Effect of electro-acupuncture combined with psychological intervention on mental symptoms and P50 of auditory evoked potential in patients with internet addiction disorder (2017)

Volume 37, Issue 1, 15 February 2017, Pages 43–48

http://dx.doi.org/10.1016/S0254-6272(17)30025-0

Abstract

OBJECTIVE

To observe the therapeutic effects of electro-acupuncture (EA) combined with psychological intervention on the symptom of somzatization or obsession and mental symptom of depression or anxiety and P50 of Auditory Evoked Potential (AEP) on internet addiction disorder (IAD).

METHODS

One hundred and twenty cases of IAD were randomly divided into an EA group, a psycho-intervention (PI) group and a comprehensive therapy (EA plus PI) group. Patients in the EA group were treated with EA. Patients in the PI group were treated with cognition and behavior therapy. Patients in the EA plus PI group were treated with electro-acupuncture plus psychological intervention. Scores of IAD, scores of the symptom checklist 90 (SCL-90), latency and amplitude of P50 of AEP were measured before and after treatment.

RESULTS

The scores of IAD after treatment significantly decreased in all groups (P < 0.05), and the scores of IAD in the EA plus PI group were significantly lower than those in the other two groups (P < 0.05). The scores of SCL-90 assembled and each factor after treatment in the EA plus PI group significantly decreased (P < 0.05). After treatment in the EA plus PI group, the amplitude distance of S1P50 and S2P50 (S1-S2) significantly increased (P < 0.05).

CONCLUSION

EA combined with PI could relieve the mental symptoms of IAD patients, and the mechanism is possibly related to the increase of cerebrum sense perception gating function.

Key words

Internet addiction disorder;
Electroacupuncture;
Psychological intervention;
Obsessive behavior;
Evoked potentials

INTRODUCTION

Internet addiction disorder (IAD) is a condition including mental disorders of intensified tolerance, withdrawal symptoms, emotional disturbance, social relation discontinuance, etc. and serial syndromes like physiological sub-health and vegetative nerve functional disturbance.^{1 ; 2} IAD could have highly negative impact on the normal psychological development and lead to serial syndromes such as emotional disturbance, conduct disorders, psychological stress, etc.³

From now on, the intervention measures for IAD mainly include pharmacologic therapy, cognitive behavior therapy, motivational interviewing and so on.⁴ Several studies also suggested that electro-acupuncture has positive therapeutic effect on IAD,^{5 ; 6} but there is no sufficient evidence to explain the therapeutic mechanism. At present the neuropsychological research showed that, the defect of sensory gating (SG) may result in multiple psychological disorders such as depression, schizophrenia and anxiety disorder.^{7 ; 8} IAD may also have a common neuropsychological basis with these disorders. SG refers to a property of the brain to restrain unrelated sensory stimuli, which is an important cognitive function. SG is usually associated with event related potentials which could be measured by P50, one of the wildly used electro-neurophysiological measurements. P50 refers to the maximum normal phase wave between 30ms and 90ms in the brain after the stimulation. It is a process that the brain has an inhibitory response to the same second stimulus after the first stimulus. So P50 of auditory evoked potentials (AEP) could reflect the inhibition function and the basic SG function of brain.⁹ Based on this, we suppose that the change of P50 before and after treatment in patients with IAD can reflect the change of SG inhibition function of brain, the therapeutic effect and be an indicator to compare different intervention measures so that to test whether the electro-acupuncture is effective and find out the more effective therapeutic method. In this study, we recruited patients with IAD and divided subjects into electro-acupuncture group (EA), psycho-intervention group (PI) and comprehensive therapy group (CT), observed the change of psychological symptoms and P50 of AEP in the three groups.

METHODS

Diagnostic standard

Diagnosis of IA was made according to the accepted standard issued by the American Association of Psychology (1997).¹⁰

Inclusive criteria

(a)

Intensified tolerance of net-play, i.e., the patient could be satisfied only by obviously increased net-playing time; or could not be fed up with the unchanged former net-playing time.

(b)

Appearance of any of the following symptoms after stopped net-play:

Evident withdrawal syndrome: Two or more symptoms appeared within several days or one month after the patient stopped or decreased the serious long time net-play behavior, including: depression; psycho-motor irritability; obsessive thinking on things that happened during net-play; a fantasy or a dream about net-play related things; voluntary or involuntary digital actions of keyboard knocking. These symptoms would induce mental depression or disturbances on sociality, work or other important things.

