Problematic use of Internet in a sample of psychiatric outpatients: preliminary observations from the “real world”

Elisabeth Prevete1,2, Giulia Minotti2, Camilla Gnagnarella1,2, Marta Ciambella1,2, Giulia Valcovich2, Francesca Sarno2, Ornella Corazza3,4,5, Luca Simione6, Giuseppe Bersani2,3

1Department of Human Neuroscience, Sapienza University of Rome, Italy; 2Psychiatry and Clinical Psychopharmacology Unit, A. Fiorini Hospital, Local Health Department of Latina, Terracina (LT), Italy; 3Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; 4Department of Clinical, Pharmacological and Biological Sciences, College Lane, University of Hertfordshire, Hatfield, United Kingdom; 5Department of Psychology and Cognitive Science, University of Trento, Italy; 6Istituto di Scienze e Tecnologie della Cognizione, CNR, Rome, Italy.

Summary. Objective. This study aims to explore the prevalence, characteristics, and psychopathology related to Problematic Use of Internet (PUI), including Internet Addiction (IA), within a sample of psychiatric outpatients. Methods. 143 psychiatric stable outpatients (18-65, mean age: 49; F=84) were included in this study, regardless of their categorical diagnosis. Socio-demographic, clinical, psychopathological, and Internet use-related data (PIU-Scale, Internet Addiction Test, devices, use, activities) were collected across the sample. Results. The prevalence of PUI ranged between 1% (IAT) and 25% (PIU-S), with a homogeneous distribution of PUI symptoms’ severity among the four main psychopathological areas (depressive, bipolar, anxiety, and psychotic disorders). PUI was correlated with age and was higher in students as in the general population. Significant associations were found between PUI symptoms and both personality and eating disorders; PUI was also positively correlated with the presence of other addictions (e.g., alcohol and/or substances). A greater proportion of patients with PUI presented other forms of behavioural addiction compared to non-symptomatic patients. Social media and online shopping, as well as video-streaming, resulted to be the main forms of PUI among patients with problematic use of the Internet. Discussion. More studies are required among students diagnosed with eating and personality disorders. The association between PUI and other addictive disorders would support the hypothesis of their common shared pathophysiology. Conclusion. Healthcare providers and educators should be made aware of such risks. More studies are needed to confirm such preliminary findings.

Key words. Behavioural addictions, problematic use of Internet, Internet Addiction, psychopathology, psychiatric outpatients.

Utilizzo problematico di Internet in un campione di pazienti psichiatrici ambulatoriali: osservazioni preliminari dal “mondo reale”.

Riassunto. Scopo. Il presente studio ha indagato prevalenza, caratteristiche ed eventuali aspetti psicopatologici associati al fenomeno dell’uso problematico di Internet (PUI), inclusa la dipendenza da Internet (IA), all’interno di un campione di pazienti psichiatrici ambulatoriali. Metodi. 143 pazienti psichiatrici in fase di compenso (18-65, età media: 49; F=84) sono stati inclusi nello studio, indipendentemente dalla categoria diagnostica. Sono state analizzate le variabili socio-demografiche, le caratteristiche psicopatologiche e le modalità di uso di Internet (PIU-Scale, Internet Addiction Test, dispositivi, uso, attività). Risultati. La prevalenza del PUI è risultata dell’1% (IAT) e del 25% (PIU-S), con una distribuzione omogenea della gravità dei sintomi legati al PUI tra le quattro principali aree psicopatologiche indagate (disturbi dello spettro depressivo, bipolare, ansioso e psicotico). Il PUI è risultato correlato con l’età ed era più presente tra gli studenti, come per la popolazione generale. Associazioni significative sono state riscontrate tra i sintomi legati al PUI e i disturbi di personalità e del comportamento alimentare; il fenomeno del PUI è risultato anche positivamente correlato con la presenza di altre dipendenze (per esempio alcool e/o sostanze). Una maggior proporzione di soggetti con PUI presentava altre forme di dipendenza comportamentale, rispetto ai pazienti non sintomatici. I social media e lo shopping online, così come il video-streaming, sono risultate le principali forme di PUI tra questi pazienti con uso problematico di Internet. Discussione. Più studi in merito sono necessari tra studenti con disturbi del comportamento alimentare e di personalità. L’associazione tra PUI e altre dipendenze supporterebbe l’ipotesi di una patofisiologia almeno parzialmente condivisa tra tali disturbi. Conclusione. I professionisti della salute e gli educatori dovrebbero essere a conoscenza di questi rischi. Ulteriori studi sono necessari per confermare questi dati preliminari.

