WhatsApp addiction and borderline personality disorder: A new therapeutic challenge.

Sir,

The introduction of smartphone is a revolutionary invention in mobile history, but its increasing use has started showing the negative consequences. Smartphone overuse can be a sign of Smartphone addiction [12] and can affect both social and health aspects of users' lives.[23] Adolescents may develop problematic behaviors, somatic symptoms, attention deficits, and aggression.[3]

WhatsApp application is utilized by almost everyone using smartphone. Its free facility to exchange text, photos, videos, forward jokes, and other information has resulted in excessive use. The impact may cause users to lose the real world interest; their entire emotion may remain restricted to the App. The loss of control, serious interference in everyday life (at school or work) and a constant dependence are some of the symptoms to identify people with WhatsApp dependence.

Borderline personality disorder (BPD) characteristics such as feeling of emptiness, getting bored easily, unstable self-image increase the proneness for WhatsApp addiction as these people may use mobile more often to stay in touch with more number of persons. Studies have found that dependent internet users rank high in terms of the feeling of loneliness, affective disorders, low self-esteem, and impulsive behavior.[4]

A 27-year-old female was presented with history of suicidal attempt by hanging. History revealed interpersonal conflict with husband that resulted in self-harm attempt. The patient agreed that her attempt was to threaten the husband with no intention to die. There were multiple such threats and attempts in past. There was also a history of unstable mood and relations with friends, easy irritability, poor impulse control, and polarized thinking from adolescent period as per the patient's parents. The patient was diagnosed with BPD and started on mood stabilizer (sodium valproate and escitalopram) for impulsivity and depressed mood along with psychotherapy to help her in anger management, improve coping styles, and stress management. Psychoeducation and counseling was done for husband.

The patient was under remission and on treatment for 2 years when husband noticed her spending more time on mobile phone compared to before with increase in the time spent on mobile with every passing day. Patient found sleeping late at night and remains chatting on WhatsApp with friends and relatives with no specific topic discussion. There was increased frequency of recharge of internet pack and sending 200–300 messages per day, sometimes even more. Patient expressed that because of high curiosity she used to check her mobile for every single message that arrives even at night which resulted in disturbed sleep and fatigability in morning hours. Patient needed mobile even while doing household chores and would take it to washroom also to check and read the messages and answer back immediately.

She tried to cut down her WhatsApp use by keeping the mobile off, blocking numbers of few friends, uninstall the WhatsApp application but could not sustain. Slowly she lost interest in other activities such as social meetings and gathering and spending time with neighbors which she used to do before. She was less concerned about the care of children and their studies. There was an increase in the irritability, and she would shout on those disturbing her while chatting. There was an impaired functioning. Sometimes she would lie and make excuses regarding WhatsApp use. There were repeated altercations and fights between husband and wife and when husband requested to stop the mobile use she threatened him about ending her life. Patient had insight into her helplessness without WhatsApp use and accepted that it was a problematic behavior but could not restrict herself. There was no history of organic antecedents, psychotic symptoms, symptoms of other addictions, features of obsessive compulsive disorder though guilt feelings about the behavior were present. Patient was clinically diagnosed as WhatsApp addiction with BPD.

Patient was shifted to fluoxetine (20 mg) and valproate was kept in the same doses that she was on. Behavioral therapy was given about how to control the craving, distract oneself, and keep herself busy with other activities and time management. It was difficult to engage her in specific psychotherapy because of BPD. Whenever confronted about the WhatsApp use, she used to become guarded, hostile, and very superficial in further responses. It is all through the multi-disciplinary approach including clinical psychologist and social worker that she could be psycho-educated about negative consequences of WhatsApp use on herself, family, and her overall functioning. The excuses on patient's part were logical as she said, it is impossible not to use internet at all as she is not addicted to Facebook, mail checks, online games, and updating one's knowledge about current affairs. Hence, she was initially advised to restrict her WhatsApp use for a limited period of the day for which she agreed. For sleep disturbances, lorazepam (2 mg) was prescribed for initial period. With regular treatment and psychotherapy (1 session/week) patient showed improvement after around 2 months as she was not using mobile at least while doing household chores. Slowly patient's use of mobile was reduced, and she could delay or refuse checking the WhatsApp and reply except for few slips. Main challenges during management were threats of rejecting the therapist and the therapy and the fact that complete stoppage of internet use was not possible because of its utility other than WhatsApp. Husband was psycho-educated and counseled about the nature and course of the illness and his role in managing the case. Patient is on regular medication and psychotherapy and well maintained since 6 months.

Though WhatsApp is one of the most commonly used applications of recent times, research in this area is very less.[5] Though we reported a female patient, literature reports a male preponderance. Onset usually occurs in late 20 s or early 30 s age group.[6] Some studies also showed that females used WhatsApp for significantly longer periods of time than males.

Researchers have found the associations among motives of smartphone use, social relations, perceived social support, and variables of psychological well-being.[7]

In this case, patient was spending increasing time on WhatsApp with a compromise of household duties, and when tried to stop the WhatsApp use, she had a craving. She tried to restrict herself but could not sustain. All this resulted in poor functioning and interpersonal problems in family. This type of symptoms syndrome is similar to any type of addiction. Internet overuse has high correlation to increased social isolation, low self-esteem,[8] aggression and impulsive behaviors. This can be applicable to WhatsApp addiction too as this case is.

DSM-V does not mention internet addiction in “addictive disorders” but conceptually the diagnosis is a compulsive-impulsive spectrum disorder.[9] In our case, it was a dilemma whether to diagnose her with internet addiction as her internet use was specifically limited only to the usage of WhatsApp.

Our patient had BPD also. Research shows that certain features of this personality like boredom susceptibility dimension were significantly correlated with internet addiction.[10] A high proclivity toward impulsivity and sensation-seeking and a low predisposition to harm avoidance was also found associated with behavioral addiction in adolescents.[11]

This patient was treated with fluoxetine and behavioral therapy along with counseling sessions for WhatsApp addiction (besides treatment for BPD). There are no evidence-based treatments for internet addiction. Cognitive behavioral therapy (CBT) may be helpful. Marital and family therapy may help in selected cases.[6] In this case, because of BPD, CBT could not be performed; hence, other behavioral approaches including time management, diversion techniques, and goal setting were tried. Some studies stated that the focus of treatment should be moderation and controlled use of internet.[12]

Thus, WhatsApp addiction may emerge as one of the important behavioral addictions having numerous negative consequences. BPD can be a risk factor to develop WhatsApp addiction. Simultaneous occurrence of these two disorders can be a therapeutic challenge for the psychiatrists.

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Conflicts of interest

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