Internet addiction in university medical students

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www.elsevier.es/rmuanl

ORIGINAL

ARTICLE

Internet

addiction

in

university

medical

students

N. Capetillo-Ventura

∗

_,

_M.

_{Juárez-Trevi˜}

_no

DepartmentofChildandAdolescentPsychiatryandPsychology,UniversityHospital‘‘Dr.JoséEleuterioGonzález’’, UANL,NuevoLeón,Mexico

Received11January2015;accepted19February2015 Availableonline14May2015

KEYWORDS Internetaddiction; Psychiatric symptoms; Personalitytype Abstract

Objective:TodeterminetheprevalenceofInternetaddiction,psychiatricsymptomsand per-sonalitytypeinuniversitystudents,andtocorrelatethesevariables.

Methods:Weenrolled 522medicalstudents,281men and241women, withameanageof 21.2years.We used asocio-demographicquestionnaire, an Internetquestionnaire (Young’s InternetAddictionTest[IAT]),theGeneralHealthQuestionnaire,andtheZuckerman-Kuhlman PersonalityQuestionnaireIII(ZKPQ).

Results:ThemeanrawscoreofrespondentsintheIATtestwas19.72points.IAhadahighly sig-nificantcorrelationwithimpulsivity(rs=0.244,p<001),neuroticism-anxiety(rs=0.304,p<001) andaggression-hostility(rs=0.143, p=0.001).Italso negativelycorrelated withworkeffort (rs=−0.136,p=0.002).Asformentalhealth,IAhadahighlysignificantcorrelationwithsomatic symptoms (rs=0.174, p<001), anxiety andinsomnia (rs=0.219, p<001), social dysfunction (rs=0.118,p<001)andseveredepression(rs=0.199,p<001).

Conclusions:The Internet is a tool for various activities. When used with control it does not causeany problems. However, when control islost, addiction occurs togetherwith its comorbidities.Certainpersonalitytypes arepredisposedtothislossofcontrolandInternet abuse.

∗_{Corresponding} _author _at: _Gonzalitos_Avenue _and _Francisco _I. MaderoAvenue,Monterrey,MitrasCentro,MonterreyNuevoLeón, Mexico.Tel.:+5218181787404.

E-mailaddress:dranellycv@hotmail.com(N.Capetillo-Ventura).

Introduction

The Internetiscurrentlyacriticalcomponentof telecom-munications,business,education,andentertainment. Itis availableworldwideandisusedtosearchforinformation, online communication, financialtransactions, retail sales,

http://dx.doi.org/10.1016/j.rmu.2015.02.003

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sexualservicesandgames,amongmanyotheruses.Withits growingpopularity,overusesoonappeared andthusanew disorder,InternetAddiction(IA).1

ThefirsttoproposethetermIAwastheAmerican psychi-atristIvanGoldbergin1995,whodescribedthepathological compulsiveuse oftheInternet, withthis termbeing defi-nitely definedbyKimberly S.Young.2 _IA_is_a _{deterioration}

inthecontrolof itsuse,manifested asaset ofcognitive, behavioralandphysiologicalsymptoms.Thatis,theperson is‘‘netdependent’’,makingextensiveuseoftheInternet, whichgeneratesadistortionofher/hispersonal,familyor professionalgoals.3

Griffiths4 _proposed _assessing _seven _specific _areas _for

Internet addiction: (a)tolerance, (b) spendingmore time than planned on the Internet, (c) spending most of their timeinactivitiesthatallowthemtobeonline,(d)spending moretimeonlinethaninsocialorrecreationalactivities,(e) continuingusedespitework,academic,economicorfamily concerns,(f)failedattempts tostop orreduce useof the Internetand (g)withdrawal. According tothis author,the diagnosisshouldbemadeinthepresenceofthreeormore oftheareasdescribed.

Hong etal5 _found _a_reduction_in _thickness_of _the_right

orbitofrontalcortexinadolescentswithInternetaddiction. Thisreflectsacommonneurobiologicalmechanismbetween IA and other addictive disorders. Young6 _classified _it _into

5 types: (1)cybersexual addiction toadult chat rooms or pornography; (2) addiction to online friendships or situa-tionsthatreplacereal-liferelationships;(3)webcompulsion togamble,auction,orobsessivelytrade;(4)thecompulsive searchforinformationontheweb,and(5)addictionto com-putergamesandprogramming.Goldberg7_prefers_to_replace

thetermIAwithpathologicalcomputeruse.

Someresearcherssuggesttheexistenceofvulnerableor high risk groups for Internet addiction, primarily focusing onstudents.A reviewin Mexico8 _concluded_that_although

it is not yet possible to make the diagnosis of ‘‘Internet addiction’’assuch,itisclearthatthebehaviorassociated withexcessiveInternetusehasfeaturesthat,becauseofits impactonanindividual’sfunctioningandinterpersonal rela-tionships,warrantsaninterventionaimedatthisproblem.

Investigatorshave attemptedtodefinetheclinical and epidemiologicalprofileof individualswithIA,suchasthat inastudybyCruzadoetal.2_who_found _that_patients_with

IAwerecharacterizedbytheiryoungage,highdaily Inter-netusertime,predominantuseofwebgames,andahigh frequencyof markedpsychoticbehaviors.Young9 _assessed

depression and IA, and her findings suggest an increase inlevelsof depressionassociatedwithInternetaddiction. Duetothesusceptibilityofyoungpeopletopresent addic-tions,inthisstudywedeterminedthepresenceofInternet addiction, psychiatric symptoms, and personality type in universitystudentsandcorrelatedthesevariables.

Methods

and

subjects

Questionnaires were administered during the period of March-April2013tomedicalstudentswhohadInternetand agreedtoparticipatevoluntarilyinthestudy.Itwasdecided toperformthisstudyinthispopulationbecauseoftheease

ofprocessingitattheUniversity.Theprojectwasreviewed andapprovedbytheEthicsCommitteeofourinstitution.

We determined the size of the sample population (p) to be studied by means of a bilateral interval with a 95% confidence interval (˛=0.05), with an estimation of

error limits±5% (B=0.05) and considering a conservative approach(p=q=0.5). The result meant that,for a popu-lation of 5192 students, a sample of 358 individuals was required.The samplingdesign usedwastwo-stage. Inthe firststagewestratifiedbyschoolyear(6strata)andinthe second, clusterswere selected. The group formed a con-glomerateofstudentsandacensuswasconductedineachof theeightclusterspresentinthesample.Sampleallocation wasproportionaltothesizeofthestratum,thatis, propor-tionaltothetotalnumberofstudentsofthatschoolyear. Forthefirstandsecondschoolyears,werandomlyselected 2groupseach,whileintherest(third,fourth,fifthandsixth) agrouporclusterwasrandomlyselectedbyschoolyear.

Application of the instruments was performed in the regular classroom, on the day and time agreed with the coursecoordinator.Theinstrumentswereappliedbygroups. Amemberofthe researchteamexplainedthepurposeof the study,conditions and data confidentiality, and volun-tary participation of the students who were present was requested.Theaveragetimetocompletethequestionnaires wasapproximately30to40min.Questionnaireswere admin-isteredtoatotalof543students,ofwhom21didnotanswer completely,thereforethesewereeliminated.

Instrumentsandvariables

The instruments considered for the study were: a ques-tionnaireofsocio-demographicvariablesincludingage,sex, marital status, level of study, persons with whom the individual lives, academic performance, and recreational activities;anInternetquestionnairethatcollects informa-tion on frequency of weekly use, time of use for each connection,connection location, andpurposeof the con-nection,andanIAtestconsistingofa20-itemquestionnaire withLikerttyperesponseswithaminimumscoreof20and amaximum of 100 (thehigher thescore, thegreater the problemcaused bytheuse ofInternet). Ascoreof 20---39 pointsisan averageonlineuserwhohascompletecontrol overitsuse,ascoreof40---69meansfrequentproblemswith Internetuse,andascoreof70---100meansthatuseofthe Internetiscausingsignificantproblems.10,11

Goldberg’sGeneral Health Questionnaireinits28-item version (GHQ 28)12 _was _also _included. _This _instrument

consists of four scales: somatic symptoms, anxiety and insomnia,socialdysfunction,andseveredepression. Inter-nalconsistency(Cronbach’salpha)ofthetotalquestionnaire variesbetween0.82and0.93.Test---retestreliabilityranges from0.85to0.90.

