may rear its ugly head at any time.

Dr. Laura Roberts (27:27):

Oh, Petros I always feel like I learn from you every single time. And I want to thank you for this wonderful discussion and thanks to you and to James for taking on this important book. It's a book that anticipates a lot of what we're going to be seeing in our clinical practices and in our academic world. We need to be able to prepare our trainees to be able to provide astute and compassionate care for folks with technological addiction. My deepest thanks to you and to James for this wonderful book.

Dr. Petros Levounis (28:00):

Thank you so much Laura for leading us with this whole book, a project of the APA. It has been a wonderful journey for me writing these books.

Speaker 3 (28:18):

Our original music is by Willow Roberts. Our executive producer, Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing, John McDuffie Publisher. Be sure to visit psychiatryonline.org/podcast, to join the conversation, access show notes, and discover new content or subscribe to us on your favorite podcast platform. Thank you.