Parole chiave. Dipendenza da Internet, dipendenze comportamentali, pazienti psichiatrici ambulatoriali, psicopatologia, uso problematico di Internet.

Introduction

Internet use has become part of daily life, and it has increased worldwide during the last decades. Eurostat estimated that around 98% of Europeans accessed the internet at least once a week during 20211. Moreover, high Internet accessibility (ranging from 68% to 90%) has been reported within 2019 over about 10 years1,2. In this scenario, characterized by a large and continuous access to the Internet, the Problematic Use of Internet (PUI) arises as a wide range of internet-related problematic behaviours, often classified as “non-substance addictions”3-5.

Conceptualized as «an Impulse-Control Disorder that does not involve poisoning»6, PUI and Internet Addiction (IA) are largely overlapping terms used to describe poorly controlled and risky behaviours related to a dysfunctional use of the Internet (e.g., online videogames, pornography, social media, among others)3,7,8. However, PUI is considered a broader term referring to a heterogeneous and complex phenomenon including, as mentioned above, several forms of Internet dysfunctional use. Amongst various forms of PUI, only Internet Gaming Disorder (IGD) and Gambling Disorder (GD) have recently been included in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)9. Overall, PUI can lead to the development of addiction symptoms, such as tolerance, craving, and withdrawal symptoms3,10. Such aspects are relevant from the public and mental health point of view3,10,11, especially with the increased diffusion of PUI reported during the Covid-19 pandemic11-13. On the other hand, IA should be considered as a more specific entity belonging to the groups of PUI and referring to the presence of addictive behaviours/symptomatology. A recent work estimated a high global prevalence of IA, among other forms of digital addictions14. Further, according to a recent metanalysis including 53,184 participants, a high prevalence for generalized IA15 was reported. PUI symptoms can be measured using specific questionnaires, such as the Problematic Internet Use Scale (PIU-S)16,17 or the Yung’s Internet Addiction Test (IAT)18,19. These scales assess similar but slightly different constructs (respectively PUI and IA) with potential different diagnostic observations that should be better defined and taken into careful consideration while using these instruments.

Several studies have suggested that PUI and IA are particularly diffuse among adolescents, young adults, and students with damaging consequences on life quality and mental health14,20-23. Typical psychiatric symptoms and disorders associated with PUI in adults and adolescents include insomnia24, post-traumatic stress disorder (PTSD)25 and bipolar symptoms26, obsessive-compulsive, depressive, anxious, and attention deficit hyperactivity disorder (ADHD) features27-30. However, these latter symptomatologic associations have been considered not specific31. Further, a significant association between PUI/IA and co-occurring psychiatric disorders, especially anxiety/depressive disorders, ADHD31-36, and autism spectrum disorders (ASD)32 has also been highlighted. Of concern are also the comorbidities with eating disorders37-39, substance use disorders31,33,39,40, including alcohol intake31,34,39-41, other behavioural addictions42, and personality disorders43,44.

Despite such extensive studies in adolescents and young adults reporting the association between PUI/IA and conditions of mental distress or psychopathological features, little is still known about this phenomenon and its correlates in patients with mental illness. Only a few studies have been conducted in adolescent and adult psychiatric patients with PUI/IA21,45-51. Evidence suggests that PUI leads to worse outcomes in psychiatric disorders, e.g., excessive use of social networks for depression52, and increased suicidality40,53,54. Moreover, subjects with PUI and psychiatric disorders have shown a lower quality of life compared to non-psychiatric patients55.

Therefore, built on this previous limited evidence, the present study aims to explore the prevalence, characteristics, and psychopathology of PUI-related within a sample of psychiatric outpatients. Based on the reviewed literature, we expected to find a higher level of prevalence of PUI in psychiatric patients respect to the general population. Moreover, we hypothesized that PUI symptoms would be associated with younger age, and with the presence of other behavioural addictions, such as gambling or substance use. Further, we would like to assess if the two main instruments at hand to assess symptoms of PUI and IA, i.e., the Problematic Internet Use Scale (PIU-S)9 and the Yung’s Internet Addiction Test (IAT)11, would lead to similar or different outcomes, and gain insight on how their results should be interpreted.