The Zuckerman-Kuhlman Personality Questionnaire III, translatedand adapted withpermission fromthe authors byGonzálezetal.13_,_consists_of₉₉ _items_with_an

alterna-tivetrueorfalseanswer.Thisquestionnaireisolatesthefive majorpersonalityfactorsproposedbyZuckerman.Impulsive SensationSeeking(ISS)consistsof19itemsthatrefertoa willingnesstotakeriskstoexperiencearousalandseeknew experiences.Theyalsorelatetothelackofplanningandthe

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Table 1 Level of education, subject under study, and groupsofstudents.

Year Subject Group N %

1 Anatomy 2 45 8.6 Biochemistry 11 46 8.8 2 Microbiology 5and11 75 14.4 3 Pathology 3 82 15.7 4 GeneralSurgery 1 67 12.8 5 Psychiatry 1 142 27.2 6 Obstetrics 1 65 12.5 Total 522 100

tendencytoactimpulsivelywithoutthinking. TheScaleof NeuroticismandAnxiety(NA)alsohasatotalof19itemsthat describeemotionalinstability,stress,worry,phobiasand/or fears, obsessive indecision and susceptibility tocriticism. AggressionHostility(AH)isascalethatconsistsof17items relatedtoverbalaggression,rudeness-impoliteness, antiso-cialbehavior,andanger.TheActivity(A)scaleconsistsof17 itemsreferringtotheneedforactivityandaninabilitytosit arounddoingnothing.TheSociability(S)scaleconsistsof17 items,andreferstothenumberoffriendsyouhaveandthe timedevotedtothem,thedesirefor partying,preference forbeingwithothersasopposedtobeingaloneanddoing activitiesalone.Finally,theInfrequencyscale(I)consistsof 10itemsrelatedtosocialdesirability,whicharenotentirely trueforeveryone.

Statisticalanalysis

Descriptiveandinferentialstatisticswereused.Forthefirst proportions,percentagesandabsolutefrequenciesfor cat-egorical variables were obtained. For continuous and/or numericvariables,measuresofcentraltendency, variabil-ity and positioning were calculated. Confidence intervals of95%for bothratiosandmeans wereobtainedfor infer-entialstatistics. Fornumeric or continuous variables,the Kolmogorov-Smirnovtestwasusedtotestthehypothesisof normality.Toexaminecorrelations,parametric(Pearson’s) or non-parametric (Spearman’s) correlation coefficients wereused.

Results

Dataanalysiswascarriedoutin522students,comprising281 menand241women.Ofthese,509weresingle,11married, onecommon-lawmarriedand1separatedwithameanage of21.24years,median 21,SD3.046withan agerangeof 15---61years(KS=0.147,p=0001).Thelevelofeducation, thesubjectunderstudyandthegroupofstudentsareshown inTable1.

Regardingacademic performance,23considered them-selvesexcellent, 107 verygood,347 good,42 poor and3 verypoor.Ofthetotal,327studentsengagedinrecreational activities and 195 did not. Activities were mainly sports, arts,reading,andvideogames.Mostlivedwiththeirfamily (84.5%).

ByanalyzingInternetuse,itwasfoundthat15students usedtheInternet1dayaweek,5students,2days,14 stu-dents,3days,33students,4days,25students,5days,33 students,6daysand397,7daysaweek.Connectionsperday were0to10times,86%,11to20times,2.4%,21to30times, 0.4%,50times,0.2%,144times,0.6%,andalways,10.4%.

Theapproximatetimeof Internetuse eachtimeauser logged in was1 to960min and 10.4% referred tostaying connectedalways. Mostwould connectfor 60min (20.1%) followedby120min(13.2%),and30min(12.6%).Theplace chosen asthe mostfrequentlyusedwasthehome,in 442 (84.7%).