Be anxious to use the Internet or a similar service for alleviating or avoiding the withdrawal symptoms.

(c)

Played internet more frequently and for a longer time than the planned amount.

(d)

Always made an effort to abate or restrain from net-play, but all attempts were in vain.

(e)

Spent a massive amount of time on Internet-related activities, such as buying net-related books, trying to run a new browser, and disposing downloaded materials.

(f)

As a result of net-play, the patient set aside or gave up important social, work or amusement activities.

(g)

Continued to play internet recklessly, although the patient knew the persistent or recurrent troubles caused by play-net on the body, sociability, profession or mentality.

Exclusive criteria

Patients: (a) had suffered from mental disorder other than IA; (b) had histories of drug addiction; (c) were with counter-indication of EA, such as severe cardiovascular diseases, hematopathies, malignant tumors, etc.; (d) were hypersensitive to EA or unable to endure the EA operation or fainting from acupuncture; and (e) who were females and were pregnant or lactating.

Study setting and clinical characteristics of participants

A total of 120 subjects who entered the clinical trial with their diagnoses meeting the standard of Internet Addiction (IA) were screened from the 1st Teaching Hospital of Chengdu University of Traditional Chinese Medicine, the Clinics for Substance Dependence of Xiqu Hospital, the General Hospital of the Chengdu Military Area, and students from Xi’nan University of Finance and Economics and Chengdu TCM University. After signing an informed consent document, they were numbered according to the sequence of their visit and assigned into three groups using a randomized digital table produced by the SAS 8.0 software (version 8.0 SAS Institute, Cary, NC, USA). Forty subjects were assigned to each of EA group, PI group, and CT group. This study was performed according to the principles of the Declaration of Helsinki (Edinburgh version, 2000). The study protocol was approved by the Ethics Committee of the 1st Teaching Hospital of Chengdu University of Traditional Chinese Medicine. Informed consent was obtained from all participants. The clinical characteristics of participants are displayed in Table 1.

Table 1.

Clinical characteristics of participants ( x¯ ± s)

		Sex (n)
Group	n	Male	Female	Age (years)	Net age (years)	Net-playing Duration (h/d)
CT	40	27	13	22.5±2.0	4.7±2.1	6.0±1.9
EA	40	25	15	21.0±2.0	4.7±1.9	5.9±2.0
PI	40	27	13	22.5±2.3	4.2±2.0	6.1±2.5

Notes: CT group: treated with psychological intervention and electro-acupuncture; EA group: treated only with electro-acupuncture; PI group: treated only with psychological intervention. CT: comprehensive therapy; EA: electro-acupuncture; PI: psycho-intervention.

Table options

Treatment

EA was applied once every other day for a successive 10 turns as one course, with two courses applied totally for each case. Acupoints selection: Baihui (GV 20), Sishengcong (EX-HN 1), Hegu (LI 4), Neiguan (PC 6), Taichong (LR 3) and Sanyinjiao (SP 6). Operation: Patients in supine position. Huatuo brand 0.25 mm × 40/25 mm stainless needles from Suzhou medical supplies Company (Suzhou, China) were used, inserted in a routine, executed uniform reinforcing-reducing method until “De Qi”. Needles were retained in Baihui (GV 20), Neiguan (PC 6) and Sanyinjiao (SP 6) for about 30 min and given a needle-running every 10 min; a group of electric stimulation was applied on one pair of the 4 acupoints of Sishengcong (EX-HN 1), using right/left points and upper/lower points alternately; another group of electric stimulation was applied on Hegu (LI 4) and Taichong (LR 3), using acupoints on the right side and left side alternately. That means, two groups of stimulation were applied on 4 acupoints (2 pairs) in a turn of EA treatment. The electric stimulation was administered using a G6805 type multi-channel electro-acupuncture apparatus which from Huayi medical instrument Factory (Shanghai, China), with the set parameters of frequency 10–100 Hz, sparse-dense wave, width 0.3 ms, the intensity of the stimulus was set depending on the patient’s tolerance and was retained for 30 min.

PI was implemented by the cognitive behavior method at 4:00–5:00 PM every 4 days, at 30 min each turn, with 5 turns as one course, and two courses were applied. It was progressed in 4 aspects: (a) To get acquainted with the patient’s early experiences, and learn the roots of his ill makeup and negative emotion; (b) to weigh on the Internet objectively and comprehensively together with the patient so as to change his cognitive components of net-infatuation and dependence; (c) to establish a scientifically rational schedule of work/rest together with the patient, to recover his life orderliness; and (d) to conduct behavior reinforcement by negotiating and subscribing to an agreement of IA abstinence together with the patient and his family members for attenuating IA gradually. In comprehensive therapy (CT) group, EA plus PI was administered, with EA for 10 turns and PI for 5 turns as one course.

