Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study

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Journal of the Formosan Medical Association xxx (xxxx) xxx

Available online at www.sciencedirect.com

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Original Article

Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study Yen-Ju Lin a,b, Ray C. Hsiao c,d, Tai-Ling Liu a,**, Cheng-Fang Yen a,* a Department of Psychiatry, Kaohsiung Medical University Hospital, and School of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan b Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai’s Home, Kaohsiung, Taiwan c Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA d Department of Psychiatry, Children’s Hospital and Regional Medical Center, Seattle, WA, USA

Received 4 January 2019; received in revised form 4 May 2019; accepted 5 October 2019

KEYWORDS Internet addiction; Psychiatric symptoms; College student

Background/Purpose: This prospective study evaluated the predictive ability of psychiatric symptoms at initial consultation for the occurrence and remission of Internet addiction during a 1-year follow-up period among college students. Furthermore, it evaluated the predictive ability of changes in psychiatric symptoms for Internet addiction at the initial consultation during the 1-year follow-up period among college students. Methods: Five hundred college students (262 women and 238 men) were recruited. The baseline and follow-up consultations measured the levels of Internet addiction and psychiatric symptoms using the Chen Internet Addiction Scale and Symptom Checklist-90 Revised, respectively. Results: The results indicated that severe interpersonal sensitivity and paranoia symptoms might predict the incidence of Internet addiction at 1-year follow-up. The college students with internet addiction did not have significant improvement in the severities of psychopathology, whereas those without internet addiction had significant improvement in obsessioncompulsion, interpersonal sensitivity, paranoid and psychoticism during the same period. Conclusion: Psychiatric symptoms and Internet addiction exhibited bidirectional relationships in college students during the 1-year follow-up period.

* Corresponding author. Department of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd, Kaohsiung, Taiwan. Fax: þ886 7 3134761. ** Corresponding author. Department of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd, Kaohsiung, Taiwan. Fax: þ886 7 3134761. E-mail addresses: [email protected] (T.-L. Liu), [email protected] (C.-F. Yen). https://doi.org/10.1016/j.jfma.2019.10.006 0929-6646/Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006

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Y.-J. Lin et al. Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).

Introduction Global rates of Internet use have increased rapidly because the Internet has become an essential tool for communication, education, and socializing.1 However, Internet addiction has become a global mental health problem.2 The association between Internet addiction and psychiatric symptoms was investigated abundantly in the 2010s. Researchers have suggested that Internet addiction leads to difficulty in maintaining real-life interpersonal relationships, impairs everyday activities, worsens academic work, and hinders occupational functioning.3e5 A meta-analysis of 31 countries revealed a global prevalence of 2.6%e10.9% of Internet addiction for all-age users.6 The estimate of incidence rates of Internet addiction varied in different age cohorts. Ko et al. proposed an incidence rate of 7.5% in young adolescents during the 1year period from Grade 7 to Grade 8,7 while incidence ranging between 2.5 and 3.6% over the 2-year period in junior high school students was reported.8 Previous studies revealed that adolescents are especially prone to develop Internet addiction.9 Cross-cultural epidemiological studies on Internet addiction have reported a remarkably higher prevalence rates among adolescents in Asian compared to those among adolescents in Western countries.9 Estimated 15.3%e17.9% of college students in Taiwan are addicted to the Internet.10,11 One of possible etiologies accounting for the various incidence and prevalence of Internet addiction among previous studies is the miscellaneous diagnostic instruments assessing Internet addiction based on different conceptual framework. Young et al. proposed Internet Addiction Diagnostic Questionnaire (IADQ) and Internet Addiction Test (IAT) as self-reported screening instruments to measure the extent of involvement with the computer and Internet addictive behavior.12,13 Generalized problematic Internet use scale (PIU) was developed to assess Internet-related cognitions and social functions.14 The Chen Internet Addiction Scale (CIAS) was validated in assessing the core symptoms of Internet addiction, as well as Internet-related social and physical problems.15 A variety of psychiatric symptoms have been proposed to be associated with Internet addiction. Cross-sectional studies have reported significant associations of Internet addiction with depressive symptoms, anxiety, obsessiveecompulsive symptoms, inattention, hyperactivity, and aggressive behaviors.16e21 Several cross-sectional studies have also discovered positive correlations between Internet addiction and the characteristic traits of psychoticism, paranoid, and interpersonal sensitivity.22e25 Lee et al. reported that the homozygous short alleles of the serotonin transporter gene promoter region may partially account for the association between excessive Internet users and depressive disorder.26 Pratarelli