Themainreasonforbeingconnectedtothenetworkmost ofthetimewassocialnetworks(Facebook,Twitter,Tumblr, chats)in43.86%,academicandresearchactivitiesin32.95% andentertainment/leisurein23.18%.

Therearedifferences inIA duetothe perception that students have of their academic performance (2=10.25,

df=3, p=0.016).Those whoperceive theiracademic per-formance aspoor and very poor had the highest Internet addictiontestscores.

TherewasnosignificantdifferenceinIAduetowhether or not a recreational activity was practiced (Z=−0.49,

p=0.620).Also,therewasnosignificantdifferenceinIAdue towhothepersonwaslivingwith(2=2.47,df=2,p=0.29).

The meanraw score of respondentsin the IAtest was 19.72, witha standard deviationof 12.54 and a range of 0---72withapossiblemaximumof100points.

Theclassificationofscoresaccordingtothe interpreta-tion of the IA test showed that 91.8% of the sample had completecontroloveritsuse,while8%hadfrequent prob-lemsandin0.2%,usecausedsignificantproblems.

Internet use caused a greater problem in men with a meanof21.25(median18.00,SD13.38)unlikewomenwitha meanof17.95(median16,SD11.25(U=28,914.5,Z=−2.88,

p=0.004). Second, fourth and fifth year students had a greaterprobleminInternetuse(2=15.62,df=5,p=0.008).

Thestudents’personalityandmentalhealth areshown inTables2and3.

AccordingtotheresultsoftheKormogorov---Smirnovtest with Lilliefors correction, a normal distribution was not foundforanyofthevariables(p<0.01).

IA has a highly significant correlation with impulsi-vity (rs=0.244, p<.001), neuroticism-anxiety (rs=0.304, p<.001) and aggression-hostility (rs=0.143, p=.001). This

was only significant with sensation seeking (rs=0.95, p=0.030).Itwasalsonegativelycorrelatedwithworkeffort (rs=−0.136,p=0.002);thegreatertheaddiction,thelower

theworkeffort.

Regarding mental health, IA had a highly significant correlation with somatic symptoms (rs=0.174, p<.001),

anxiety and insomnia (rs=0.219, p<.001), social

dysfunc-tion(rs=0.118, p<.001)andseveredepression(rs=0.199, p<.001).Personalityandmentalhealthinthegroupsformed accordingtoIAtestinterpretationareshowninTable4.

Discussion

Wefound, likeYoung3 _and_others,_that_men_have_a_higher

prevalenceofInternetaddiction.Despitethelowfrequency of IA reportedby the students in ouranalysis, it appears

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Table2 ResultsoftheZuckerman-KuhlmanIIIquestionnairesubscales.

Subscale Mean Median Minimum Maximum SD KS

Neuroticism-anxiety 0.3534 0.3158 0.3326 0.3743 0.2421 0.123 Activity

GeneralActivity 0.4650 0.4444 0.4447 0.4853 0.2359 0.104

WorkEffort 0.5943 0.6250 0.5757 0.6129 0.2160 0.150

Sociability

PartiesandFriends 0.3795 0.3333 0.3606 0.3984 0.2195 0.150

Intolerancetobeingalone 0.5194 0.500 0.4969 0.5419 0.2611 0.121 Impulsivenessandsensationseeking

Impulsiveness 0.3123 0.250 0.2921 0.3324 0.2339 0.139

SensationSeeking 0.5536 0.5455 0.5322 0.5751 0.2490 0.092

Aggressiveness-hostility 0.3826 0.3529 0.3656 0.3995 30.34 0.091

Infrequent 0.2316 0.2 0.2169 0.2463 1.710 0.171

that most usethe network seven daysa week, mostly 10 times aday, spending an hour oneach connection,which seemsgenerallyaneverydaybehaviorofyoungpeople.Itis notablethatmostresponded thattheyfrequentlysurfthe webforalongerperiodthanintended,whichshowsalack ofcontrolintheiruse.

WenotedaremarkablyludicnatureofInternetusesince mostofthetimetheyconnectedtothenetworkto partici-pateinsocialnetworksandleisure.

