Abstract
A high rate of personality disorders (PD) was found in individuals with Internet addiction (IA) in previous studies using clinical and limited sample sizes. The present study further made comparisons between gender, and incorporated a control group to compare the frequencies of PD between individuals with IA and those without IA. Five hundred and fifty-six college students (341 females) completed self-report surveys, and were later given diagnostic interviews to assess for a personality disorder diagnosis. Males with IA showed a higher frequency of narcissistic PD, while females with IA showed a higher frequency of borderline, narcissistic, avoidant or dependent PD when compared to those without IA. The high rate of PD among Internet addicts may be associated with the core features of specific PD psychopathology. Gender differences in the PD frequencies among IA individuals provide indications for understanding the psychopathological characteristics of personality disorders in Internet addicts.
Introduction
With the growing importance of the Internet in everyday life, Internet addiction (IA) has been greatly researched and often referred to base on its superficial similarity to common addictive disorders such as drugs, alcohol, or impulse control disorders such as pathological gambling (Morahan-Martin and Schumacher, 2000; Shapira et al., 2000; Shaw and Black, 2008; Young, 1998). Although IA prevalence may vary according to age, sex and ethnicity, studies have found it to prevail more commonly among college students (Morahan-Martin and Schumacher, 2000; Young, 2004). Encouraged by professors and administrators to make full use of the vast resources on the Internet, while access is possible anytime via computer labs, wired dorms, and around campus (Kandell, 1998), college students are also susceptible to IA due to the amount of leisure time, and a newly experienced freedom from parental control and monitoring (Young, 2004). Worldwide prevalence of IA ranged from 1.6% to 18% (Shaw and Black, 2008). In Taiwan, 19.8% of adolescents (Ko et al., 2005) and 15.3-17.9% college students were identified as having IA (Lin et al., 2011; Tsai et al., 2009). Having trouble going about their normal schedules, many students spend too much time online and have trouble logging off, frequently not recognizing the problem when it is happening.
Previous studies investigated personality characteristics that are vulnerable to the development of IA (Black et al., 1999; Morahan-Martin and Schumacher, 2000; Shapira et al., 2000; Yang et al., 2005). Studies using self-reports have found an association between
borderline personality features (Dalbudak et al., 2014) and IA, as well as narcissistic
personality traits (Kim et al., 2008) and online game addiction. Using advertisement and word-of mouth, Black and colleagues(1999) recruited 21 individuals who reported excessive
disorder (PD), the most frequent being borderline (24%), narcissistic (19%), and antisocial (19%) PD. They speculated that those with borderline personality disorder (BPD) use the computer and Internet out of impulsivity and as a tool to relieve boredom and loneliness, antisocial PD may crave the novelty and excitement of computer use, and narcissistic PD may use the computer to satisfy their self-absorbing characteristics. With a sample size of 21 individuals and a lack of control group, it served as the first study to look into the relationship between PD and IA, yet it only examined the total time spent on the Internet and lacked a precise IA assessment. Bernardi and Pallanti(2009) surveyed 50 self-referred psychiatric outpatients using the Internet Addiction Scale. Examination was conducted to the 15
individuals who had IA and found 14% with BPD, 7% with obsessive-compulsive PD (OCPD), and 7% with avoidant PD. A cross-sectional study on 50 college students with IA indicated 22% with narcissistic PD, 10% with BPD, 4% with OCPD, 2% with schizotypal PD, and 2% with antisocial PD, and were presented with a higher psychopathology than those without a comorbidity (Floros et al., 2014).
Internet has become a significant source of information and communication for individuals. The characteristics shared between certain PD features and IA illuminated the possible vulnerabilities of particular PD characteristics in the online environment (Shaw and Black, 2008). Previous studies focused on clinically IA samples and lacked a control group comparison on individuals without IA. Thus, using a larger sample and a well-controlled study, it is worthy to examine the frequency of PD between college students with IA compared to those without IA. Additionally, due to the high association found between males and IA (Lin et al., 2011; Mok et al., 2014), the present study analyses will be stratified by gender for further comparisons.
Methods
Participants and Procedures
This study was approved by the institutional review board for the protection of human participants, and written informed consent was obtained for survey administration and
interview. Participants were recruited from five technical colleges located in Southern Taiwan by cluster sampling and then by department. 577 college students were sampled during phase one. A total of 562 students completed the survey and were incorporated into the study (response rate=97.4%). Students filled out informed consent and were invited to participate voluntarily; confidentiality was stressed. At phase two, diagnostic interviews using the Chinese version of the Modified Schedule of Affective Disorders and Schizophrenia-Lifetime
(CMSADS-L) short form were given independently and in private to the 562 participants. Administration was conducted by trained graduate-level clinical psychology students, and licensed clinical psychologists.