proposed that obsessive self-focused rumination might cause repetitive use of the Internet.27 Reicher proposed the deindividuated effect in the Internet which might lower the threshold for exhibiting socially inhibited behaviors and further contributed to aggressive behaviors.28 Individuals with avoidance coping style was positively correlated with Internet addiction,29 while higher levels of emotional and avoidant coping were associated with higher levels of paranoia.30 However, most of previous studies have examined the relationship between Internet addiction and the sole dimension of psychiatric symptoms. The review study determined that multiple dimensions of psychiatric symptoms related to Internet addiction.31 Further study using the scales such as the Symptom Checklist-90-Revised that measure multiple dimensions of psychiatric symptoms may provide knowledge to the relationship between Internet addiction and psychopathology. Moreover, the crosssectional design of the previous studies limited the possibility of determining the temporal relationship between Internet addiction and psychiatric symptoms. Prospective studies examining the relationship between Internet addiction and psychiatric symptoms are relatively scant. A 2-year prospective study determined that emotional problems, depression, and social phobia at baseline are predictive of Internet addiction.32 A 9-month prospective study reported that Internet addiction at baseline is predictive of depression.33 A 2-year longitudinal study found that both pathological Internet use symptoms and emotional problems may contribute to the vicious cycle that supports the perpetuation of pathological Internet use.34 Studies on the temporal bidirectionality of the relationship between Internet addiction and psychiatric symptoms are scant. To our knowledge, only one study examined the temporal bidirectionality of the relationship between Internet addiction and psychiatric symptoms. Dong and colleagues (2011) reported that depression, anxiety, and hostility on the Symptom Checklist-90-Revised (SCL-90-R) were the sequela but not the precursors of Internet addiction in a 1-year longitudinal study; however, Internet addiction in that study was diagnosed through retrospective assessment. Prospective studies on the bidirectional interaction between Internet addiction and psychiatric symptoms in the same study group may provide further evidence for the reciprocal relationships between Internet addiction and multidimensional psychiatric symptoms and serve as the basis for prevention programs. This study evaluated the prediction of psychiatric symptoms at the initial consultations for the occurrence and remission of Internet addiction during a 1-year followup period among college students. Furthermore, it evaluated the prediction of changes in psychiatric symptoms for Internet addiction at the initial consultation during the 1-

Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006

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Psychiatric symptoms and Internet addiction year follow-up period among college students. We hypothesize that psychiatric symptoms at baseline predict the occurrence and nonremission of Internet addiction 1 year later and that Internet addiction predicts exacerbation of psychiatric symptoms 1 year later.

Methods Participants Through advertising, 500 college students between 20 and 30 years old (262 women and 238 men) were recruited and participated in this study. Their mean age was 22.1 years (standard deviation [SD]: 1.8 years). Informed consent was obtained from all participants prior to assessment. The study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital.

Measures Chen Internet Addiction Scale We used the self-administrated Chen Internet Addiction Scale (CIAS) to assess the severity of participants’ Internet addiction in the month preceding the study.15 The CIAS contains 26 items rated using a four-point Likert scale with scale scores ranging from 26 to 104.15 High scores indicate severe Internet addiction. The internal reliability (Cronbach’s a) of the CIAS in the present study was .93. A 67e68 cut-off point on the CIAS has the highest diagnostic accuracy and acceptable sensitivity and specificity.35 Accordingly, those with CIAS scores of 68 were assigned to the Internet addiction group. Symptom Checklist-90-Revised The SCL-90-R is a self-report scale designed to measure the general psychopathology associated with the constructs of somatization, obsessionecompulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, and sleep and appetite problems.36 The SCL-90-R consists of 90 symptom statements that participants use to rate severity on the basis of their experiences during the preceding week. Each item is rated on a five-point scale of distress (0e4), ranging from “not at all” to “extremely.” High scores on the SCL-90-R indicate that participants have severe psychiatric symptoms. The validity of the Chinese-language version of the SCL-90-R for assessing the neurotic symptomatology of patients in Taiwan was established.37