Measurement

The clinical conditions of the patients were appraised by scoring using the self-rating scale for IAD and SCL-90. The scores were taken 2 times respectively at the beginning and the end of the trial, and the results was recorded. The self-rating scale for IAD was formulated by Kimberly Young, University of Pittsburgh, USA.¹¹

The SCL-90 consists of 90 items, and is divided into 5 levels by scoring 1–5.¹² The total scores and the average marks of the positive items as well as the scores of factors including somatization symptoms, obsessive-compulsion symptoms, interpersonal sensitivity, depression, anxiety, hostility and horrible, paranoid, psychotic symptoms were analyzed.

All the determinations were operated under the appraiser’s instruction, in a quiet environment, with the testee in a clear-headed manner and his attention fixed. The appraisement was then accomplished by a specially appointed technologist.

Observation on ERP was carried out at 9:00–12:00 am in a shielded room, adopting the method of Su et al, ¹³ using the MEB 9200-evoked potential detector from Nihon Kohden Company (Tokyo, Japan). Unified instructive speech and testing parameters were followed during the test, and the operation was performed by a settled person.

According to the international 10/20 systemic method for electroencephalogram, the recording electrodes were placed at the central point of the scalp (Cz) and the midpoint of the forehead with the earth connected; the reference electrodes located at the bilateral earlaps, the impedance set between the electrode and the skin at < 5 kΩ. Double-clicks (S1, S2) were evoked by the external signal generator with a frequency of 85Hz. The clicks were rectangular waveform and 0.10ms in duration. Each trial consisted of two clicks (S1, S2) with an inter-stimulus interval of 500ms. The trials were repeated with an internal of 10s. Subjects were given 32 groups of double-stimulus through headphones. The stimuli of S1 and S2 were sampled synchronically and respectively. Input signal was amplified 200ms to analysis window. P50 evoked by S1 was conditioning (S1-P50) while by S2 was testing (S2-P50). Latency and amplitude of S1-P50 and S2-P50 as well as the ratio of the amplitude of S2-P50 and S1-P50 (S2/S1), and the difference between the amplitude of S1-P50 and S2-P50 (S1-S2) were documented.

Statistical Analysis

Data were expressed as mean ± standard deviation ( x¯ ± s), and analyzed with SPSS 13.0 (version 13.0 SPSS Inc., Chicago, IL, USA), T-test, one-way analysis of variance, χ² test, Ridit test were performed to test the differences between the groups. P < 0.05 was considered statistically significant.

RESULTS

A total of 112 subjects reached the final analysis of the trial (Figure 1). Eight subjects dropped out: one subject in the EA group dropped out due to fainting during the first EA treatment; among four subjects in the PI group, one dropped out due to acute appendicitis after two PI treatments, two due to a school examination before the 4th PI treatment, and the last one due to the need to visit his severely sick grandmother after the 4th PI treatment; among three subjects in the CT group, one dropped out after the first treatment for an out-of-town excursion, two to take an examination after the 1st and 3rd CT, respectively.

Figure 1.

Flow diagram of the participants

CT group: treated with psychological intervention and electro-acupuncture; EA group: treated only with electro-acupuncture; PI group: treated only with psychological intervention. CT: comprehensive therapy; EA: electro-acupuncture; PI: psycho-intervention.

Figure options

Comparison of IA Scores

The IA scores before treatment in the three groups were insignificantly different (P > 0.05). After treatment, the score decreased in all the three groups (P < 0.05), and the IA degree ranked them as CT < EA < PI (all P < 0.05, Table 2).

Table 2.

Comparison of IA scores of PI, EA, CT groups ( x¯ ± s)

Group	n	Pre-treatment	Post-treatment
PI	36	71±6	54±14^a
EA	39	72±8	48±15^{a ; b}
CT	37	75±8	40±11^{a, b ; c}

P < 0.05, compared with before treatment;

P < 0.05, compared with the PI group;

P < 0.05, compared with the EA group.