In order to diagnose IA in college students, Ko and colleagues (Ko et al., 2009)
proposed to exclude those with psychotic disorders and bipolar disorder. Thus, six participants in the present study with schizophrenia and/or bipolar disorder were excluded from the analysis (N=556).
Instruments
Demographic Questionnaire
Participants filled out demographic information, such as gender, age, grade level,
Personality Disorder Features Scale (PDFS)
Personality disorder features were assessed through a self-reported questionnaire based on the personality disorder diagnosis from DSM-IV, the Personality Diagnostic Questionnaire 4+ and the Structured Clinical Interview for DSM-III-R (SCID-II) (Ko et al., 1997). The PDFS has a total of 108 questions answered on a yes or no basis. The Cronbach’s alpha for the paranoid personality features subscale was 0.68, schizoid personality features subscale was 0.75, schizotypal personality features subscale was 0.64, antisocial personality features subscale was 0.80, borderline personality features subscale was 0.70, histrionic personality features subscale was 0.58, narcissistic personality features subscale was 0.70, avoidant personality features subscale was 0.65, dependent personality features subscale was 0.61, and obsessive-compulsive personality features subscale was 0.53.
Chen’s Internet Addiction scale (CIAS)
The CIAS (Chen et al., 2003) has 26 items and responses are made from rarely/never (1) to almost always (4). Total scores ranged from 26 to 104 with higher scores indicating a greater IA severity. The two-week split-half reliability was 0.83 with an internal consistency of 0.79 to 0.93. In reference to the diagnostic criteria of IA, the 67/68 cut-off had a high diagnostic accuracy (81.5%), Cohen κ value (0.61), DOR (18.22), and specificity (92.6%), indicating 67/68 as the best cut-off point to differentiate individuals with and without IA among college students (Ko et al., 2009). Accordingly, students in the present study with a CIAS score ≥68 were categorized with IA.
Chinese version of the Modified Schedule of Affective Disorders and Schizophrenia-Lifetime Short form (CMSADS-L)
Interviews were conducted by trained graduate-level examiners using the CMSADS-L short form, a semi-structured diagnostic interview based on SADS-L, and personality disorders were incorporated in reference to Structured Clinical Interviews for DSM-IV (SCID II). The inter-rater reliability of the CMSADS-L was good (Huang et al., 2004). Familiarity of the CMSADS-L was a requirement by each interviewers. Each trainee had to view a minimum of 6 CMSADS-L training videos of case vignettes, which was followed by consensus ratings. To be certified, the trainee had to achieve good to excellent agreement with the consensus diagnosis, and inter-rater reliability was good. During the actual diagnostic interview, in order to confirm a PD diagnosis, participants were asked a series of PD core symptoms. Questions were asked pertaining to how they behaved, felt or thought most of the time throughout their lifetime. These symptoms had to be long-termed and stably presented in the individual. Participants were asked not to include symptoms occurring only when they were in certain situations (e.g. when depressed, under substance use, having a medical condition, etc.). A PD diagnosis was fulfilled when participants endorsed the minimum criteria pertaining to the DSM-IV standards, and expressed to have caused social or occupational dysfunction. The final diagnosis of each participant was reviewed, cross-referenced with the participants’ PDFS score, and best-estimate diagnoses were made by consensus of project staff.
Statistical Analysis
All statistical calculations and analyses were done using the Statistical Package for the Social Science, Version 19.0. t-test was conducted to compare the age, Internet usage time, IA
severity, and IA subscales between the IA and non-IA groups. Finally, chi-square analyses analyzed the difference in frequencies of personality disorders between the IA and non-IA groups. A P<.05 was considered as significant.
Results
Demographic data and IA severity among IA, and non-IA.
A total of 215 males and 341 females were incorporated into the study analyses.
Participants who scored ≥68 on the CIAS were classified into the IA group (N=73) and those who scored <68 on the CIAS were categorized into the non-IA group (N=483). In females, 32 (9.4%) were categorized with IA, and in males, 41 (19.1%) met the IA cut-off.