Study process and statistical analysis During the initial assessment, all participants were invited to complete the CIAS and SCL-90-R. The participants were invited to again complete the CIAS and SCL-90-R 1 year later. Depending on the initial and follow-up CIAS scores, the participants were assigned to one of four groups (Fig. 1). Participants deemed nonaddicted in the initial assessment were stratified into group I or II on the basis of subsequent nonaddiction or addiction status, respectively. The remaining participants, who were initially deemed

3 Internet addicts, were stratified into group III or IV based on remission or continuation of the behavior, respectively. A chi-square and a t tests was used to evaluate the difference in gender and age between groups I and II and between groups III and IV, respectively. A p < .05 was considered significant for these two tests. The relationships between the incidence of Internet addiction and psychiatric symptoms at the initial consultation for the members of groups I and II were investigated by Mann-Whitney U test. The relationships between the remission of Internet addiction and psychiatric symptoms at the initial consultation for the members of groups III and IV were also investigated by Mann-Whitney U tests. Because of multiple comparison of nine dimensions of psychopathology on the SCL-90R, a p < .006 (.05/9) was considered significant for MannWhitney U tests. Additionally, we aspired to evaluate whether changes in psychiatric symptoms during the 1-year period differed between college students with and without Internet addiction at the initial consultation. A Wilcoxon signed ranks test was used to evaluate the change in psychiatric symptoms on the SCL-90-R between the initial and followup consultation for all participants in the Internet addiction and nonaddiction groups based on their classification in the initial consultation. A p < .006 was considered significant for Wilcoxon signed ranks tests. All statistical analyses were performed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA).

Results A total of 324 college students (65.8%, 169 women and 155 men) underwent follow-up assessment 1 year later. Of 176 participants who did not receive the follow-up assessment, 96 (54.5%) were disconnected, 48 (27.3%) refused participating in the follow-up assessment, and 32 (18.2%) had motivation but were not able to participate in the follow-up assessment due to work or army service. No difference in gender was found between participants who received and did not receive the follow-up assessment (p Z .884), whereas participants who received the follow-up assessment were older than those who did not receive the followup assessment (p Z .047). No difference in the proportion of internet addiction was found between participants who received and did not receive the follow-up assessment (p Z .819). Of the 268 participants in groups I and II who had no Internet addiction at the initial consultation, 20 (7.5%) were deemed to have Internet addiction at the follow-up consultation (group II). Of the 56 individuals in groups III and IV who had Internet addiction at the initial consultation, 26 (46.4%) were classified as free of Internet addiction at the follow-up consultation (group III). Comparisons of the demographic characteristics and SCL-90-R psychiatric symptoms between groups I and II are presented in Table 1. The results reveal that compared with group I, group II had more severe interpersonal sensitivity and paranoia on the SCL-90-R at the initial assessment, indicating that severe interpersonal sensitivity and paranoia symptoms on these SCL-90-R subscales might predict the incidence of Internet addiction at 1-year follow-up.

Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006

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Y.-J. Lin et al. All participants Initial assessment

Non addiction

Internet addiction

Follow-up assessment

Non addiction

Internet addiction

Non addiction

Internet addiction

Group I (n = 248)

Group II (n = 20)

Group III (n = 26)

Group IV (n = 30)

Figure 1 Participants were assigned to one of four addiction groups. The participants deemed nonaddicted at baseline assessment were stratified into groups I and II based on the follow-up evaluation as nonaddicted or addicted, respectively. The participants deemed addicted initially but who had remitted on follow-up were assigned to group III, whereas those who remained addicted were assigned to group IV.