Table options

Comparison of SCL-90 Scores

After treatment, the total SCL-90 scores and every factor scores decreased significantly (P < 0.05); in EA group, except the factor of hostility and horror, the total scores and other factor scores significantly decreased (P < 0.05); in PI group, except the scores of somatization and horror, the total scores and scores of other factors significantly decreased. The total scores and the average marks of the positive items as well as the scores of factors including somatization symptoms, obsessive-compulsion symptoms, interpersonal sensitivity, depression, anxiety, hostility and horrible, paranoid, psychotic symptoms and other factors in CT group were significantly lower than in the EA group and PI group (P < 0.05). The total scores and every factor scores of EA group were insignificantly different from those in PI group (P < 0.05, Table 3).

Table 3.

Comparison of SCL-90 scores of PI, EA, CT groups ( x¯ ± s)

	PI		EA		CT
Factor	Pre-treatment	Post-treatment	Pre-treatment	Post-treatment	Pre-treatment	Post-treatment
Total score	127.9±570.0	90.6±56.4^a	136.6±63.5	95.3±80.1^a	141.7±36.3	61.0±26.4^{a, b ; c}
The average marks of the positive items	1.8±0.6	1.5±0.6^a	1.9±0.5	1.5±0.8^a	1.9±0.4	1.1±0.4^{a, b ; c}
Somatization	1.2±1.0	1.0±0.8	1.4±0.9	1.0±0.9^a	1.4±0.6	0.6±0.4^{a ; c}
Obsessive-compulsion	1.9±0.6	1.4±0.7^a	2.1±0.7	1.4±0.9^a	1.9±0.4	1.0±0.5^{a, b ; c}
Interpersonal sensitivity	1.6±0.9	1.1±0.7^a	1.8±0.8	1.3±1.0^a	2.1±0.8	0.9±0.5^a
Depression	1.7±0.7	1.3±0.8^a	1.6±0.7	1.1±0.9^a	1.7±0.5	0.7±0.4^{a, b ; c}
Anxiety	1.5±0.9	1.1±0.8^a	1.5±0.8	1.1±0.9^a	1.5±0.6	0.6±0.4^{a, b ; c}
Hostility	1.5±0.6	1.0±0.6^a	1.6±0.9	1.2±1.0	1.7±0.8	0.8±0.5^{a ; c}
Horrible	1.0±0.8	0.7±0.7	1.1±0.9	0.7±0.9	1.3±0.8	0.5±0.3^a
Paranoid	1.7±0.8	1.2±0.8^a	1.7±0.8	1.2±1.0^a	2.0±0.7	0.9±0.5^a
Psychotic symptoms	1.2±0.9	0.8±0.7^a	1.4±1.2	0.8±0.9^a	1.2±0.7	0.4±0.3^{a, b ; c}
Other factors	1.2±0.7	0.8±0.6^a	1.5±0.9	1.0±1.1^a	1.1±0.6	0.5±0.3^{a, b ; c}

P < 0.05, compared with pre-treatment;

P < 0.05, compared with the PI group;

P < 0.05, compared with the EA group.

Table options

Comparison of Latency and Amplitude of P50

After treatment, latency of S1-P50 in PI group and S2-P50 in CT group was significantly increased (P < 0.05). Latency of S1-P50 in CT group was significantly reduced than that in PI group and EA group (P < 0.05). The difference between amplitude of S1-P50 and S2-P50 (S1-S2) was significantly increased (P < 0.05). S1-S2 in EA group was also higher than before but had insignificant difference (P > 0.05, Table 4 ; Table 5).

Table 4.

Comparison of latency of P50 of PI, EA, CT groups (ms, x¯ ± s)

		Latency of S1-P50		Latency of S2-P50
Group	n	Pre-treatment	Post-treatment	Pre-treatment	Post-treatment
PI	36	54±17	64±20^a	52±18	61±26
EA	39	59±12	65±19	61±19	58±26
CT	37	53±15	55±20^{b ; c}	46±15	58±25^a

P < 0.05, compared with pre-treatment;

P < 0.05, compared with the PI group;

P < 0.05, compared with the EA group.

Table options

Table 5.

Comparison of amplitude of P50 of PI, EA, CT groups (μV, x¯ ± s)

			Pre-treatment				Post-treatment
Group	n	S1-P50	S2 -P50	S2/S1	S1-S2	S1-P50	S2-P50	S2/S1	S1-S2
PI	36	15.9±12.0	8.9±5.7	0.7±0.5	6.9±6.0	18.4±15.1	7.7±5.7	0.6±0.6	10.8±8.5^a
EA	39	14.5±10.3	7.5±6.3	0.7±0.5	7.0±6.6	16.1±7.6	7.4±3.7	0.7±0.5	8.7±4.2
CT	37	13.2±8.4	7.2±6.9	0.7±0.5	6.0±3.3	15.8±10.5	8.0±4.8	0.6±0.4	7.9±4.8^a

P < 0.05, compared with pre-treatment.