Methods

Participants

All patients referred to the outpatient psychiatric unit of Psychiatry and Clinical Psychopharmacology (University), A. Fiorini Hospital (Latina Province, Italy), were routinely considered for this study regardless of their categorical diagnosis. Inclusion criteria were the following: (i) age between 18 and 65 years; absence of (ii) acute psychiatric symptoms; (iii) neurodegenerative disorders; or (iv) moderate-to-severe intellectual disability. Patients who did not fulfil the mentioned inclusion criteria were excluded from the study. The primary diagnosis, determined by the clinical evaluation following the DSM-59 criteria and reported in the medical records, was considered for all patients, including those with multiple diagnoses. Diagnoses were obtained from their medical records, and participants were subsequently divided into 8 groups, based on their main diagnosis, which were: Anxiety Disorder (AD); Depressive Disorder (DD); Psychotic Disorder (PSyD); Bipolar Disorder (BD); Eating Disorder (ED); Obsessive-Compulsive Disorder (OCD); Personality Disorder (PD), including all clusters (A, B and C); and Substance Use Disorder (SUD). Overall, a total of 143 patients (84 females and 59 males; with a mean age of 49; range 18-65 years), were included in this study.

After applying all the inclusion criteria, we collected a sample including 143 patients, 50 (35% of the sample) were with AD; 47 (32,9%) with DD; 17 (11,9%) with PSyD; 14 (9.8%) with BD; 7 (4,9%) with ED; 3 (2,1%) with OCD; 3 (2,1%) with PD; and 2 (1,4%) with SUD. Most of the patients had more than one diagnosis (N = 105; 73,4% vs 26,6% of single diagnosis), showing the following psychiatric comorbidities: PD (55,3%), DD (15,8%), SUD (13,2%), AD (10,5%) and ED (2%). For more details on descriptive statistics see Table 1.




Measures and procedures

The anonymity of personal information was assured, and participants provided their written informed consent. We used a semi-structured interview typically administered to all patients as per standard clinical practice, collecting the following data: (1) socio-demographic information (i.e., age, sex, residence, job status, education level, and marital status); and (2) clinical variables including psychiatric diagnosis; the presence of addictive disorders (behavioural addictions vs substance use disorder) and patient’s insight; PUI was evaluated through the Problematic Internet Use Scale (PIU-S)9, the Yung’s Internet Addiction Test (IAT)11, and an inventory about both Internet device’s hold/frequency of use, i.e., PC, smartphone, tablet, smartwatch and videogame console; and main online activities, i.e., none, social media, instant messaging, email, source platform, news sites, entertaining, online streaming, online shopping, gambling, gaming, massive multiplayer online role-playing game (MMORPG), pornography, and drug selling.

PIU-S is a self-report questionnaire having good psychometric properties and internal coherence (Cronbach’s α= 0.88)9. It is widely used to investigate the impact of Internet use on an individual’s life (including school, work, relations, personal stress, withdrawal symptoms, and mood alterations). The scale consists of 13 dichotomous (0= “no”; 1= “yes”) items9,10. The total score ranges between 0 to 13, and a cut-off of ≥4 is used to assess a problematic use of the Internet (PUI); a score of 1-3 points indicates a mild level of PUI symptoms9,10; for the study, we used the official Italian version (Cronbach’s α= 0.89)10.

We also applied the Italian version of IAT, a self-administrated questionnaire with good psychometric proprieties (Cronbach’s α= 0.82)11. IAT is commonly used to assess the presence of IA and includes 20 items rated on a 5-point Likert scale (from 1= “rarely” to 5= “always”). Typical addiction’s symptoms (e.g., salience, excessive use, working neglect, anticipation, lack of control, and social neglect)11 can be identified taking into account the scores: a score of 20-49 indicates normal Internet use, 50-79 is related to occasional or often PUI, a score ≥80 is suggestive of presence of IA11,12.

All procedures of the study were conducted according to the Principles of Human Rights.

Results

Prevalence of PUI

Overall, PUI prevalence was different when considering either the PIU-S (25%) or the IAT (1%), showing the differences in psychometric properties between the two questionnaires. More specifically, the receiver operating characteristic (ROC) analysis (the outcome was the admission of having a PUI) indicated that both tests have good diagnostic qualities with the PIU-S being highly sensitive and lower specific, and the opposite for IAT. The suggested cut-off for the questionnaires is respectively 4.5 (PIU-S) and 36.5 (IAT). Considering the prevalence for the PIU-S items and the medium score for IAT one, the distribution of the single questions is shown in Table 2.