Comparisons of the demographic characteristics and SCL-90-R psychiatric symptoms between groups III and IV are presented in Table 1. The participants in group III were younger than those in group IV. However, no dimension of psychiatric symptoms was significantly associated with Internet addiction remission. The results of SCL-90-R score comparison between the initial and follow-up consultations among the participants with and without Internet addiction at the initial consultation are shown in Table 2. The results of Wilcoxon signed ranks test revealed that the severities of obsessioncompulsion, interpersonal sensitivity, paranoid and psychoticism in the nonaddiction group significantly decreased from the initial and follow-up consultations, whereas the severities of all dimensions of psychopathology in the internet addiction group did not improve significantly from the initial and follow-up consultations.

Discussion This prospective study examined the bidirectionality of psychopathology and Internet addiction among college students in Taiwan. The results indicated that severe interpersonal sensitivity and paranoia symptoms on these SCL-90R subscales might predict the incidence of Internet addiction at 1-year follow-up. The severities of obsession-compulsion, interpersonal sensitivity, paranoid and psychoticism in the nonaddiction group significantly decreased during the oneyear period of follow-up, whereas the severities of all dimensions of psychopathology in the internet addiction group did not improve significantly during the same period.

Effects of psychopathology on internet addiction development In accordance with the results of previous studies,7,24 the present study determined that high interpersonal sensitivity

predicted the development of Internet addiction in the 1year follow-up period. College students with high interpersonal sensitivity exhibited low self-esteem, high sensitivity to criticism, reliance on others, and high insecurity in interpersonal relationships.38 Moreover, problematic Internet users exhibited higher interpersonal sensitivity, asocial behavior, unassertiveness, criticism, and distrust than those without Internet problems.38 College students with high interpersonal sensitivity have feelings of inadequacy, inferiority and self-doubt.39 They obtained more support and self-confidence from the Internet rather than face-to-face interaction and may indulge in the virtual world and isolate themselves from the outside environment.38 Previous studies showed that individuals with Internet addiction have more often personality disorders than those without.40 Furthermore, the scale of interpersonal sensitivity was higher in those with cluster B and cluster C personality disorder.41 Ko et al. suggested that low interpersonal sensitivity predicted remission of Internet addiction in adolescents.7 Further research is warranted to examine the effect of psychotherapy for modification of interpersonal sensitivity to prevent the development of Internet addiction. The present study determined that baseline paranoid ideation predicted the development of Internet addiction 1 year later. Paranoid ideation is associated with excessive fear or anxiety.42 Regarding the neurobiology of the development of paranoia, Corlett et al. reported the aberrant prediction error in fronto-striatal learning systems and inappropriate engagement of the brain’s fear system.43 Moreover, a review of neuropsychological and neuroimaging findings of Internet addiction identified frontostriatal loops as a main neural correlates of addictive behavior.44 In accordance of previous studies, individuals with avoidance coping style was positively correlated with Internet addiction,29 while higher levels of emotional and avoidant coping were associated with higher levels of paranoia.30 However, the present study assessed selfreported paranoid ideation on the SCL-90-R but not

Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006

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Psychiatric symptoms and Internet addiction Table 1

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Comparisons between groups I and II and groups III and IV of demographic characteristics and psychiatric symptoms.

Gendera Female Male Age (years)b SCL-90-Rc Somatization Obsession-compulsion Interpersonal sensitivity Depression Anxiety Hostility Phobia Paranoid Psychoticism

Group I (n Z 248) n (%) or mean (SD)

Group II (n Z 20) n (%) or mean (SD)

p

Group III (n Z 26) n (%) or mean (SD)

Group IV (n Z 30) n (%) or mean (SD)

p

129 (50.0) 119 (48.0) 22.3 (2.0)

11 (55) 9 (45) 22.4 (1.9)

.797

14 (46.7) 16 (53.3) 22.6 (1.9)

.410

.729

15 (57.7) 11 (42.3) 21.6 (1.2)

4.7 8.1 6.2 7.3 5.5 2.7 1.7 3.4 3.7

7.6 (6.6) 10.9 (4.9) 9.2 (5.0) 10.3 (5.3) 6.1 (3.9) 3.5 (4.1) 2.5 (2.1) 6.1 (4.1) 5.3 (3.3)