The IA group reported a significantly increased Internet usage time per week in IA compared to the non-IA group; and the IA group showed significantly higher scores in IA severity (CIAS total score) as well as all five subscales (e.g. Compulsive Internet use,
Withdrawal Symptoms, Tolerance Symptoms, Interpersonal & Health Related Problems, Time Management Problems) among both genders. (Table 1)
Frequencies of personality disorders among IA and non-IA
We further examined and compared the rate of all the personality disorders in the IA and non-IA group. For the entire sample as a whole, 20 of the 73 in the IA group (27.4%) and 67 of the 483 in the non-IA group (13.9%) were diagnosed with at least one PD. The IA group showed a higher PD frequency compared to the non-IA group (χ2=8.79, P<.01). In particularly, the IA group showed a significantly higher frequency of borderline (N=9, 12.3%; χ2=15.50, P<.001), narcissistic (N=4, 5.5%; χ2=15.12, P<.001), avoidant (N=12, 16.4%; χ2=12.07, P<.01),
and dependent PD (N=7, 9.6%; χ2=7.74, P<.01) when compared to the non-IA group. Compared separately, 11 of the 32 females in the IA group (34.4%) and 41 of the 309 in the non-IA group (13.3%) were diagnosed with at least one PD. The female IA group showed a higher PD frequency compared to the females non-IA group (χ2=10.00, P<.01); on the other hand, 9 of the 41 males in the IA group (22.0%) and 26 of the 174 in the non-IA group (14.9%) were diagnosed with at least one PD, showing no significant difference between the IA and non-IA group in overall PD frequency among males.
Gender differences in the rate of each personality disorders were observed when females and males were analyzed separately (Table 2). For males, the IA group showed a significantly higher frequency of narcissistic PD (N=3, 7.3%; χ2=8.26, P<.01) when compared to the non-IA group. For females, the IA group showed a significantly higher frequency of borderline (N=7, 21.9%; χ2=25.65, P<.001), narcissistic (N=1, 3.1%; χ2=3.90, P<.05), avoidant (N=8, 25.0%; χ2=14.22, P<.001), and dependent PD (N=5, 15.6%; χ2=9.49, P<.01) when compared to the non-IA group.
Discussion
The present study examined the rate of IA in male and female college students, and explored the association of personality disorders among individuals with IA. The rate of IA was found to be 19.1% in males and 9.4% in females, which was in accordance with previous studies showing males to be highly associated with IA (Lin et al., 2011).
We found that both genders showed a higher frequency of narcissistic PD in the IA group compared to the non-IA group. Narcissistic PD is a pervasive pattern of grandiosity, require for admiration, and an inflated sense of self-importance (American Psychiatric
Association, 2013). The anonymity of the online environment empowers users to control the information projected about them, and serves as a self-promoting platform to enhance a sense of self. Social networking sites, such a Facebook, can further increase one’s self-esteem through the feedbacks of public glory (Mehdizadeh, 2010). It is also possible to speculate that perhaps individuals with Narcissistic PD may value the Internet platform to gain recognition and admiration from other users such that online gaming can be reinforcing due to its bolstering of self-esteem (Kim et al., 2008). However, due to the small sample sizes and heterogeneity found in the PD group, expanding a larger sample size is necessary for future studies to make further comparisons.
In the present study, a higher frequency of borderline was found in female students with IA compared to those without IA. Examining the differences in how gender may experience BPD symptoms, data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that chronic feelings of emptiness and affective instability appeared to be two of the BPD symptoms most significantly discriminant in women than in men. The authors further suggested that women might respond with greater levels of self-focus in response to negative affect (Hoertel et al., 2014). Affective dysregulations have been
described as a core element of BPD, and those who are more prone to it are often more susceptible to developing depressive symptoms and anxiety (Zanarini, 2005). Similarly, findings in IA have shown a significant correlation between IA and depressive symptoms (Lin et al., 2011). Korean high school students who reported excessive Internet use had traits that were easily affected by feelings, and were more emotionally unstable (Yang et al., 2005). Thus, we might speculate that female BPD individuals who are burdened with the sense of dysphoric feelings can now make rapid attempts on the Internet in expect to make up for this unfavorable
perception, and thus be motivated to become Internet addicted. Further studies can attempt to examine the specific types of outcome expectancies that may lure BPD individuals with dysphoric feelings of loneliness to want to spend an excessive time online.