Relationship between PUI and socio-demographic data

We conducted a series of analyses in order to evaluate the relationship between the presence of PUI and socio-demographic variables of the sample. In all the analyses, we included both the scores at IAT and PIU-S as measures of PUI. For the continuous variables (e.g., age and education level), we used bivariate Pearson’s correlation, whereas one-way ANOVA analysis was used to compare questionnaires’ scores between groups for the categorical variables (e.g., residence, marital status, and job status). We found a significant negative correlation between PUI and age, with r=-0.49, p<0.01, and r=-0.47, p<0.01, respectively for PIU-S and IAT scores. We also found a significant effect on PUI symptoms of job status, F6.136=2.98, p<0.01, for PIU-S score, but not for IAT score, with higher levels of PUI in students. Overall, this analysis indicated that young students had on average a higher presence of PUI. Analysis of the other socio-demographic variables did not show any significant effect on or relationship with PUI.

Relationship between PUI and psychopathology

A one-way ANOVA between groups was realized to evaluate the prevalence of PUI symptoms among different diagnostic groups. No significant main effect of the group on PUI severity as measured with both PIU-S and IAT was found concerning the main diagnostic groups (DD, PsyD, AD, and BD). However, the effect of the empirically derived diagnostic groups was significant for both PIU-S, F5,155= 4.39, p<0.01, and IAT score, F5,135= 4.12, p<0.01. Post-hoc t-tests revealed that the two diagnostic categories of ED and PD reported higher scores respect to the other groups (p<0.05 for all comparisons).

Relationship between PUI and addictions

An ANOVA test revealed an association between PUI severity and IA’s insight of the patients with PUI (PIU-S, F7,135= 19.74, p<0.01; IAT, F7,135= 25.68, p<0.01), with more severe PUI linked to a reduced insight. Further, in post-hoc analysis, all comparisons related to items evaluating IA’s insight were significant (p<0.05).

A Pearson’s Chi-Squared test was used to compare the PIU-S’s severity group with the presence of another behavioural addiction: although the general effect was significant for “absence of behavioral addictions”, post-hoc analysis showed that such addictive behaviors are more frequent in patients with mild-severe PUI (1-3-point score or more) symptoms (p<0.05 for all comparisons). ANOVA analysis also revealed a link between the presence of current or past abuse of substances/alcohol and PUI in both scales (PIU-S, F1,141=9.70, p<0.01; IAT, F1,141 =10.52, p<0.01). For more details see also Table 3.




Correlational analysis between PUI and pattern of internet use

As reported in Table 4, further analysis showed a positive association between PUI, PC, and smartphone use considering both scales.




According to the χ2 test, instead, we found an association between PIU-S’s severity symptoms and some specific activities: mild-severe PUI symptoms were associated with the prevalent use of social networks, instant messaging, source platforms, and online streaming.

Discussion

Although several psychiatric symptoms/disorders have been frequently associated with PUI/IA in adolescent and adult populations25-34,56,57, limited evidence21,45-51 on PUI/IA among psychiatric patients is available. This observational study is thus one of the first investigations into the PUI phenomenon, conducted with a sample of psychiatric outpatients, irrespective of their categorical diagnosis. Among the 143 participants enrolled in this study, the prevalence of PUI was estimated between 1% (using the IAT score) and 25% (using the PIU-S score), with these questionnaires showing a different value according to their different intrinsic characteristics. As previously mentioned, the PIU-S and the IAT questionnaires are used to evaluate similar but different conditions, with the IA only being part of a wider and more complex PUI phenomenon. Such results highlight, in line with previous evidence58,59, the need of a unique diagnostic tool to assess this form of behavioral addiction. Such findings would also suggest that IA and PUI, terms widely used in the literature to define the same construct, may be considered as two separate entities. IA appears to describe a more severe condition in comparison to the mild addictive behavior defined by the PUI umbrella.

In this study, the PUI phenomenon presented a homogenous distribution among the main psychopathological areas (AD, DD, PSyD, BD, OCD). This result confirmed previous evidence reporting a significant link between PUI, AD, DD and OCD27-31,34,56,57. Further, it adds information on the potential link between PUI and the other diagnostic categories considered (BD; PSyD). This aspect is consistent with findings from a recent study which found no difference in mental health-related Internet use among psychiatric patients with different diagnoses45. It is also in line with previous findings31 suggesting that, in psychiatric patients, PUI might not be only considered as a sign of addictive behaviors, but also as a way to cope with anxiety-depressive symptoms related to a spectrum of psychological disorders. In fact, according to the “mood enhancement hypothesis”, individuals may escape from negative emotions using recreational activities. Thus, such theory might help to understand the link between depressive/anxiety features and PUI60.

Further, it has been found a strong correlation between PUI symptoms’ severity and PD, ED, and other addictions, including both behavioral and substance use (e.g., alcohol and/or substances) disorders. These results are consistent with previous works revealing a significant association between PUI and (i) PD, especially personality clusters A and B (e.g., borderline) and obsessive-compulsive or avoidant tracts43,44; (ii) ED37-39,61; (iii) alcohol abuse and addictive disorders31,33,34,39-42.

The relation between PUI and both addictive behaviors and past/current alcohol/substance abuse found in the sample would provide some support to the theory hypothesizing the presence of a common neurobiological mechanism underlying all these disorders62,63, with recent evidence suggesting the involvement of compulsive and impulsive features in several forms of PUI60. In fact, evidence suggests the potential role of impulsivity/compulsivity circuits and prefrontal functions (e.g., executive control functions)60,62,63 in the generation of PUI, with a continuous call for more studies on this topic.

The level of PUI in this sample of psychiatric outpatients was significantly associated with both age and job status, with younger patients, mainly students, reporting more severe PUI symptoms. These results are consistent with data in the literature reporting a wide presence worldwide of PUI among adolescents, young adults, and students (e.g.,14,20-23,42,64-69), and confirm such demographic variables as relevant risk factors linked to the development of PUI. The findings from our study are also in line with evidence from two recent studies reporting IA in young psychiatric patients21,47 and with a study describing the association between PUI, lower age and psychiatric comorbidity in a sample of more than three hundred adult psychiatric patients46.

PUI/IA has been linked per se to several psychopathological conditions25-34,56,57 and to the worsening of their prognosis26,40,53 or of patients’ quality of life51,55. Thus, the results of the present study would highlight the importance for clinicians to monitor Internet usage patterns in psychiatric patients, especially if young, regardless of their diagnosis. Patients in mental health treatment who have behavioral addictions and comorbid PUI might benefit from more targeted education surrounding how to avoid using the Internet to reinforce those behaviors (e.g., using the Internet for online gambling, purchasing drugs or alcohol, or perpetuating disordered eating). This might potentially help to avoid the addictive effect of PUI-related psychopathology in worsening the psychiatric disorders’ specific features.

Limitations

This study has the strength to have investigated the PUI phenomenon in a sample of psychiatric outpatients collecting observations from the “real world”, while also adding the comparison between IA and PUI. Nevertheless, it also has several limitations: (1) its transnosographic with non-randomized recruitment design does not allow a specific analysis of the PUI phenomenon for each psychiatric categorial diagnosis, with a limited number of subjects for each diagnostic group; (2) participants were evaluated in only one center, thus results of the present study are only preliminary and should be interpreted with caution; (3) diagnoses are clustered, which may influence the homogeneity shown in the spread of PUI among participants; (4) further, data were related to patients’ self-reports, with the potential risk of social bias; (5) only psychiatric outpatients in a stable psychopathological condition have been enrolled in such a study, this might have defined a potential selection bias; (6) part of the study was conducted during the COVID-19 pandemic, which is suggested to have contributed to the worsening of PUI15-17,60 and this might have influenced the results of our study. Finally, (7) another limiting element per se is the lack of a standardized model for the recognition of PUI and its classification, suggesting, in line with previous research58,59 the necessity to introduce unanimous diagnostic criteria.

Conclusions

PUI is a growing health concern, and the present study adds further evidence on the association between PUI and psychiatric disorders, with the prevalence of PUI in young students, especially those diagnosed with eating disorders and personality disorders, confirming previous findings. The association between PUI and other addictive disorders would also support the hypothesis of their common shared pathophysiology. Healthcare providers and educators should be made aware of such risks. Further, longitudinal studies are needed to confirm these preliminary findings and to better define the directionality of the complex relationship between PUI and psychiatric disorders.

Conflict of interests: the authors have no conflict of interests to declare.

References

1. Eurostat. Individuals - Frequency of Internet Use. Last update: 30-03-2022.

2. Kaess M, Klar J, Kindler J, et al. Excessive and pathological Internet use - Risk-behavior or psychopathology? Addict Behav 2021; 123: 107045.

3. Fineberg NA, Demetrovics Z, Stein DJ, et al. Manifesto for a European research network into Problematic Usage of the Internet. Eur Neuropsychopharmacol 2018; 28: 1232-46.

4. Mihajlov M, Vejmelka L. Internet addiction: a review of the first twenty years. Psychiatr Danub 2017; 29: 260-72.

5. Zou Z, Wang H, d’Oleire Uquillas F, Wang X, Ding J, Chen H. Definition of substance and non-substance addiction. In: Zhang X, Shi J, Tao R (eds). Substance and non-substance addiction. Singapore: Springer Singapore, 2017.

6. Young KS. Psychology of computer use: XL. Addictive use of the Internet: a case that breaks the stereotype. Psychol Rep 1996; 79 (3 Pt 1): 899-902.

7. Dell’Osso B, Di Bernardo I, Vismara M, et al. Managing problematic usage of the Internet and related disorders in an era of diagnostic transition: an updated review. Clin Pract Epidemiol Ment Health 2021; 17: 61-74.

8. Cataldo I, Billieux J, Esposito G, Corazza O. Assessing problematic use of social media: where do we stand and what can be improved? Curr Opin Behav Sci 2022; 45: 101145.

9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association, 2013.

10. Bersani FS, Barchielli B, Ferracuti S, et al. The association of problematic use of social media and online videogames with aggression is mediated by insomnia severity: a cross-sectional study in a sample of 18- to 24-year-old individuals. Aggress Behav 2022; 48: 348-55.

11. Cataldo I, Burkauskas J, Dores AR, et al. An international cross-sectional investigation on social media, fitspiration content exposure, and related risks during the COVID-19 self-isolation period. J Psychiatr Res 2022; 148: 34-44.

12. Masaeli N, Farhadi H. Prevalence of Internet-based addictive behaviors during COVID-19 pandemic: a systematic review. J Addict Dis 2021; 39: 468-88.

13. Gansner M, Nisenson M, Lin V, Pong S, Torous J, Carson N. Problematic Internet use before and during the COVID-19 pandemic in youth in outpatient mental health treatment: app-based ecological momentary assessment study. JMIR Ment Health 2022; 9: e33114.

14. Meng SQ, Cheng JL, Li YY, et al. Global prevalence of digital addiction in general population: a systematic review and meta-analysis. Clin Psychol Rev 2022; 92: 102128.

15. Pan YC, Chiu YC, Lin YH. Systematic review and meta-analysis of epidemiology of Internet Addiction. Neurosci Biobehav Rev 2020; 118: 612-22.

16. Morahan-Martin J, Schumacher P. Incidence and correlates of pathological Internet use among college students. Comput Human Behav 2000; 16: 13-29.

17. Roma P, Ricci F, Kotzalidis GD, et al. Psychopathology and personality in problematic Internet users. Riv Psichiatr 2019; 54: 24-30.

18. Widyanto L, McMurran M. The psychometric properties of the Internet addiction test. Cyberpsychol Behav 2004; 7: 443-50.

19. Fisoun V, Floros G, Siomos K, Geroukalis D, Navridis K. Internet addiction as an important predictor in early detection of adolescent drug use experience-implications for research and practice. J Addict Med 2012; 6: 77-84.

20. Veisani Y, Jalilian Z, Mohamadian F. Relationship between Internet addiction and mental health in adolescents. J Educ Health Promot 2020; 9: 303.

21. Wang S, Xia L, Wang J, et al. Prevalence and Clinical correlates of Internet Addiction symptoms and their association with quality of life in adolescents with major depressive disorder: a multicenter cross-sectional study. Front Psychiatry 2022; 13: 819704.

22. Machimbarrena JM, González-Cabrera J, Ortega-Barón J, Beranuy-Fargues M, Álvarez-Bardón A, Tejero B. Profiles of problematic Internet use and its impact on adolescents’ health-related quality of life. Int J Environ Res Public Health 2019; 16: 3877.

23. Bianchini V, Cecilia MR, Roncone R, Cofini V. Prevalence and factors associated with problematic Internet use: an Italian survey among L’Aquila students. Riv Psichiatr 2017; 52: 90-3.

24. Lam LT. Internet gaming addiction, problematic use of the Internet, and sleep problems: a systematic review. Curr Psychiatry Rep 2014; 16: 444.

25. Lee JY, Kim SW, Kang HJ, et al. Relationship between problematic Internet use and post-traumatic stress disorder symptoms among students following the Sewol ferry disaster in South Korea. Psychiatry Investig 2017; 14: 871-5.

26. 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 Psychiatry 2013; 47: 153-9.

27. Potembska E, Pawłowska B, Szyman´ska J. Psychopathological symptoms in individuals at risk of Internet addiction in the context of selected demographic factors. Ann Agric Environ Med 2019; 26: 33-8.

28. Chamberlain SR, Redden SA, Stein DJ, Lochner C, Grant JE. Impact of obsessive-compulsive personality disorder symptoms in Internet users. Ann Clin Psychiatry 2017; 29: 173-81.

29. Moretta T, Buodo G. The relationship between affective and obsessive-compulsive symptoms in Internet use disorder. Front Psychol 2021; 12: 700518.

30. Boudabous J, Feki I, Sellami R, Baati I, Trigui D, Masmoudi J. Anxiety and problematic Internet use in Tunisian students. Tunis Med 2020; 98: 745-9.

31. Starcevic V, Khazaal Y. Relationships between behavioural addictions and psychiatric disorders: what is known and what is yet to be learned? Front Psychiatry 2017; 8: 53.

32. Restrepo A, Scheininger T, Clucas J, et al. Problematic Internet use in children and adolescents: associations with psychiatric disorders and impairment. BMC Psychiatry 2020; 20: 252.

33. 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: 1-8.

34. Ho RC, Zhang MW, Tsang TY, et al. The association between Internet addiction and psychiatric co-morbidity: a meta-analysis. BMC Psychiatry 2014; 14: 183.

35. Wang BQ, Yao NQ, Zhou X, Liu J, Lv ZT. The association between attention deficit/hyperactivity disorder and Internet addiction: a systematic review and meta-analysis. BMC Psychiatry 2017; 17: 260.

36. Menéndez-García A, Jiménez-Arroyo A, Rodrigo-Yanguas M, et al. Internet, video game and mobile phone addiction in children and adolescents diagnosed with ADHD: a case-control study. Adicciones 2022; 34: 208-17.

37. Ioannidis K, Taylor C, Holt L, et al. Problematic usage of the Internet and eating disorder and related psychopathology: a multifaceted, systematic review and meta-analysis. Neurosci Biobehav Rev 2021; 125: 569-81.

38. Hinojo-Lucena FJ, Aznar-Díaz I, Cáceres-Reche MP, Trujillo-Torres JM, Romero-Rodríguez JM. Problematic Internet use as a predictor of eating disorders in students: a systematic review and meta-analysis study. Nutrients 2019; 11: 2151.

39. Kotyuk E, Magi A, Eisinger A, et al. Co-occurrences of substance use and other potentially addictive behaviors: epidemiological results from the Psychological and Genetic Factors of the Addictive Behaviors (PGA) Study. J Behav Addict 2020; 9: 272-88.

40. Park S, Jeon HJ, Bae JN, Seong SJ, Hong JP. Prevalence and psychiatric comorbidities of Internet addiction in a nationwide sample of Korean adults. Psychiatry Investig 2017; 14: 879-82.

41. Lanthier-Labonté S, Dufour M, Milot DM, Loslier J. Is problematic Internet use associated with alcohol and cannabis use among youth? A systematic review. Addict Behav 2020; 106: 106331.

42. Ben Thabet J, Ellouze AS, Ghorbel N, et al. [Factors associated with Internet addiction among Tunisian adolescents]. Encephale 2019; 45: 474-81.

43. Bernardi S, Pallanti S. Internet addiction: a descriptive clinical study focusing on comorbidities and dissociative symptoms. Compr Psychiatry 2009; 50: 510-6.

44. Laconi S, Andréoletti A, Chauchard E, Rodgers RF, Chabrol H. [Problematic Internet use, time spent online and personality traits]. Encephale 2016; 42: 214-8.

45. Balhara YPS, Singh S, Bhargava R. The pattern of problematic Internet use and mental health-related Internet use among psychiatric outpatients at a tertiary care center. Ci Ji Yi Xue Za Zhi 2020; 32: 198-204.

46. de Vries HT, Nakamae T, Fukui K, Denys D, Narumoto J. Problematic Internet use and psychiatric co-morbidity in a population of Japanese adult psychiatric patients. BMC Psychiatry 2018; 18: 9.

47. Li ZL, Liu R, He F, et al. Prevalence of Internet addiction disorder and its correlates among clinically stable adolescents with psychiatric disorders in China during the COVID-19 outbreak. Front Psychiatry 2021; 12: 686177.

48. Zhou R, Zhang JJ, Liu YD, et al. Internet addiction in adolescent psychiatric patient population: a hospital-based study from China. Clin Child Psychol Psychiatry 2023; 28: 199-211.

49. Winds K, Aebi M, Plattner B. Problematic Internet use among adolescent male and female psychiatric inpatients: a gender perspective. Child Psychiatry Hum Dev 2024; 55: 497-509.

50. Bai W, Cai H, Wu S, et al. Internet addiction and its association with quality of life in patients with major depressive disorder: a network perspective. Transl Psychiatry 2022; 12: 138.

51. Yang JJ, Bai W, Guo T, et al. The prevalence of Internet addiction and its association with quality of life among clinically stable patients with major depressive disorder. J Affect Disord 2022; 314: 112-6.

52. Aydin O, Çökmüs¸ FP, Balikçi K, Sücüllüog˘lu-Dikici D, Ünal-Aydin P. The problematic use of social networking sites associates with elevated symptoms in patients with major depressive disorder. Int J Soc Psychiatry 2020; 66: 496-503.

53. Cheng YS, Tseng PT, Lin PY, et al. Internet addiction and its relationship with suicidal behaviors: a meta-analysis of multinational observational studies. J Clin Psychiatry 2018; 79: 17r11761.

54. Bersani FS, Accinni T, Carbone GA, et al. Problematic use of the Internet mediates the association between reduced mentalization and suicidal ideation: a cross-sectional study in young adults. Healthcare (Basel) 2022; 10: 948.

55. Dieris-Hirche J, Te Wildt BT, Pape M, et al. Quality of Life in Internet use disorder patients with and without comorbid mental disorders. Front Psychiatry 2022; 13: 862208.

56. Al Mukhaini AM, Al Houqani FA, Al Kindi RM. Internet addiction and depression among postgraduate residents: a cross-sectional survey. Sultan Qaboos Univ Med J 2021; 21: 408-15.

57. Andrade ALM, Scatena A, Bedendo A, et al. Findings on the relationship between Internet addiction and psychological symptoms in Brazilian adults. Int J Psychol 2020; 55: 941-50.

58. Kuss DJ, Lopez-Fernandez O. Internet addiction and problematic Internet use: a systematic review of clinical research. World J Psychiatry 2016; 6: 143-76.

59. Kuss DJ, Griffiths MD, Karila L, Billieux J. Internet addiction: a systematic review of epidemiological research for the last decade. Curr Pharm Des 2014; 20: 4026-52.

60. Fineberg NA, Menchón JM, Hall N, et al. Advances in problematic usage of the Internet research - A narrative review by experts from the European network for problematic usage of the Internet. Compr Psychiatry 2022; 118: 152346.

61. Ivezaj V, Potenza MN, Grilo CM, White MA. An exploratory examination of At-Risk/Problematic Internet Use and disordered eating in adults. Addict Behav 2017; 64: 301-7.

62. Brand M, Young KS, Laier C. Prefrontal control and Internet addiction: a theoretical model and review of neuropsychological and neuroimaging findings. Front Hum Neurosci 2014; 8: 375.

63. Goodman A. Neurobiology of addiction. An integrative review. Biochem Pharmacol 2008; 75: 266-322.

64. Balhara YPS, Mahapatra A, Sharma P, Bhargava R. Problematic Internet use among students in South-East Asia: current state of evidence. Indian J Public Health 2018; 62: 197-210.

65. Ali R, Mohammed N, Aly H. Internet addiction among medical students of Sohag University, Egypt. J Egypt Public Health Assoc 2017; 92: 86-95.

66. Asiri S, Fallahi F, Ghanbari A, Kazemnejad-Leili E. Internet addiction and its predictors in guilan medical sciences students, 2012. Nurs Midwifery Stud 2013; 2: 234-9.

67. Macur M, Király O, Maraz A, Nagygyörgy K, Demetrovics Z. Prevalence of problematic Internet use in Slovenia. Zdr Varst 2016; 55: 202-11.

68. Moreno MA, Jelenchick L, Cox E, Young H, Christakis DA. Problematic Internet use among US youth: a systematic review. Arch Pediatr Adolesc Med 2011; 165: 797-805.

69. Taha MH, Shehzad K, Alamro AS, Wadi M. Internet use and addiction among medical students in Qassim University, Saudi Arabia. Sultan Qaboos Univ Med J 2019; 19: e142-e7.