.026 .015 .006 .010 .306 .441 .026 .001 .015

9.8 (8.7) 13.8 (6.7) 9.5 (6.7) 14.0 (8.2) 10.1 (6.6) 5.0 (4.1) 4.5 (4.4) 5.5 (4.4) 5.5 (4.8)

10.9 (9.5) 14.1 (7.1) 11.3 (7.5) 13.7 (9.0) 10.3 (7.3) 5.5 (5.1) 4.0 (4.2) 6.4 (4.2) 6.4 (5.1)

.705 .915 .370 .687 .961 .875 .740 .365 .519

(5.6) (5.8) (5.4) (6.5) (4.8) (3.2) (2.5) (3.6) (4.1)

.019

SCL-90-R: Symptom Checklist-90-Revised. Group I and II: The participants deemed nonaddicted at baseline assessment were stratified into groups I and II based on the follow-up evaluation as nonaddicted or addicted, respectively. Group III and IV: The participants deemed addicted initially but who had remitted on follow-up were assigned to group III, whereas those who remained addicted were assigned to group IV. a Chi-square test. b t test. c Mann-Whitney U test.

through face-to-face interviews and thus could not determine the real characteristics of the paranoid ideation that the participants reported. Paranoid ideation may make college students feel unsafe when they go outside and interact with others. The Internet may provide them an

environment in which they feel comfortable and can decide with whom they wish to interact and in what activities they wish to participate. Thus, the risk of developing Internet addiction may increase among college students with high paranoid ideation.

Table 2 Psychiatric symptoms on Symptom Checklist-90-Revised at the initial and follow-up consultations among the participants with and without Internet addiction at the initial consultation: Wilcoxon signed ranks test. Initial investigation Mean (SD) Internet addiction group (n Z 56) Somatization 10.4 (9.0) Obsession-compulsion 13.9 (6.9) Interpersonal sensitivity 10.5 (7.1) Depression 13.9 (8.6) Anxiety 10.2 (6.9) Hostility 5.3 (4.7) Phobia 4.2 (4.3) Paranoid 6.0 (4.3) Psychoticism 6.0 (5.0) Non-Internet addiction group (n Z 268) Somatization 4.9 (5.7) Obsession-compulsion 8.3 (5.7) Interpersonal sensitivity 6.4 (5.4) Depression 7.6 (6.5) Anxiety 5.6 (4.8) Hostility 2.8 (3.3) Phobia 1.8 (2.5) Paranoid 3.6 (3.7) Psychoticism 3.9 (4.0)

Follow-up investigation Mean (SD)

Z

p

8.4 (9.2) 11.7 (8.3) 9.2 (6.6) 12.9 (10.5) 8.9 (7.6) 4.6 (4.7) 3.5 (4.3) 5.3 (4.9) 6.7 (6.7)

1.869 2.223 1.432 -.738 1.912 1.269 1.285 -.973 .816

.062 .026 .152 .460 .056 .204 .199 .330 .415

4.0 7.1 4.9 6.8 5.4 2.5 1.5 2.8 3.2

2.605 4.088 5.112 2.493 1.041 1.847 2.652 4.624 3.571

.009 <.001 <.001 .013 .298 .065 .008 <.001 <.001

(5.4) (6.2) (5.0) (7.4) (5.6) (3.5) (2.5) (3.8) (4.4)

Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006

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Effect of internet addiction on psychopathology Normally, the skills of interpersonal interaction, social cognition and communication mature with age in early adulthood as the brain grow45,46; as time go by, the individuals may develop ability and accumulate experiences to analyze the interpersonal and intrapersonal stimuli and cope with them efficiently. The individuals may establish their confidence to manage multidimensional difficulties encountered in daily lives and therefor feel less anxious toward unknown. The matureness may partially account for the result of the present study that the severities of obsession-compulsion, interpersonal sensitivity, paranoid and psychoticism in the nonaddiction group significantly decreased in follow-up consultations. However, the severities of all dimensions of psychopathology in the internet addiction group did not improve significantly 1 year later. Internet addiction may reduce the opportunities for college students to engage in face-to-face social activities and further compromise Internet users’ ability to learn what others think, how to interact with peers maturely, how to behave in a socially acceptable manner, and how to develop empathy. In addition, evidence of decreased brain functional connectivity in circuits linking cortical to subcortical regions was found in adolescents with Internet addiction.47 College students with Internet addiction may be less mature in both brain functional connectivity and personality construction than those without Internet addiction.

Limitations This study had several limitations that should be considered when interpreting the results. First, the study data were exclusively self-reported. Therefore, using only one data source may have influenced our findings and resulted in shared-method variance. Second, SCL-90-R is more useful for measuring static mental states than psychiatric diagnoses. Hence, we could not infer from our result the bidirectionality of the relationship between Internet addiction and psychiatric diagnoses as previous studies do. Third, the number of members of the Internet addiction group was relatively small. This highlights the necessity of large perspective studies with longer follow-up periods. Fourth, we did not assess the content of the Internet activity. In addition, present study utilized only two assessments since the ideal methodological approach to tackle bidirectional relationship often demand three or more assessments.

Conclusion This prospective investigation in college students demonstrated that severe interpersonal sensitivity and paranoia symptoms might predict the incidence of Internet addiction at 1-year follow-up. The college students with internet addiction did not have significant improvement in the severities of psychopathology during the one-year period of follow-up, whereas those without internet addiction had significant improvement in obsession-compulsion, interpersonal sensitivity, paranoid and psychoticism during the same period. Intensive screening should be emphasized for

Y.-J. Lin et al. college students with psychiatric symptoms to prevent the development of Internet addiction. Furthermore, strategies implemented for early intervention in Internet addiction are therefore critical to college students for improving their psychological symptoms.

Funding sources This study was supported by Kaohsiung Medical University Hospital (Grant No. KMUH103-3M38). The funding supported conduction of the study, collection of data, and preparation of original study report. No funding was available for writing manuscript or publishing article.

Authors’ contribution YJL: Study concept and design, obtained funding, study supervision. RCH: Study concept and design, analysis and interpretation of data. TLL: Analysis and interpretation of data, statistical analysis. CFY: Study concept and design, analysis and interpretation of data, statistical analysis, obtained funding, study supervision. All authors had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Ethics approval and consent to participate The study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital.

Consent for publication Not applicable.

Declaration of Competing Interest The authors have no conflicts of interest relevant to this article.

Acknowledgments This study was supported by Kaohsiung Medical University Hospital (Grant No. KMUH103-3M38).

Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jfma.2019.10.006.

References 1. Greydanus DE, Greydanus MM. Internet use, misuse, and addiction in adolescents: current issues and challenges. Int J Adolesc Med Health 2012;24:283e9.

Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006

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Psychiatric symptoms and Internet addiction 2. Block JJ. Issues for DSM-V: internet addiction. Am J Psychiatry 2008;165:306e7. 3. Anderson KJ. Internet use among college students: an exploratory study. J Am Coll Health 2001;50:21e6. 4. Chou C, Hsiao MC. Internet addiction, usage, gratification, and pleasure experience: the Taiwan college students’ case. Comput Educ 2000;35:65e80. 5. Kubey RW, Lavin MJ, Barrows JR. Internet use and collegiate academic performance decrements: early findings. J Commun 2001;51:366e82. 6. Cheng C, Li AY. Internet addiction prevalence and quality of (real) life: a meta-analysis of 31 nations across seven world regions. Cyberpsychol, Behav Soc Netw 2014;17:755e60. 7. Ko CH, Yen JY, Yen CF, Lin HC, Yang MJ. Factors predictive for incidence and remission of internet addiction in young adolescents: a prospective study. Cyberpsychol Behav 2007;10: 545e51. 8. Li R, Shi G, Ji J, Wang H, Wang W, Wang M, et al. A 2-year longitudinal psychological intervention study on the prevention of internet addiction in junior high school students of Jinan city. Biomed Res 2017;28:10033e8. 9. Kuss DJ, Griffiths MD, Karila L, Billieux J. Internet addiction: a systematic review of epidemiological research for the last decade. Curr Pharmaceut Des 2014;20:4026e52. 10. Lin MP, Ko HC, Wu JY. Prevalence and psychosocial risk factors associated with internet addiction in a nationally representative sample of college students in Taiwan. Cyberpsychol, Behav Soc Netw 2011;14:741e6. 11. Tsai HF, Cheng SH, Yeh TL, Shih CC, Chen KC, Yang YC. The risk factors of Internet addiction - a survey of university freshmen. Psychiatry Res 2009;167:294e9. 12. Young KS. Internet addiction: the emergence of a new clinical disorder. Cyberpsychol Behav 1998;3:237e44. 13. Young KS. Caught in the Net: how to recognize the signs of Internet addiction and a winning strategy for recovery. New York: Wiley; 1998. 14. Caplan SE. Problematic Internet use and psychosocial well-being: development of a theory-based cognitive-behavioral measurement instrument. Comput Hum Behav 2002;18:553e75. 15. Chen SH, Weng LJ, Su YJ, Wu HM, Yang PF. Development of Chinese internet addiction scale and its psychometric study. Chin J Psychol 2003;45:279e94. 16. Jang KS, Hwang SY, Choi JY. Internet addiction and psychiatric symptoms among Korean adolescents. J Sch Health 2008;78: 165e71. 17. Ko CH, Yen JY, Liu SC, Huang CF, Yen CF. The associations between aggressive behaviors and internet addiction and online activities in adolescents. J Adolesc Health 2009;44:598e605. 18. Ko CH, Yen JY, Chen CS, Chen CC, Yen CF. Psychiatric comorbidity of internet addiction in college students: an interview study. CNS Spectr 2014;13:147e53. 19. Muller KW, Dreier M, Duven E, Giralt S, Beutel ME, Wolfling K. Adding clinical validity to the statistical power of large-scale epidemiological surveys on internet addiction in adolescence: a combined approach to investigate psychopathology and development-specific personality traits associated with internet addiction. J Clin Psychiatry 2017;78:e244e51. 20. Park S, Hong KE, Park EJ, Ha KS, Yoo HJ. The association between problematic internet use and depression, suicidal ideation and bipolar disorder symptoms in Korean adolescents. Aust N Z J Psychiatr 2013;47:153e9. 21. Yang CK, Choe BM, Baity M, Lee JH, Cho JS. SCL-90-R and 16PF profiles of senior high school students with excessive internet use. Can J Psychiatr 2005;50:407e14. 22. Alavi SS, Alaghemandan H, Maracy MR, Jannatifard F, Eslami M, Ferdosi M. Impact of addiction to internet on a number of

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25.

26.

27.