Table options

DISCUSSION

In this study, the results of the self-rating scale for IAD in this study showed that after treatment the score of IAD significantly decreased. The score in CT group was significantly lower than in EA and PI group. That’s to say, the comprehensive therapy (EA + PI) could have a significant effect in treating IAD.

SCL-90 could totally reflect the Psychological symptoms of the participants with analysis of sense, emotion, thinking, consciousness, behavior as well as life style, interpersonal relationship, diet and sleep, etc. It could diagnose whether the people are in mental disorder or not.^{14; 15 ; 16} In this study, after CT, the total score and score of every factor of SCL-90 significantly decreased (P < 0.05); and the total score and the average marks of the positive items as well as the scores of factors including obsessive-compulsion symptoms, depression, anxiety, psychotic symptoms and other factors in CT group were significantly lower than in the EA group and PI group. The result showed, the CT could regulate the psychological state and improve the level of mental health.

Sensory gating (SG) refers to a property of the brain to restrain unrelated sensory stimuli. This kind of property is closely related to the directivity of mental activity. The brain could restrain unrelated stimuli through SG in order to avoid stimuli overload. The defect of SG may result in multiple psychological disorders especially disorders of attention.¹⁷ AEP P50, a delayed positive component of mean evoked potential, often appears as 30∼90ms after stimulation, being an objective electric physiological index reflecting SG. When the subjects received repeated stimulation with short intervals, the amplitude of AEP P50 would decrease. Such kind of reflection is an automatic note precursor inhibitory ability of brain to remove unrelated stimuli. The ratio of the amplitude of S2-P50 and S1-P50 (S2/S1), and the difference between amplitude of S1-P50 and S2-P50 (S1-S2) could reflect the basic function of SG of brain.^{18 ; 19} The smaller ratio of S2/S1, or the larger difference of S1-S2, the stronger function of SG.

It was shown in this study that after CT the difference between amplitude of S1P50 and S2P50 (S1-S2) increased significantly, suggesting that CT could alleviate the mental symptoms of the patients by regulating the function of SG and reducing unrelated stimuli overload.

In conclusion, the study confirmed that the CT could alleviate the mental symptoms of IAD patients, and the mechanism might be related to its effects in enhancing the brain sensory gating function of IAD patients.

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Supported byNational Natural Science Foundation of China: Research of Central Mechanism on Electro Acupuncture in Desalinating Internet Addiction of Patients with Pathological Internet Use based on Mirror Neuron System(No. 81574047); Research of Central Responsive Mechanism on Electro Acupuncture in the Adjustment of Internet Addiction Impulse Control Disorder(No. 81072852); Fund of the Fok Ying Tung Education Foundation: Research of Central Integration Mechanism on Electro Acupuncture in the Adjustment of Prefrontal Cortex-Buckle Impulse Control Loops related to Internet Addiction(No. 131106); The Training Funds of Academic and Technical Leader in Sichuan Province: Research on the Central Mechanism of Electro-Acupuncture Rehabilitation Treatment for Internet Addiction Based on Brain Working Memory Network; Applied Basic Research Projects of Sichuan Provincial Science and Technology Department: Research of Central Integration Mechanism on the Effect of Electro Acupuncture on Brain Working Memory of Internet Addiction Disorder Patients(No. 2013JY0162); Sichuan Provincial Health Department Project: Research on Brain Working Ability and the Characteristics of Electroencephalograph Entropy in IAD Patients(No. 110083); People-Benefiting Technology Research and Development Project of Chengdu Science and Technology Bureau: Research on Electro Acupuncture in 5-HT and 5-HTT Gene as Well as its Expression Control of Pathological Internet Use Patients(No. 2014-HM01-00180-SF); The Colleges and Universities Application Achievement-transformation Project Plan in Chengdu Municipal Science and Technology Bureau: Research of Central Responsive Mechanism and the Effect of Electro Acupuncture on Working Memory Of IAD Patients(No. 12DXYB148JH-002)

Correspondence to: Prof. Zhu Tianmin, College of Acupuncture and Massage, Chengdu University of Traditional Chinese Medicine, Chengdu 610075, China, Telephone: +86-13608216905

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