We found that female students with IA showed a higher frequency of avoidant PD compared to those without IA. Individuals with avoidant PD, which is often associated with interpersonal dysfunction, often report having difficulties with being assertive and are socially inhibited (Cummings et al., 2013). Avoidant PD has a high symptom similarity with
generalized social anxiety disorder, and on a continuum, may represent a more severe form of social anxiety disorder (Marques et al., 2012). Social anxiety and associated symptoms have been found to be more associated with women than in men (Hofmann et al., 2010; Kuusikko-Gauffin et al., 2012). Thus, it is probable that high anxiety features towards real-world social interactions may allow females to use the Internet for more interpersonal communication purposes. Internet communication seems especially appealing to women (Weiser, 2000) and social networking sites, such as Facebook, was found to be a more important part of daily interactions among women when compared to men (Lemieux et al., 2013). Thus, females with social anxiety may perceive social-networking sites as a comfortable way to interact with others. Consequently, those who are socially inhibited, and who have limited real-life networks, might find social networking sites to be beneficial due to the easy access to interpersonal interaction without the demands of face-to-face proximity and intimacy (Kuss and Griffiths, 2011). This simple door to interpersonal communication may cause an increased time commitment for females with avoidant PD, possibility resulting in excessive or addictive Internet use.
with IA compared to those without IA. Individuals with dependent PD have been reported to occur more frequently in women than in men and are described as having a pervasive need to be taken care of, and requires assurance from others that often leads to submissiveness (American Psychiatric Association, 2013), viewing self as helpless and others as strong and competent (Disney, 2013). The need to seek for reassurance in offline relationships was
correlated with Facebook reassurance seeking, and predicted a decrease in self-esteem which in turn predicted increased feelings that one does not belong and is a burden (Clerkin et al., 2013). The vast information and support-web of networks provided by the Internet may provide a sense of empowerment and refuge for females who feel themselves inept. Social networking sites such as Facebook may serve as a valuable avenue for females with low self-esteem to construct and benefit from online interpersonal relationships. Thus, individuals with dependent PD who constantly need the reassurance of others and seek the support of a relationship (Wang and Wang, 2013) will crave Internet use as means of fulfilling what they cannot in real life.
Additionally, it is worthy to note the limited participants with cluster A PDs that have IA compared to cluster B and cluster C PDs. The frequency of cluster A PDs found in the present study was small compared to the number of students reported in cluster B and C (cluster A = 9; cluster B = 41; cluster C = 76). The present study findings are consistent with previous literature, showing that Internet addicts have a low frequency of cluster A PDs
(Bernardi and Pallanti, 2009; Black et al., 1999; Floros et al., 2014). Individuals with cluster A PDs have been found to be more detached from society, and are ego-syntonic (Triebwasser et al., 2012 & 2013), many of which are indifferent to the interaction with others and are affect constricted (such as in schizoid PD; Triebwasser et al., 2012). On the other hand, the nature of the Internet makes for fast communication and interconnections that provides platforms to
satisfy those in need. Thus, it may not be surprising to find individuals with certain PD features, who may not feel as integrated as they want to be in real life, to instead, find themselves lured to the pleasures of cyberspace. Those with cluster B “dramatic” personality features are clinically characterized by affect dysregulation and impulsivity, and may use the Internet in a similar fashion as in alcohol addiction, such as for disinhibition, sensation seeking, and psychoticism (Douzenis et al., 2012). Individuals with cluster C personality features are generally depicted by anxiety and interpersonal problems, and exhibit traits of high harm avoidance (Jylha et al., 2013) and thus may use the Internet to seek interpersonal interactions (Caplan, 2007). Finally, the small sample size in the cluster A PD group may explain the limited IA found among this group. Expanding a larger sample size is necessary for future studies to make further comparisons.
In our study, a higher frequency of narcissistic PD was found in males with IA, and a higher frequency of borderline, narcissistic, avoidant or dependent PD was reported in females with IA. Pathologies related to online mechanisms are given a greater attention in psychiatry and clinical psychology (King and Delfabbro; 2013). Findings from the present study highlight that IA is linked to an enduring pattern of personal experience that deviates from the cultural expectations, is inflexible and pervasive across situations, and may cause functioning
impairment in daily life. Thus, the high co-occurrence between PD and IA found in the present study may provide empirical evidence and valuable reference supporting the inclusion of IA in the DSM.
Some limitations need to be noted. First, we did not consider the comorbidity of other psychiatric disorders, such as ADHD, and substance abuse, which might influence findings. Additionally, this study adopted a cross-sectional design. To obtain more substantial results to
the underlying relationship between PD and IA, longitudinal designs should be applied in the future to examine the stability of PD frequencies among individuals with IA.
Conclusions
Despite the limitations, the present research was the first study to incorporate a control group and make comparison between genders to examine the relationship of PD to IA. We found that males with IA showed a higher frequency of narcissistic PD, while females with IA showed a higher frequency of borderline, narcissistic, avoidant or dependent PD when
compared to those without IA. Further studies should incorporate possible mediating or moderating factors, such as the role of outcome expectancy of Internet use, affective dysregulation, or interpersonal interaction, in the association of PD and IA.
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Table 1. Demographic and clinical data among male and female college students
IA (M/SD) non-IA (M/SD) t-test
Male
(N=41) (N=174)
Age 19.73 (±1.10) 19.79 (±.94) 0.32
Internet usage time (hrs/week) 33.33 (±25.53) 24.51 (±20.36) 2.35* IA severity (CIAS total) 78.05 (±10.01) 51.57 (±11.18) 13.91*** Compulsive Internet use 15.24 (±2.54) 9.52 (±2.36) 13.76*** Withdrawal Symptoms 15.32 (±2.77) 9.86 (±2.67) 11.71*** Tolerance Symptoms 12.59 (±1.99) 8.19 (±1.95) 12.92*** Interpersonal & Health Related
Problems
20.44 (±3.31) 13.78 (±3.57) 10.89*** Time Management Problems 14.39 (±2.48) 10.14 (±2.81) 8.89***
Female
(N=32) (N=309)
Age 19.94 (±.76) 20.10 (±.87) 1.10
Internet usage time (hrs/week) 43.63 (±35.54) 20.47 (±18.65) 5.86*** IA severity (CIAS total) 75.27 (±6.33) 49.08 (±11.33) 12.86*** Compulsive Internet use 15.16 (±2.02) 9.17 (±2.79) 11.84*** Withdrawal Symptoms 15.50 (±2.26) 9.85 (±2.82) 10.96*** Tolerance Symptoms 12.34 (±2.10) 8.27 (±2.25) 9.81*** Interpersonal & Health Related
Problems
17.69 (±2.56) 12.73 (±3.28) 8.30*** Time Management Problems 14.47 (±2.91) 9.01 (±2.67) 10.92*** IA=Internet Addiction; CIAS=Chen’s Internet Addiction Scale; * p<0. 05; ***p<0.001
Table 2. Frequencies of personality disorders among male and female individuals
Personality Disorders IA (N/%) Non-IA (N/%) χ2
(N=41) (N=174) Male Paranoid PD (N=1) 0 (0%) 1 (0.6%) .24 Schizoid PD (N=1) 0 (0%) 1 (0.6%) .24 Schizotypal PD (N=0) 0 (0%) 0 (0%) null Antisocial PD (N=4) 1 (2.4%) 3 (1.7%) .09 Borderline PD (N=7) 2 (4.9%) 5 (2.9%) .42 Histrionic PD (N=2) 0 (0%) 2 (1.2%) .48 Narcissistic PD (N=4) 3 (7.3%) 1 (0.6%) 8.26** Avoidant PD (N=11) 4 (9.8%) 7 (1.5%) 2.25 Dependent PD (N=5) 2 (4.9%) 3 (4.0%) 1.45 Obsessive Compulsive PD (N=11) 2 (4.9%) 9 (5.2%) .01 (N=32) (N=309) Female Paranoid PD (N=5) 1 (3.1%) 4 (1.3%) .68 Schizoid PD (N=1) 0 (0%) 1 (0.3%) .10
Antisocial PD (N=3) 1 (3.1%) 2 (0.7%) 2.05 Borderline PD (N=15) 7 (21.9%) 8 (2.6%) 25.65*** Histrionic PD (N=4) 1 (3.1%) 3 (1.0%) 1.17 Narcissistic PD (N=2) 1 (3.1%) 1 (0.3%) 3.90* Avoidant PD (N=27) 8 (25.0%) 19 (6.2%) 14.22*** Dependent PD (N=16) 5 (15.6%) 11 (3.6%) 9.49** Obsessive Compulsive PD (N=6) 0 (0%) 6 (1.9%) .63 PD=Personality Disorder; *p<0. 05; **p<0. 01; ***p<0.001