Overall, we found a small percentageof students who haveproblemswithInternetuse(8.2%);however,thisagrees withtheliteratureandthecomorbiditiesfoundinInternet addiction.

IthasbeenstatedthatproblematicuseoftheInternetis onlythemanifestationofanunderlyingproblem, highlight-ing frequent comorbidities with mood disorders, anxiety, andotheraddictions.14_Mustafa15_investigated_the

relation-shipbetweenIAandpsychiatricsymptomsandhefound a significant relationship between daily use of the Internet andthedegreeofpsychiatricsymptomssuchasdepression, obsessivecompulsion,interpersonalsensitivity,anxiety, hos-tility, phobicanxiety,paranoidideation and psychoticism. Withlongeruse,morepsychiatricsymptomsoccur.Healso found a significant association between the severityof IA andthedegreeofpsychiatricsymptomatology.

Ebeling-Witteetal.16_found_that_scores_of_shyness_were

associatedwithproblematicInternetuse.Thatis,the net-work is usedtoreduce thedeficit perceived in social life by establishing virtual friendships online and to alleviate feelingsoflonelinessanddepressionandtoavoidattending stressfulplaces.Incontrast,ShapiraandGoldsmith17_found

inapopulationofsubjectswithproblemswithInternetuse that100%metDSM-IVcriteriaforimpulsecontroldisorders nototherwisespecified.

Inanexploratorystudyonbehavioralproblemsrelatedto Internetuse,asubgroupofnetizenswhoexpressedgreater anxiety and social dysfunctionwas identified throughthe GHQ-28.18

Armstrong, Phillips and Saling19 _concluded _that

self-esteemandthenumberofhoursperweekusingthenetwork werethevariablesthatbestpredictedproblemsrelatedto theInternet.However,impulsivity wasnotrelated,which madetheauthorsconcludethatunlikeotheraddictions,IA isnotcharacterizedbythistrait.

In2012,astudyofEgyptianadolescentsfoundthat sub-jectswithproblematicInternetuseweremorelikelytohave anxietydisorders(socialphobia,specificphobia,and gener-alizedanxietydisorder).20

Articlesthatmentionthecoexistenceofpsychiatric dis-ordersandInternetaddictionwerefoundinareviewofdata fromPubMedcarried out upto November 3,2009. Based onthis review, IA is associated withsubstance use disor-der,attentiondeficitandhyperactivitydisorder,depressive disorder,socialphobia,andhostility.21

Kubeyetal.22_reported_four_times_more_academic

deteri-orationinstudentswithIAthanwasnotedintheperception ofacademicperformanceinoursample.Astothequestion ofwhetherornotperforminganyrecreational (extracurric-ular)activitieshasaneffect---seekingapossibleprotective factor---nosignificant differencewasfoundintermsofIA andpracticing(ornot)theseactivities.

GarciadelCastillo23 _found_in_his_study_of_university

stu-dentsthat the psychosocial profile of the group withthe highestfrequencyofInternetuseshowedahigherscorein the‘‘cognitivesocialskills’’ dimension(F=3.76,p=0.01), whichindicatesthatthereisagreaterpresenceof‘‘negative thoughts’’inthegroupwiththegreatestfrequencyofuse, interferingin different social situations. The presence of

Table3 ResultsofMentalHealthsubscales.

Subscale Mean Median Minimum Maximum SD KS

Somaticsymptoms 10.98 10.00 10.69 11.26 3.316 0.159

Anxietyandinsomnia 11.01 10.00 10.65 11.36 4.083 0.168

Socialdysfunction 13.17 13.00 12.91 13.42 2.999 0.132

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T able 4 Internet addiction, personality and mental health. Activity Sociability Frequency Age Neuroticism- Anxiety General Activity W ork Effort P arties and Friends Intolerance to being alone Use control 92% 21.21 0.3369 0.4657 0.6026 0.3745 0.5276 Frequent problems with use 7.9% 21.66 0.5340 0.4566 0.5022 0.4390 0.4329 Significant problems 0.2% 19 0.8947 0.4444 0.3750 0.3333 0.1250 Activity Impulsiveness and Sensation Seeking Mental health Impulsivness Sensation Seeking Agressiveness/ Hostility Infrequent Somatic symptoms Anxiety and insomnia Social dysfunction Severe depression Total Use control 0.2997 0.5515 0.3760 0.2300 10.86 10.85 13.08 8.05 42.85 Frequent problems with use 0.4543 0.5809 0.4577 0.2463 12.14 12.65 14.00 10.07 48.87 Significant problems 0.5000 0.4545 0.4706 0.4000 20 19 18 12 69

