Problematic Internet Users and Psychiatric Morbidity in a Sample of Egyptian Adolescents

doi:10.4236/psych.2012.38096

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Psychology

2012. Vol.3, No.8, 626-631

Published Online August 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.38096

626

Problematic Internet Users and Psychiatric Morbidity in a Sample

of Egyptian Adolescents*

Mona Reda1, Menan Rabie2, Nesrin Mohsen2, Aisha Hassan3

1Institute of Childhood Postgraduate Studies, Ain Shams University, Cairo, Egpyt

2Institute of Psychiatry, Ain Shams University, Cairo, Egpyt

3Ministry of Health, Ahmed Maher Hospital, Alexandria, Egpyt

Email: [email protected]

Received May 8th, 2012; revised June 7th, 2012; accepted July 10th, 2012

Background: A growing body of research suggests that Problematic Internet use is becoming more com-

mon in society as on-line usage increases everyday. Is psychiatric morbidity common among problematic

internet users? What are the characteristics of these patients? Methods: 501 adolescents (295 males), 11 -

18 years old, recruited from 2 private (group 1) and 2 governmental schools (group 2). All were subjected

to A Psychiatric sheet, An Informative designed questionnaire, Fahmy and El Sherbiny’s Social

Classification Scale, Young internet addiction test (IAT), and Mini International Neuropsychiatric Inter-

view for children and adolescents (MINI KID). Results: Comparison between the two groups in regard

places of use of internet, number of computers available, money spent on internet activities, parental

knowledge of use, duration of use and purpose of use, revealed significant differences. Problematic

internet use was more frequent in group 1, while internet addiction was more frequent in group 2. A

significant relation was found between IAT score and social phobia, specific phobia and oppositional

defiant disorder, and a highly significant relation with generalized anxiety disorder and ADHD. Female

sex, horror movies and internet problematic use are independent predictors of psychiatric morbidity. Male

sex, private schools, high social class are independent predictors for internet use problems in our sample.

Conclusion: This study revealed that Egyptian adolescents are at high risk for problematic internet use

and to a lesser extent Internet Addiction. Adolescents with Problematic Internet use were more prone to

psychiatric disorders (social phobia, specific phobia, oppositional defiant disorders, generalized anxiety

disorder and ADHD).

Keywords: Problematic Internet Use; Psychiatric Morbidity; Adolescents

Introduction

Within the context of the development of new information

and communication technologies, the Internet has become a means

of accessing information, interpersonal communication and

entertainment. Its widespread use has important repercussions

at the individual, social, technological and economic levels

(Munoz et al., 2010). In Egypt, more than 80% of Internet Café

clients were young people, 60% of the youth surveyed spent

their time chatting, 20% browsing pornography sites, 12%

conducting business or scientific work and 8% visiting political

sites (UNDP & INP, 2010).

This study was initiated in light of the relatively high

prevalence of Egyptian Internet users coinciding with the new

era of Problematic internet use allover the world. Dysfunctional

use of such technology probably leads to changes in the

psychological profiles of the young population and may inter-

fere with the person’s social life, school work, or job-related

tasks at work, enhancing withdrawal from the real world, and at

certain occasions constituting a predisposing factor for the

appearance of psychiatric disorders.

Problematic Internet Use (PIU) has received increasing

research attention; a consistent definition of this construct has

not been currently applied. PIU has been proposed as a novel

entity of dysfunctional behavioral patterns similar to those

identified within the spectrum of impulse control disorders.

Worldwide, the prevalence of PIU among adolescents and

young adults has been observed to range between 2% and 11%

(Aboujaoude, 2010).

Researchers have established that the disorder develops into

a dependency for the person; they experience tolerance and

withdrawal affects (Ferris, 2003). Similar to what an addict of

any other substance goes through, and becomes just as isolated

as them. Rejecting the real world and adopting the Internet as a

route of escape to a mood altering experience (DeAngelis, 2000).

Given the recent expansion and the expected increase in

internet availability and usage in the coming years, it is important

that healthcare professionals be informed about this behavior

and its associated problems; internet addiction is a newly

emergent disorder. It has been found to be associated with a

variety of psychiatric disorders (Ko et al., 2012) as well as,

subjective distress, functional impairment and Axis I psychiatric

disorders (Shapira et al., 2000).

Hypothesis of the Study

*The submitted manuscript contains original unpublished work and is

not being submitted for publication elsewhere at the same time. There

is no conflict of interest.

The hypothesis of the study was that adolescents experienc-

ing problematic internet use have psychiatric morbidity.

M. REDA ET AL.

Aim of the Study

Primarily explore current psychiatric morbidity in problematic

adolescent internet users and its potential risk factors.

Design and Methods

Participants

Cross sectional design was applied for purpose of the study;

all data were collected during the first semester of academic

year 2010-2011. The study was approved by the ethical committee

of the Institute of Postgraduate Studies, Ain-Shams University,

as well as, school administrations and parents of participants,

after careful explanation of the study and its objectives, a

written consent of approval to participate was obtained from

parents as well as students after ensuring confidentiality of data.

Source of the sample was randomly selected students from

16 classes in four high schools, two private international schools

(moderate to high annual fees) and two governmental schools

(no annual fees) all students were encouraged to participate in

the study (N = 539). No exclusion criteria, including demographic

and/or socioeconomic characteristics, for the study participants

were applied.

Assessments

Ain Shams University Psychiatric sheet: that includes items

related to demographic information (age, sex, school grade),

family history, past history, psychiatric symptoms and examination.

Informative designed questionnaire: to assess patterns of

internet use, including questions to identify the following: the

location of internet access: 1) one’s own home portal; 2) a

friend’s home portal; and 3) internet café portal. The scope of

internet sites accessed included: 1) educational (a. study, b.

information, c. research); 2) entertainment (a. email, b. chatting,

c. online games); 3) other specific uses to be named. Also

duration and frequency of internet use, as well as parents’

awareness of internet use.

Fahmy and El Sherbiny’s Social Classification Scale (Fahmy

& El Sherbini, 1988): the classification is based on 5 parameters:

education of the father, education of the mother, income,

crowding index and sanitation. The parameter yields a total

score. Score of 25 - 30 is considered high social class 1, score

of 20 - 25 is considered middle & high middle social class 2,

score of 15 - 20 is considered low social class 3, score of 14 or

lower is considered very low social class 4.

The Young Internet Addiction Test (IAT): was used to detect

problematic internet use and internet addiction (Young, 1999).

The IAT is a 20 items questionnaire on which the person is

asked to rate the items on a 5 point scale. It can be used in

clinical settings to screen for internet abuse among adults and

adolescents. It classifies internet users into three groups: Aver age

Users who have complete control over their internet activities,

problematic users who experience frequent problems due to

their internet activities and Internet Addicts who experience

significant problems due to their dependence on internet activities.

The IAT is a valid and reliable instrument that can be used in

research (Widyanto & Mcmurran, 2004). It was translated to

Arabic in the current study. The reliability of the translated

version was tested in a pilot study of 50 subjects (age and sex

matching control); Cronbach’s Alpha based on standardized

items was .814.

The Mini International Neuropsychiatric Interview for

children and adolescents (MINI KID) (Sheehan et al., 1998)

was used to identify psychiatric morbidity. The MINI KID is a

structured clinical interview for the major Axis I disorders. It

was developed jointly by psychiatrists and clinicians in the

United States and Europe, for DSM-IV and ICD-10 psychiatric

disorders. It is divided into 22 modules designated by letters,

each corresponding to psychiatric diagnostic category. With an

administration time of approximately 15 minutes, it was designed

to meet the need for a short but accurate structured psychiatric

interview for multicenter clinical trials and epidemiology studies

and to be used as a first step in outcome tracking in non research

clinical settings. The reliability of the translated version was

tested in a pilot study of 100 subjects; Cronbach’s Alpha based

on standardized items was .795.

Procedure

The study proper was performed at the Institute of Childhood

Postgraduate Studies, Ain Shams University Hospitals in the

period from the beginning of January 2009 to the end of June

2010. The students were subjected to the following:

Informed consent was obtained from all students before they

participated in the study.

Each student was interviewed by one of the researchers by

the use of Ain Shams University Psychiatric sheet. This took

about 15 - 30 minutes. An Informative designed questionnaire

and Fahmy and El Sherbiny’s Social Classification Scale were

given to each student so that he fills them in, which took about

5 - 10 minutes. Then the student was submitted to The MINI

KID for Psychiatric diagnosis. This step took about 15 - 25

minutes.

Data Analysis

The collected data were analyzed by the Statistical Package

for Social Sciences (SPSS), version 15 and expressed as following:

Chi-square test was used to compare qualitative variables between

groups, Fisher exact test was used instead of chi-square when

one or more expected cell < 5. Unpaired t-test was used for

comparison of quantities variables, binary logistic regression

analysis was used to find out the most significant independent

predictors affecting outcome by using backward Likelihood

ratio technique. Statistical analyses were conducted with the

application of the SAS version 9.0 (SAS Institute Inc., USA)

software package, P-value (P) of P value > .05 insignificant,

≤ .05 was the criterion for significance and P < .01 highly

significant.

Results

The sample of the study constituted of 501 adolescent

students recruited from 2 private schools (group 1) and 2

governmental schools (group 2). The interview and all assessments

were conducted in presence of a research team member, with

response rate (100%). 295 male students (59%), 206 female

students (41%) with no significant difference (X2 = 0, P ≥ .05),

aged between 11 - 18 years old, with highly significant difference

in money spent on internet activities between two groups, as

well as social class according to Fahmy and El-Sherbiny Social

Classification Scale (X2 = 127, P ≥ .001), (X2 = 14, P ≥ .001)

respectively as shown in Table 1.

Comparison between two groups in regard places of use of

internet (Table 2), number of computers available, parental

M. REDA ET AL.

628

Table 1.

Comparison between both groups as regard general data.

Variables Private (N = 251) Governmental (N = 250) Chi square P-value Significance

Age Mean + SD

15 + 1.5

Mean + SD

14.1 + 1.4 .7 >.05 NS

Gender N (%) N (%) 0 >.05 NS

Female 104 (41.4%) 103 (41.2%)

Male 147 (58.6%) 147 (58.8%)

Spend 127 <.001 HS

<5 41 (16.3%) 144 (61.3%)

6 - 10 82 (32.7%) 72 (30.6%)

>11 117 (46.6%) 19 (8.1%)

NA 11 (4.4%) 15 (6.0%)

Social class 14 <.001 HS

Very low 31 (12.3%) 37 (14.8%)

Low 8 (3.2%) 14 (5.6%)

Middle 5 (2.0%) 20 (8.0%)

High 207 (82.5%) 179 (71.6%)

Table 2.

(a) Comparison between both groups in regard to internet use; (b) Comparison between both groups in regard to purpose of internet use.

(a)

Sig P X2 Governmental N = 250Private N = 251 Variables

HS <.001 22

220 (88%)

30 (12%)

247 (98.4%)

4 (1.6%)

Home Yes

S <.05 Fisher

81 (32.4%)

169 (67.6%)

108 (43.0%)

143 (57.0%)

School Yes

NS >.05 .11

56 (22.4%)

193 (77.2%)

1 (.4%)

69 (27.5%)

182 (72.5%)

Café Yes

HS <.001 48

38 (15.2%)

212 (84.8%)

110 (43.8%)

141 (56.2%)

Friend house Yes

S <.05 8

20 (8%)

230 (92%)

42 (16.7%)

209 (83.3%)

Other places Yes

HS <.001 7 2 + .4 3 + .6 Number of computers

HS <.001 20

177 (70.8%)

64 (25.6%)

9 (3.6%)

217 (86.4%)

33 (13.2%)

1 (.4%)

Parents knowledge Always

Sometimes

Never

S <.05 7.5

64 (25.6%)

160 (64.0%)

19 (7.6%)

6 (2.4%)

1 (.4%)

45 (17.9%)

169 (67.3%)

22 (8.8%)

15 (6.0%)

How long using < 1 hour

1 - 4 hours

5 - 10 hours

>10 hours

(b)

HS <.001 19 107 (42.8%) 157 (62.5%) Study

S <.05 Fisher 156 (62.4%) 176 (70.1%) Information

S <.05 Fisher 168 (67.2%) 186 (74.1%) Research

Educational

S <.05 Fisher 121 (48.4%) 192 (76.5%) E-mail

HS <.001 Fisher 135 (54.0%) 207 (82.5%) Chat

S <.05 Fisher 163 (65.2%) 143 (56.9%) On line games

Entertainment

knowledge of use, duration of use and purpose of use, revealed

significant differences all in favor of group 1.

Applying IAT indicated numerical difference in regard to

problematic internet use. It was more frequent in group 1, while

internet addiction was more frequent in group 2, with sig-

nificant difference in favor of group 1 (private schools) (X2 = 5,

P ≤ .05) as shown in Table 3. For statistical reasons, both

groups were summated and named problematic internet users

(PIU) group.

Testing for Frequency of internet use and duration of internet

use was significant in favor of students with problematic use (x2

= 20.47, p ≥ .05, x2 = 21.35, p ≥ .001) respectively.

Using MINI-KID showed no significant difference between

the two groups in regard to psychiatric disorders, still when

using Fisher extract test a significant relation was found

between IAT score and social phobia, specific phobia and

oppositional defiant disorder (P ≤ .05) in all, and a highly

significant relation with generalized anxiety disorder and

Attention deficit hyperactive disorder (P ≤ .001) in all, as

shown in Table 4.

M. REDA ET AL.

Table 3.

Comparison between both groups as regards IA score.

P-value Chi square Govern, N = 250 Private N = 251

202 (80.8%) 184 (73.3%) No IA

45 (18.0%) 66 (26.3%) Some <.05

3 (1.2%) 1 (.4%) