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The association between Internet addiction and dissociation among Turkish college students
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Comprehensive Psychiatry 53 (2012) 422 – 426 www.elsevier.com/locate/comppsych
The association between Internet addiction and dissociation among Turkish college students Fatih Canan a,⁎, Ahmet Ataoglu b , Adnan Ozcetin b , Celalettin Icmeli b b
a Psychiatry Clinic, Bolu Izzet Baysal Mental Health Hospital, Bolu, Turkey Department of Psychiatry, Duzce University School of Medicine, Duzce, Turkey
Abstract Purpose: This study aimed to investigate Internet use patterns and Internet addiction among young adult university students and to examine the correlation between excessive Internet use and dissociative symptoms. Methods: The study was conducted among 1034 students, aged between 18 and 27 years. Internet Addiction Scale, Dissociative Experiences Scale, and a sociodemographic query form were used in the collection of data. Pearson correlation analysis, the t test, and χ 2 test were used for data analysis. Results: According to the Internet Addiction Scale, 9.7% of the study sample was addicted to the Internet. The Pearson correlation analysis results revealed a significant positive correlation between dissociative experiences and Internet addiction (r = 0.220; P b .001) and weekly Internet use (r = 0.227; P b .001). Levels of Internet addiction were significantly higher among male students than female students (P b .001). The Internet use pattern also differed significantly between sexes. Conclusions: According to the results of this study, Internet addiction is a relatively frequent phenomenon among young adult college students in Turkey. Excessive Internet use is associated with higher levels of dissociative symptoms. © 2012 Elsevier Inc. All rights reserved.
1. Introduction Dissociation is generally defined as “a disruption in the usually integrated functions of consciousness, memory, identity, and perception of the environment” [1]. Dissociative experiences are common in the general population and become pathologic when they cause marked distress and interfere with functioning [2]. Dissociative symptoms may intersect with different kinds of psychiatric disorders [3], and a growing body of literature indicates that dissociation has a negative influence on treatment outcome in several psychiatric syndromes [4]. Excessive or problematic use of the Internet has been a topic of discussion in the academic literatures for more than a decade. Although a standardized definition has not been uniformly agreed upon, it is generally recognized that problematic Internet use involves an individual's inability to
⁎ Corresponding author. Tel.: +90 374 2752525; fax: +90 374 2752423. E-mail address: [email protected] (F. Canan). 0010-440X/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2011.08.006
control his or her use of the Internet, negative consequences (e.g., failing in school, decreased productivity), and marked distress and/or functional impairment [5,6]. Whether Internet addiction is a primary addictive disorder or a secondary disorder of other psychiatric disorders has remained controversial [7]. Cross-sectional studies on samples of patients report high comorbidity of Internet addiction with psychiatric disorders such as major depression [8], bipolar disorder [9], obsessive-compulsive disorder [10], attentiondeficit/hyperactivity disorder [11], and substance use disorder [9]. The association of Internet addiction with dissociation has heretofore been evaluated only in a few studies with small sample sizes. In the first study concerning this topic [12], an association was found between dissociative symptoms and higher hours spent per week on the Web among adult outpatients who were admitted to overusing the Web. The second study [13] has enrolled 312 undergraduate students revealing that individuals with Internet addiction experienced more dissociative symptoms than nonaddicts in relationship with alexithymia. In addition, in an experimental
F. Canan et al. / Comprehensive Psychiatry 53 (2012) 422–426
study with 30 individuals [14], virtual reality was shown to induce dissociation. We believe these findings should be replicated in a larger sample of subjects. Our aim was to investigate Internet use patterns and Internet addiction among young adult university students. In addition, the present study examined the relationship between Internet addiction and dissociative experiences in a large nonclinical population, namely Turkish college students. 2. Methods 2.1. Participants The study was conducted among the college students aged 18 to 27 years at Duzce University (Turkey) between March and July 2007. The target subjects of this study were all the students in Duzce University (n = 3456). The recruitment process was performed in classrooms. A total of 1123 students voluntarily participated as subjects for the study (32.4%). Participants received no credit or compensation for their participation in the study. After oral information and consent, all participants were asked to complete Internet Addiction Scale (IAS), Dissociative Experiences Scale (DES), and a sociodemographic query form. Eighty-nine students were excluded from the study because of missing data resulting in an analytical sample of 1034 students. The study was approved by the Committee of Duzce University School of Medicine Local Ethical Committee for Clinical and Laboratory Studies. 2.2. Measures 2.2.1. Internet Addiction Scale The IAS is a self-report instrument consisting of 36 items based on the 7 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, substance dependence criteria and 2 additional criteria recommended by Griffiths [15]. The same authors [16] carried out the reliability and validity study among undergraduate students. Because of low interitem correlations, 5 items were deleted. The revised form of the scale consisted of 31 items (e.g., “I have stayed on the Internet longer than I intended to,” “I feel that life without the Internet would be boring and empty,” “I have attempted to spend less time on the Internet but I have been unable to do so.”). The IAS is a highly reliable and internally consistent measure (Cronbach α = .95). The scale was translated into Turkish, and psychometric properties of the Turkish version of the scale was evaluated among high school students revealing a highly significant test-retest reliability (r = 0.98; P b .001) [17]. An interitem reliability reduced the initial scale from 31 to 27 items (with Cronbach α of .94). Scale items are rated on a 5-point Likert scale (1, never; 2, rarely; 3, sometimes; 4, frequently; 5, always), with higher scores representing greater Internet addiction. A cutoff score of 81 (3 × 27 items) was suggested as indicative of Internet addiction. The cutoff score was arbitrarily determined by the developers of the scale.
423
2.2.2. Dissociative Experiences Scale The DES is a 28-item self-report instrument. The DES was developed by Bernstein and Putnam [18], and it has adequate test-retest reliability, good split-half reliability, and good clinical validity. It can be completed in 10 minutes and scored in less than 5 minutes. It is easy to understand, and the questions are framed in a normative way that does not stigmatize the respondent for positive responses. The respondent slashes the line, which is anchored at 0% on the left and 100% on the right, to show how often he or she has this experience. The overall DES score is obtained by adding up the 28 item scores and dividing by 28; this yields an overall score ranging from 0 to 100. Scores higher than 30 may indicate the presence of a dissociative disorder [19]. The scale contains a variety of dissociative experiences, many of which are normal experiences. The DES has very good validity and reliability and good overall psychometric properties. The Turkish version of the scale [20] has reliability and validity as high as its original form. 2.2.3. Sociodemographic Query Form We developed a 14-item sociodemographic questionnaire with items pertaining to age, sex, type, and extent of Internet use (e.g., “How many hours do you spend online per week?”). 2.3. Statistical analysis Statistical analysis was performed using the SPSS package (SPSS 16 for windows; SPSS Inc, Chicago, IL). Student 2-tailed t test was used to compare the significance of the differences between two groups (students with or without Internet addiction and students with or without dissociative disorder). The χ 2 analyses were used to compare categorical variables. Pearson correlation analysis was used to determine the correlation coefficients between the variables. Differences were considered significant if P values were .05 or less. 3. Results The sample consisted of 616 male students (59.6%) and 418 female students (40.4%), with a mean age of 20.41 ± 2.06 years (range, 18-27 years). According to the IAS, 9.7% of the study sample was found to be addicted to the Internet. Comparison of students with or without Internet addiction with respect to age, mean DES score, and duration of weekly Internet use are represented in Table 1. As shown in Table 2, Table 1 Comparison of students with or without Internet addiction (Student t test) Internet addiction
P
Yes (n = 101) No (n = 927) Age 20.2 ± 2.1 Duration of the Internet use, h/wk 19.0 ± 5.8 DES 29.5 ± 14.6
20.4 ± 2.0 6.7 ± 4.3 18.3 ± 10.4
.810 b.001 b.001
424
F. Canan et al. / Comprehensive Psychiatry 53 (2012) 422–426
Table 2 Internet use pattern among Turkish college students
Table 4 Comparison of students with or without a dissociative disorder (Student t test)
Male (n = 616) Female (n = 418) P a
Duration of Internet use, h/wk 7.7 ± 5.3 IAS a 54.4 ± 18.1 Internet addicts b 78 Most frequent Internet activities b Web surfing 41 (6.6%) E-mail 9 (1.5%) Video sites 112 (18.2%) Chat rooms/Internet 296 (48.1%) messaging Online games 141 (22.9%) Academic activities 17 (2.8%) a b
6.2 ± 4.2 47.3 ± 14.9 23
b.001 b.001 b.001
36 (8.6%) 8 (1.9%) 44 (10.5%) 307 (73.4%)
b.001
Student t test. χ 2 Test.
78 (12.6%) of male students and 23 (5.5%) of female students were Internet addicts, and the difference was statistically significant (P b .001). In addition, male students scored significantly higher than the female students on the total IAS. The Internet had been most frequently reported to be used for chat rooms and Internet messaging (58.3%). Video sites and online games were most frequently used by women (18.1% vs 10.5% and 22.8% vs 1.9%, respectively). Most frequent Internet activities of the students with or without Internet addiction were found to be significantly different (P b .05) (Table 3). According to DES, 172 students (16.6%) had scores higher than 30, indicating the presence of a dissociative disorder. The students with a dissociative disorder scored higher on the IAS and spent more time on the Web. Comparison of students with or without a dissociative disorder with respect to age, mean IAS score, and duration of weekly Internet use are shown in Table 4. Forty-two (41.5%) of the students with Internet addiction also had a dissociative disorder. This finding was statistically significant according to the χ 2 test (P b .001). The students with a dissociative disorder were found most frequently to use the Internet for chat rooms/Internet messaging (73.8%) (Table 5). A correlation matrix showing the relationships between age, duration of the Internet use, IAS, and DES scores are presented in Table 6. Duration of weekly Internet use and IAS scores were positively related to DES scores (P b .001).
Table 3 Most frequent Internet activities of students with or without Internet addiction (χ 2 test)
Web surfing E-mail Video sites Chat rooms/Internet messaging Online games Academic activities
Yes (n = 101)
No (n = 927)
10 (9.9%) 0 8 (7.9%) 63 (62.4%) 20 (19.8%) 0
67 (7.2%) 17 (1.8%) 148 (15.9%) 540 (58.3%) 129 (13.9%) 32 (3.5%)
P
Yes (n = 172) No (n = 862) Age 20.3 ± 1.9 Duration of the Internet use, h/wk 9.3 ± 6.9 IAS 58.2 ± 21.3
20.5 ± 2.1 6.7 ± 4.3 50.2 ± 15.9
.470 b.001 b.001
4. Discussion
8 (1.9%) 15 (3.6%)
Internet addiction
Dissociative disorder
A considerable amount of literature published so far on Internet addiction reveals that it is a worldwide phenomenon [21]. The lack of a standardized definition and diagnostic instruments that show adequate reliability and validity across countries are significant limitations in estimating the prevalence of problematic Internet use. Despite the diversity in definition, Internet addiction is generally reported as a widespread condition among college students with prevalence rates ranging from 5.9% [22] to 18.3% [23]. In the present study, the rate of Internet addiction among university students was found to be 9.7%, similar with the previously reported rates from Turkey [17,24]. This finding indicates that 1 of 10 college students in Turkey is affected by problematic Internet use. Although limited studies have shown no sex-related differences [25], accumulating data suggest that men are more likely to meet criteria for Internet addiction than are women [22,26,27]. We have found that 12.6% of male students and 5.5% of female students were Internet addicts, supporting the idea that men are more prone to be addicted to the Internet. We have also found that men were more likely to use the Internet for playing online games when compared with women (22.8% vs 1.9%). It has been proposed that men and women and boys and girls use the Internet differently [28]. For example, in a study of Taiwanese adolescents (n = 395), significantly higher proportion of men than women were found to have played online games [29]. In an interesting functional magnetic resonance imaging (fMRI) study by Hoeft et al [30], men were shown to exhibit greater connectivity and activation in the mesocorticolimbic systems during video game playing than women. This finding may indicate a possible neural process causing the greater propensity of men for playing online games in a repetitive Table 5 Most frequent Internet activities of students with or without a dissociative disorder (χ 2 test)
P
Most frequent Internet activities
.027
Web surfing E-mail Video sites Chat rooms/Internet messaging Online games Academic activities
Dissociative disorder Yes (n = 172)
No (n = 862)
4 (2.3%) 2 (1.2%) 15 (8.7%) 127 (73.8%) 21 (12.2%) 3 (1.7%)
73 (8.5%) 15 (1.7%) 141 (16.4%) 474 (54.9%) 128 (14.8%) 29 (3.4%)
P b.001
F. Canan et al. / Comprehensive Psychiatry 53 (2012) 422–426 Table 6 Pearson's correlation coefficient analysis for age, duration of the Internet use, IAS, and DES scores
Age Duration of the Internet use, h/wk IAS DES
Duration of the Internet use, h/wk
IAS
DES
−0.044 1
−0.065⁎ 0.844⁎⁎
−0.036 0.227⁎⁎
1
0.220⁎⁎ 1
⁎ P b .05. ⁎⁎ P b .001.
manner. Despite the differences in Internet use patterns between sexes have also been established by other studies [31,32], the reasons underlying these differences are yet to be investigated in detail. Up until now, few studies in the English literature have mentioned the relationship between dissociation and Internet addiction. In their recent study, Bernardi and Pallanti [12] enrolled 50 adult outpatients who were referred for different psychiatric complaints (mainly depressive mood) and were admitted to overusing the Web. The participants were screened using the Young's Internet Addiction Scale (YIAS) and DES. Although DES scores and YIAS scores were not found to be associated, a positive correlation was found between DES scores and higher hours spent per week on the Web. De Berardis et al [13] have evaluated 312 nonclinical undergraduate students using YIAS, DES, and Toronto Alexithymia Scale and found that individuals with Internet addiction experienced more dissociative symptoms than nonaddicts and that alexithymia affected the relationship between problematic Internet use and dissociative experiences. Moreover, in their experimental study with 30 nonclinical individuals (aged between 22 and 49 years), Aardema et al [14] have demonstrated that virtual reality induced dissociation. Our study corroborates previous studies revealing a positive relationship between dissociative symptoms and problematic Internet use. In the present study, a significant positive correlation was found between DES and IAS scores. The students with dissociative disorder (according to DES) were found to have significantly greater scores on IAS and higher hours spent per week on the Web. Furthermore, Internet addicts (according to IAS) were also found to have significantly greater scores on DES. Some of the main symptoms of dissociative disorders, such as dissociation, derealization, depersonalization, identity confusion, and identity alteration, may (at least theoretically) be associated with the unique characteristics of the Internet (e.g., anonymity). Our findings indicate a statistical relation between dissociative symptoms and problematic Internet use but do not offer causality. These findings are of complex interpretation. Overuse of the Internet may cause the individual to re-experience the dissociative process, which is present in the nature of the Internet, when she or he is off-line.
425
Detachment, conceived of as a continuum of severity of symptoms, and characterized by Prince [33] (as “coconsciousness,” the presence of 2 separate streams of consciousness), may be an important feature of the Internet addiction [12]. Although dissociation contributes obviously to difficulties in identifying feelings, paradoxically, Internet-induced transient dissociative states may be considered as an effort to identify and express feelings in a fragmented way that are otherwise difficult to access. Another finding of this study is that most students (73.8%) with a dissociative disorder most frequently used the Internet for Internet messaging. This may be explained by the convenience in developing alternative identities on the Web. The present study needs to be evaluated in light of several limitations. The participants were not screened for childhood traumatic experiences, which are claimed to play important role in the etiology of dissociative disorders [34]. Hence, it could not be investigated whether dissociative symptoms are independently associated with Internet addiction, or overusing the Internet is a consequence of childhood trauma-related dissociative disorders. Another limitation is the use of self-report questionnaires instead of structured interview instruments. Thus, a true diagnosis of dissociative disorders could not be made, and the relationship of Internet addiction with different types of dissociative disorders (e.g., dissociative identity disorder and dissociative amnesia) could not be evaluated. According to the results of this study, Internet addiction is fairly prevalent among Turkish college students. To the best of our knowledge, the current study represents the largest sample size showing a positive relationship between dissociative symptoms and Internet addiction. Our findings draw attention to the existence of a rule of dissociative symptoms in Internet addiction phenomenology. Further studies, using structured interview instruments, should be undertaken to better explain the causality of these relatively common conditions.
References [1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: Author; 1994. [2] Ross CA, Joshi S, Currie R. Dissociative experiences in the general population. Am J Psychiatry 1990;147:1547-52. [3] Horen SA, Leichner PP, Lawson JS. Prevalence of dissociative symptoms and disorders in an adult psychiatric inpatient population in Canada. Can J Psychiatry 1995;40:185-91. [4] Spitzer C, Barnow S, Freyberger HJ, Grabe HJ. Dissociation predicts symptom-related treatment outcome in short-term inpatient psychotherapy. Aust N Z J Psychiatry 2007;41:682-7. [5] Ko CH, Yen JY, Chen CS, Chen CC, Yen CF. Psychiatric comorbidity of Internet addiction in college students: an interview study. CNS Spectr 2008;13:147-53. [6] Leung L. Net-Generation attributes and seductive properties of the Internet as predictors of online activities and Internet addiction. Cyberpsychol Behav 2004;7:333-48. [7] Shaffer HJ, Hall MN, Vander Bilt J. “Computer addiction”: a critical consideration. Am J Orthopsychiatry 2000;70:162-8.
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[8] Young KS, Rogers RC. The relationship between depression and Internet addiction. Cyberpsychol Behav 1998;1:25-8. [9] Shapira NA, Goldsmith TD, Keck PE, Khosla UM, McElroy SL. Psychiatric features of individuals with problematic Internet use. J Affect Disord 2000;57:267-72. [10] Black DW, Belsare G, Schlosser S. Clinical features, psychiatric comorbidity, and health-related quality of life in persons reporting compulsive computer use behavior. J Clin Psychiatry 1999;60: 839-44. [11] Yoo HJ, Cho SC, Ha J, Yune SK, Kim SJ, Hwang J, et al. Attention deficit hyperactivity symptoms and Internet addiction. Psychiatry Clin Neurosci 2004;58:487-94. [12] Bernardi S, Pallanti S. Internet addiction: a descriptive clinical study focusing on comorbidities and dissociative symptoms. Compr Psychiatry 2009;50:510-6. [13] De Berardis D, D'Albenzio A, Gambi F, Sepede G, Valchera A, Conti CM, et al. Alexithymia and its relationships with dissociative experiences and Internet addiction in a nonclinical sample. Cyberpsychol Behav 2009;12:67-9. [14] Aardema F, O'Connor K, Côté S, Taillon A. Virtual reality induces dissociation and lowers sense of presence in objective reality. Cyberpsychol Behav Soc Netw 2010;13:429-35. [15] Griffiths M. Internet addiction: does it really exist? In: Gackenbach J, editor. Psychology and the Internet. New York: Academic Press; 1998. p. 61-75. [16] Nichols LA, Nicki RM. Development of a psychometrically sound Internet addiction scale: a preliminary step. Psychol Addict Behav 2004;18:381-4. [17] Canan F, Ataoglu A, Nichols LA, Yildirim T, Ozturk O. Evaluation of psychometric properties of the internet addiction scale in a sample of Turkish high school students. Cyberpsychol Behav Soc Netw 2010;13: 317-20. [18] Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986;174:727-35. [19] Carlson EB, Putnam FW. An update on the Dissociative Experiences Scale. Dissociation 1993;6:16-27. [20] Yargiç LI, Tutkun H, Sar V. The reliability and validity of the Turkish version of the Dissociative Experiences Scale. Dissociation 1995;8: 10-3.
[21] Shapira NA, Lessig MC, Goldsmith TD, Szabo ST, Lazoritz M, Gold MS, et al. Problematic Internet use: proposed classification and diagnostic criteria. Depress Anxiety 2003;17:207-16. [22] Chou C, Hsiao M-C. Internet addiction, usage, gratification, and pleasure experience: the Taiwan college students' case. Comput Educ 2000;35:65-80. [23] Niemz K, Griffiths M, Banyard P. Prevalence of pathological Internet use among university students and correlations with self-esteem, the General Health Questionnaire (GHQ), and disinhibition. Cyberpsychol Behav 2005;8:562-70. [24] Tahiroğlu AY, Çelik GG, Uzel M, Özcan N, Avci A. Internet use among Turkish adolescents. Cyberpsychol Behav 2008;11:537-43. [25] Brenner V. Psychology of computer use: XLVII. Parameters of Internet use, abuse and addiction: the first 90 days of the Internet Usage Survey. Psychol Rep 1997;80:879-82. [26] Liu T, Potenza MN. Problematic Internet use: clinical implications. CNS Spectr 2007;12:453-66. [27] Johansson A, Gotestam K. Internet addiction: characteristics of a questionnaire and prevalence in Norwegian youth (12-18 years). Scand J Psychol 2004;45:223-9. [28] Chou C, Condron L, Belland JC. A review of the research on internet addiction. Educ Psychol Rev 2005;17:363-88. [29] Ko C-H, Yen J-Y, Chen C-C, Chen S-H, Yen C-F. Gender differences and related factors affecting online gaming addiction among Taiwanese adolescents. J Nerv Ment Dis 2005;193:273-7. [30] Hoeft F, Watson CL, Kesler SR, Bettinger KE, Reiss AL. Gender differences in the mesocorticolimbic system during computer gameplay. J Psychiatr Res 2008;42:253-8. [31] Young KS. Internet addiction: the emergence of a new clinical disorder. Cyberpsychol Behav 1998;11:237-44. [32] Morahan-Martin J, Schumacher P. Incidence and correlates of pathological Internet use among college students. Comput Hum Behav 2000;16:13-29. [33] Prince M. The psychological principles and filed of psychotherapy. In: Hale NG, & Prince M, editors. Psychotherapy and multiple personality: Selective essay. Cambridge (Mass): Harvard University Press; 1975. p. 114-36. [34] Putnam FW. Dissociation as a response to extreme trauma. In: Kluft RP, editor. Childhood Antecedents of Multiple Personality. Washington, DC: American Psychiatric Association Press; 1985. p. 66-97.
Comprehensive Psychiatry 53 (2012) 422 – 426 www.elsevier.com/locate/comppsych
The association between Internet addiction and dissociation among Turkish college students Fatih Canan a,⁎, Ahmet Ataoglu b , Adnan Ozcetin b , Celalettin Icmeli b b
a Psychiatry Clinic, Bolu Izzet Baysal Mental Health Hospital, Bolu, Turkey Department of Psychiatry, Duzce University School of Medicine, Duzce, Turkey
Abstract Purpose: This study aimed to investigate Internet use patterns and Internet addiction among young adult university students and to examine the correlation between excessive Internet use and dissociative symptoms. Methods: The study was conducted among 1034 students, aged between 18 and 27 years. Internet Addiction Scale, Dissociative Experiences Scale, and a sociodemographic query form were used in the collection of data. Pearson correlation analysis, the t test, and χ 2 test were used for data analysis. Results: According to the Internet Addiction Scale, 9.7% of the study sample was addicted to the Internet. The Pearson correlation analysis results revealed a significant positive correlation between dissociative experiences and Internet addiction (r = 0.220; P b .001) and weekly Internet use (r = 0.227; P b .001). Levels of Internet addiction were significantly higher among male students than female students (P b .001). The Internet use pattern also differed significantly between sexes. Conclusions: According to the results of this study, Internet addiction is a relatively frequent phenomenon among young adult college students in Turkey. Excessive Internet use is associated with higher levels of dissociative symptoms. © 2012 Elsevier Inc. All rights reserved.
1. Introduction Dissociation is generally defined as “a disruption in the usually integrated functions of consciousness, memory, identity, and perception of the environment” [1]. Dissociative experiences are common in the general population and become pathologic when they cause marked distress and interfere with functioning [2]. Dissociative symptoms may intersect with different kinds of psychiatric disorders [3], and a growing body of literature indicates that dissociation has a negative influence on treatment outcome in several psychiatric syndromes [4]. Excessive or problematic use of the Internet has been a topic of discussion in the academic literatures for more than a decade. Although a standardized definition has not been uniformly agreed upon, it is generally recognized that problematic Internet use involves an individual's inability to
⁎ Corresponding author. Tel.: +90 374 2752525; fax: +90 374 2752423. E-mail address: [email protected] (F. Canan). 0010-440X/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2011.08.006
control his or her use of the Internet, negative consequences (e.g., failing in school, decreased productivity), and marked distress and/or functional impairment [5,6]. Whether Internet addiction is a primary addictive disorder or a secondary disorder of other psychiatric disorders has remained controversial [7]. Cross-sectional studies on samples of patients report high comorbidity of Internet addiction with psychiatric disorders such as major depression [8], bipolar disorder [9], obsessive-compulsive disorder [10], attentiondeficit/hyperactivity disorder [11], and substance use disorder [9]. The association of Internet addiction with dissociation has heretofore been evaluated only in a few studies with small sample sizes. In the first study concerning this topic [12], an association was found between dissociative symptoms and higher hours spent per week on the Web among adult outpatients who were admitted to overusing the Web. The second study [13] has enrolled 312 undergraduate students revealing that individuals with Internet addiction experienced more dissociative symptoms than nonaddicts in relationship with alexithymia. In addition, in an experimental
F. Canan et al. / Comprehensive Psychiatry 53 (2012) 422–426
study with 30 individuals [14], virtual reality was shown to induce dissociation. We believe these findings should be replicated in a larger sample of subjects. Our aim was to investigate Internet use patterns and Internet addiction among young adult university students. In addition, the present study examined the relationship between Internet addiction and dissociative experiences in a large nonclinical population, namely Turkish college students. 2. Methods 2.1. Participants The study was conducted among the college students aged 18 to 27 years at Duzce University (Turkey) between March and July 2007. The target subjects of this study were all the students in Duzce University (n = 3456). The recruitment process was performed in classrooms. A total of 1123 students voluntarily participated as subjects for the study (32.4%). Participants received no credit or compensation for their participation in the study. After oral information and consent, all participants were asked to complete Internet Addiction Scale (IAS), Dissociative Experiences Scale (DES), and a sociodemographic query form. Eighty-nine students were excluded from the study because of missing data resulting in an analytical sample of 1034 students. The study was approved by the Committee of Duzce University School of Medicine Local Ethical Committee for Clinical and Laboratory Studies. 2.2. Measures 2.2.1. Internet Addiction Scale The IAS is a self-report instrument consisting of 36 items based on the 7 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, substance dependence criteria and 2 additional criteria recommended by Griffiths [15]. The same authors [16] carried out the reliability and validity study among undergraduate students. Because of low interitem correlations, 5 items were deleted. The revised form of the scale consisted of 31 items (e.g., “I have stayed on the Internet longer than I intended to,” “I feel that life without the Internet would be boring and empty,” “I have attempted to spend less time on the Internet but I have been unable to do so.”). The IAS is a highly reliable and internally consistent measure (Cronbach α = .95). The scale was translated into Turkish, and psychometric properties of the Turkish version of the scale was evaluated among high school students revealing a highly significant test-retest reliability (r = 0.98; P b .001) [17]. An interitem reliability reduced the initial scale from 31 to 27 items (with Cronbach α of .94). Scale items are rated on a 5-point Likert scale (1, never; 2, rarely; 3, sometimes; 4, frequently; 5, always), with higher scores representing greater Internet addiction. A cutoff score of 81 (3 × 27 items) was suggested as indicative of Internet addiction. The cutoff score was arbitrarily determined by the developers of the scale.
423
2.2.2. Dissociative Experiences Scale The DES is a 28-item self-report instrument. The DES was developed by Bernstein and Putnam [18], and it has adequate test-retest reliability, good split-half reliability, and good clinical validity. It can be completed in 10 minutes and scored in less than 5 minutes. It is easy to understand, and the questions are framed in a normative way that does not stigmatize the respondent for positive responses. The respondent slashes the line, which is anchored at 0% on the left and 100% on the right, to show how often he or she has this experience. The overall DES score is obtained by adding up the 28 item scores and dividing by 28; this yields an overall score ranging from 0 to 100. Scores higher than 30 may indicate the presence of a dissociative disorder [19]. The scale contains a variety of dissociative experiences, many of which are normal experiences. The DES has very good validity and reliability and good overall psychometric properties. The Turkish version of the scale [20] has reliability and validity as high as its original form. 2.2.3. Sociodemographic Query Form We developed a 14-item sociodemographic questionnaire with items pertaining to age, sex, type, and extent of Internet use (e.g., “How many hours do you spend online per week?”). 2.3. Statistical analysis Statistical analysis was performed using the SPSS package (SPSS 16 for windows; SPSS Inc, Chicago, IL). Student 2-tailed t test was used to compare the significance of the differences between two groups (students with or without Internet addiction and students with or without dissociative disorder). The χ 2 analyses were used to compare categorical variables. Pearson correlation analysis was used to determine the correlation coefficients between the variables. Differences were considered significant if P values were .05 or less. 3. Results The sample consisted of 616 male students (59.6%) and 418 female students (40.4%), with a mean age of 20.41 ± 2.06 years (range, 18-27 years). According to the IAS, 9.7% of the study sample was found to be addicted to the Internet. Comparison of students with or without Internet addiction with respect to age, mean DES score, and duration of weekly Internet use are represented in Table 1. As shown in Table 2, Table 1 Comparison of students with or without Internet addiction (Student t test) Internet addiction
P
Yes (n = 101) No (n = 927) Age 20.2 ± 2.1 Duration of the Internet use, h/wk 19.0 ± 5.8 DES 29.5 ± 14.6
20.4 ± 2.0 6.7 ± 4.3 18.3 ± 10.4
.810 b.001 b.001
424
F. Canan et al. / Comprehensive Psychiatry 53 (2012) 422–426
Table 2 Internet use pattern among Turkish college students
Table 4 Comparison of students with or without a dissociative disorder (Student t test)
Male (n = 616) Female (n = 418) P a
Duration of Internet use, h/wk 7.7 ± 5.3 IAS a 54.4 ± 18.1 Internet addicts b 78 Most frequent Internet activities b Web surfing 41 (6.6%) E-mail 9 (1.5%) Video sites 112 (18.2%) Chat rooms/Internet 296 (48.1%) messaging Online games 141 (22.9%) Academic activities 17 (2.8%) a b
6.2 ± 4.2 47.3 ± 14.9 23
b.001 b.001 b.001
36 (8.6%) 8 (1.9%) 44 (10.5%) 307 (73.4%)
b.001
Student t test. χ 2 Test.
78 (12.6%) of male students and 23 (5.5%) of female students were Internet addicts, and the difference was statistically significant (P b .001). In addition, male students scored significantly higher than the female students on the total IAS. The Internet had been most frequently reported to be used for chat rooms and Internet messaging (58.3%). Video sites and online games were most frequently used by women (18.1% vs 10.5% and 22.8% vs 1.9%, respectively). Most frequent Internet activities of the students with or without Internet addiction were found to be significantly different (P b .05) (Table 3). According to DES, 172 students (16.6%) had scores higher than 30, indicating the presence of a dissociative disorder. The students with a dissociative disorder scored higher on the IAS and spent more time on the Web. Comparison of students with or without a dissociative disorder with respect to age, mean IAS score, and duration of weekly Internet use are shown in Table 4. Forty-two (41.5%) of the students with Internet addiction also had a dissociative disorder. This finding was statistically significant according to the χ 2 test (P b .001). The students with a dissociative disorder were found most frequently to use the Internet for chat rooms/Internet messaging (73.8%) (Table 5). A correlation matrix showing the relationships between age, duration of the Internet use, IAS, and DES scores are presented in Table 6. Duration of weekly Internet use and IAS scores were positively related to DES scores (P b .001).
Table 3 Most frequent Internet activities of students with or without Internet addiction (χ 2 test)
Web surfing E-mail Video sites Chat rooms/Internet messaging Online games Academic activities
Yes (n = 101)
No (n = 927)
10 (9.9%) 0 8 (7.9%) 63 (62.4%) 20 (19.8%) 0
67 (7.2%) 17 (1.8%) 148 (15.9%) 540 (58.3%) 129 (13.9%) 32 (3.5%)
P
Yes (n = 172) No (n = 862) Age 20.3 ± 1.9 Duration of the Internet use, h/wk 9.3 ± 6.9 IAS 58.2 ± 21.3
20.5 ± 2.1 6.7 ± 4.3 50.2 ± 15.9
.470 b.001 b.001
4. Discussion
8 (1.9%) 15 (3.6%)
Internet addiction
Dissociative disorder
A considerable amount of literature published so far on Internet addiction reveals that it is a worldwide phenomenon [21]. The lack of a standardized definition and diagnostic instruments that show adequate reliability and validity across countries are significant limitations in estimating the prevalence of problematic Internet use. Despite the diversity in definition, Internet addiction is generally reported as a widespread condition among college students with prevalence rates ranging from 5.9% [22] to 18.3% [23]. In the present study, the rate of Internet addiction among university students was found to be 9.7%, similar with the previously reported rates from Turkey [17,24]. This finding indicates that 1 of 10 college students in Turkey is affected by problematic Internet use. Although limited studies have shown no sex-related differences [25], accumulating data suggest that men are more likely to meet criteria for Internet addiction than are women [22,26,27]. We have found that 12.6% of male students and 5.5% of female students were Internet addicts, supporting the idea that men are more prone to be addicted to the Internet. We have also found that men were more likely to use the Internet for playing online games when compared with women (22.8% vs 1.9%). It has been proposed that men and women and boys and girls use the Internet differently [28]. For example, in a study of Taiwanese adolescents (n = 395), significantly higher proportion of men than women were found to have played online games [29]. In an interesting functional magnetic resonance imaging (fMRI) study by Hoeft et al [30], men were shown to exhibit greater connectivity and activation in the mesocorticolimbic systems during video game playing than women. This finding may indicate a possible neural process causing the greater propensity of men for playing online games in a repetitive Table 5 Most frequent Internet activities of students with or without a dissociative disorder (χ 2 test)
P
Most frequent Internet activities
.027
Web surfing E-mail Video sites Chat rooms/Internet messaging Online games Academic activities
Dissociative disorder Yes (n = 172)
No (n = 862)
4 (2.3%) 2 (1.2%) 15 (8.7%) 127 (73.8%) 21 (12.2%) 3 (1.7%)
73 (8.5%) 15 (1.7%) 141 (16.4%) 474 (54.9%) 128 (14.8%) 29 (3.4%)
P b.001
F. Canan et al. / Comprehensive Psychiatry 53 (2012) 422–426 Table 6 Pearson's correlation coefficient analysis for age, duration of the Internet use, IAS, and DES scores
Age Duration of the Internet use, h/wk IAS DES
Duration of the Internet use, h/wk
IAS
DES
−0.044 1
−0.065⁎ 0.844⁎⁎
−0.036 0.227⁎⁎
1
0.220⁎⁎ 1
⁎ P b .05. ⁎⁎ P b .001.
manner. Despite the differences in Internet use patterns between sexes have also been established by other studies [31,32], the reasons underlying these differences are yet to be investigated in detail. Up until now, few studies in the English literature have mentioned the relationship between dissociation and Internet addiction. In their recent study, Bernardi and Pallanti [12] enrolled 50 adult outpatients who were referred for different psychiatric complaints (mainly depressive mood) and were admitted to overusing the Web. The participants were screened using the Young's Internet Addiction Scale (YIAS) and DES. Although DES scores and YIAS scores were not found to be associated, a positive correlation was found between DES scores and higher hours spent per week on the Web. De Berardis et al [13] have evaluated 312 nonclinical undergraduate students using YIAS, DES, and Toronto Alexithymia Scale and found that individuals with Internet addiction experienced more dissociative symptoms than nonaddicts and that alexithymia affected the relationship between problematic Internet use and dissociative experiences. Moreover, in their experimental study with 30 nonclinical individuals (aged between 22 and 49 years), Aardema et al [14] have demonstrated that virtual reality induced dissociation. Our study corroborates previous studies revealing a positive relationship between dissociative symptoms and problematic Internet use. In the present study, a significant positive correlation was found between DES and IAS scores. The students with dissociative disorder (according to DES) were found to have significantly greater scores on IAS and higher hours spent per week on the Web. Furthermore, Internet addicts (according to IAS) were also found to have significantly greater scores on DES. Some of the main symptoms of dissociative disorders, such as dissociation, derealization, depersonalization, identity confusion, and identity alteration, may (at least theoretically) be associated with the unique characteristics of the Internet (e.g., anonymity). Our findings indicate a statistical relation between dissociative symptoms and problematic Internet use but do not offer causality. These findings are of complex interpretation. Overuse of the Internet may cause the individual to re-experience the dissociative process, which is present in the nature of the Internet, when she or he is off-line.
425
Detachment, conceived of as a continuum of severity of symptoms, and characterized by Prince [33] (as “coconsciousness,” the presence of 2 separate streams of consciousness), may be an important feature of the Internet addiction [12]. Although dissociation contributes obviously to difficulties in identifying feelings, paradoxically, Internet-induced transient dissociative states may be considered as an effort to identify and express feelings in a fragmented way that are otherwise difficult to access. Another finding of this study is that most students (73.8%) with a dissociative disorder most frequently used the Internet for Internet messaging. This may be explained by the convenience in developing alternative identities on the Web. The present study needs to be evaluated in light of several limitations. The participants were not screened for childhood traumatic experiences, which are claimed to play important role in the etiology of dissociative disorders [34]. Hence, it could not be investigated whether dissociative symptoms are independently associated with Internet addiction, or overusing the Internet is a consequence of childhood trauma-related dissociative disorders. Another limitation is the use of self-report questionnaires instead of structured interview instruments. Thus, a true diagnosis of dissociative disorders could not be made, and the relationship of Internet addiction with different types of dissociative disorders (e.g., dissociative identity disorder and dissociative amnesia) could not be evaluated. According to the results of this study, Internet addiction is fairly prevalent among Turkish college students. To the best of our knowledge, the current study represents the largest sample size showing a positive relationship between dissociative symptoms and Internet addiction. Our findings draw attention to the existence of a rule of dissociative symptoms in Internet addiction phenomenology. Further studies, using structured interview instruments, should be undertaken to better explain the causality of these relatively common conditions.
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