negative thoughts is associated with the use and abuse of theInternetin searchingfor‘‘relationships and friend-ship’’(r=0.14;p=0.016)andimproving‘‘emotionalstate’’ (r=0.16;p=0.007).Theseresultsagreewiththoseofother authors who emphasize the tendency to escape, shyness andintroversion,socialphobia,andalso,incontrasttothe levelsofneuroticism,self-confidence,self-reliance,orthe search for feelings as personal characteristics associated withgreateruseandevenabuseoftheInternet,coinciding withourstudyregardingthehighlysignificantcorrelationof IAwithneuroticism-anxiety(rs=0.304,p<0.001),described

asemotionalinstability,stress,worry,phobiasand/orfears, obsessive indecision, and susceptibility to criticism. This alsocoincideswithwhatsomeresearchersthinkaboutthe network; thatit isa means ofeasy accessfor anonymous socialinteraction,thusconstitutingaspacewhere commu-nication can be less hampered by deficits in the ability of interpersonal relationships. It is important to remem-ber that the network has become the medium for social development. In this sense it often does not eliminate socialrelations,onlychangesthemeanstodeveloporeven generate emotional wellbeing in thosewith difficulties in face-to-face socialization. Therefore, we would have to rethink those items of interference in social life for the diagnosisofInternetabuse.

WeagreewiththeconclusionofSalmanetal.24_,_that

psy-chiatristsandpsychologistsinvolved inthefieldof mental health mustbewell informedabout mentalproblems due toInternetaddiction,suchasanxiety,depression, aggres-sion,andemploymentandeducationaldissatisfaction,and considerthatIAanditscomorbiddisordersshouldbe prop-erlyevaluatedandtreatedat thesametime.Finally,it is alsoimportanttopayattentiontoInternetaddictioninthe treatmentofpeoplewiththesepsychiatricdisorders.

Becausetheparticipantsampleiscomposedexclusively ofuniversitystudents,wecouldsaythatgeneralizationof theresultstotheentirepopulationisnotpossiblebecauseof theirhighculturallevel.However,theresultscangenerate some ideaof whathappensin the social group--- namely, youngindividuals---whoarebeinginfluencedbyuseofthe Internet.

ThemeansbywhichaccesstotheInternetwasachieved, includinghomecomputers,laptopsor smartphones,were not taken into account in the study. This fact interferes with network access and facilitates more frequent, even problematicuse.Inaddition,sincethesamplewasmedical students,theycouldhavesimilarcharacteristicsinlifestyle and personality. Therefore, research in other university groupscouldgivealessbiasedideaofthesecharacteristics.

Conclusion

Although an associationbetween IAandpsychiatric symp-tomsexist,itmaybebeneficialforthosewithdifficultyin establishing face-to-face relationships. Due to the preva-lence of impulsivity and neuroticism/anxiety in people with Internet addiction, we think it would be prudentto better define the diagnostic criteria of addiction since impulsivity is relatedtoother addictionsand,in thecase of Internetuse, couldbeharmful. Itis important tonote thatthe Internetis atoolfor variousactivities(research,

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education,socialization, and as a means of long-distance communication),which,usedwithcontrol,doesnotcause any problems, but losing that control causes addiction and its comorbidities. Also, certain personality types are predisposedtothislossofcontrolandabuse.

Conflicts

of

interest

Theauthorsdeclarethattheyhavenoconflictsofinterest andtheyreceivednofundsforthiswork.

Acknowledgements

We thank Sergio Lozano-Rodríguez, M.D. for his help in translatingthemanuscript,MarcoV.Gómez-Mezaforhis sta-tisticaladviceandAnaE.GutierrezCortésforreviewingthe manuscript.

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