28. 29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

psychiatric symptoms in students of isfahan universities, Iran, 2010. Int J Prev Med 2012;3:122e7. Cao F, Su L. Internet addiction among Chinese adolescents: prevalence and psychological features. Child Care Health Dev 2007;33:275e81. Kelleci M. I S. Psychiatric symptoms in adolescents with internet use: comparison without internet use. Cyberpsychol, Behav Soc Netw 2010;13:191e4. Senormanci O, Saracli O, Atasoy N, Senormanci G, Kokturk F, Atik L. Relationship of Internet addiction with cognitive style, personality, and depression in university students. Compr Psychiatr 2014;55:1385e90. Lee YS, Han DH, Yang KC, Daniels MA, Na C, Kee BS, et al. Depression like characteristics of 5HTTLPR polymorphism and temperament in excessive internet users. J Affect Disord 2008; 109:165e9. Pratarelli ME, Browne BL, Johnson K. The bits and bytes of computer/Internet addiction: a factor analytic approach. Behav Res Methods Instrum Comput 1999;31:305e14. Reicher SD, Russell S, Tom P. A social identity model of deindividuation phenomena. Eur Rev Soc Psychol 1995;6:161e98. Michelle ML, Thorsteinsson EB. Internet addiction, psychological distress, and coping responses among adolescents and adults. Cyberpsychol, Behav Soc Netw 2017;20:296e304. Freeman D, Garety PA, Bebbington PE, Smith B, Rollinson R, Fowler D, et al. Psychological investigation of the structure Psychological investigation of the structure of paranoia in a non-clinical population. Br J Psychiatry 2005;186:427e35. Ko CH, Yen JY, Yen CF, Chen CS, Chen CC. The association between Internet addiction and psychiatric disorder: a review of the literature. Eur Psychiatry 2012;27:1e8. Ko CH, Yen JY, Chen CS, Yeh YC, Yen CF. Predictive values of psychiatric symptoms for internet addiction in adolescents: a 2-year prospective study. Arch Pediatr Adolesc Med 2009;163: 937e43. Lam LT, Peng ZW. Effect of pathological use of the internet on adolescent mental health: a prospective study. Arch Pediatr Adolesc Med 2010;164:901e6. Strittmatter E, Parzer P, Brunner R, Fischer G, Durkee T, Carli V, et al. A 2-year longitudinal study of prospective predictors of pathological Internet use in adolescents. Eur Child Adolesc Psychiatry 2016;25:725e34. Ko CH, Yen JY, Chen SH, Yang MJ, Lin HC, Yen CF. Proposed diagnostic criteria and the screening and diagnosing tool of Internet addiction in college students. Compr Psychiatr 2009;50:378e84. Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol Bull 1973;9:13e28. Tsai MT, Wen JK, Lin HN, Soong WT, Chen CC. Application of self-rating symptom scales to psychiatric outpatients. Bull Chin Soc Neurol Psychiatry 1978;4:47e56 [In Chinese]. Xiuqin H, Huimin Z, Mengchen L, Jinan W, Ying Z, Ran T. Mental health, personality, and parental rearing styles of adolescents with Internet addiction disorder. Cyberpsychol, Behav Soc Netw 2010;13:401e6. Dalbudak E, Evren C, Topcu M, Aldemir S, Coskun KS, Bozkurt M, et al. Relationship of Internet addiction with impulsivity and severity of psychopathology among Turkish university students. Psychiatry Res 2013;210:1086e91. Zadra S, Bischof G, Besser B, Bischof A, Meyer C, John U, et al. The association between Internet addiction and personality disorders in a general population-based sample. J Behav Addict 2016;5:691e9. Wu JY, Ko HC, Lane HY. Personality disorders in female and male college students with internet addiction. J Nerv Ment Dis 2016;204:221e5.

Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006

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MODEL

8 42. Moutoussis M, Williams J, Dayan P, Bentall RP. Persecutory delusions and the conditioned avoidance paradigm: towards an integration of the psychology and biology of paranoia. Cogn Neuropsychiatry 2007;12:495e510. 43. Corlett PR, Taylor JR, Wang XJ, Fletcher PC, Krystal JH. Toward a neurobiology of delusions. Prog Neurobiol 2010;92:345e69. 44. Cerniglia L, Zoratto F, Cimino S, Laviola G, Ammaniti M, Adriani W. Internet Addiction in adolescence: neurobiological, psychosocial and clinical issues. Neurosci Biobehav Rev 2017;76:174e84.

Y.-J. Lin et al. 45. Arain M, Haque M, Johal L, Mathur P, Nel W, Rais A, et al. Maturation of the adolescent brain. Neuropsychiatric Dis Treat 2013;9:449e61. 46. Choudhury S, Blakemore SJ, Charman T. Social cognitive development during adolescence. Soc Cogn Affect Neurosci 2006;1:165e74. 47. Hong SB, Zalesky A, Cocchi L, Fornito A, Choi EJ, Kim H, et al. Decreased functional brain connectivity in adolescents with internet addiction. PLoS One 2013;8:e57831.

Please cite this article as: Lin Y-J et al., Bidirectional relationships of psychiatric symptoms with internet addiction in college students: A prospective study, Journal of the Formosan Medical Association, https://doi.org/10.1016/j.jfma.2019.10.006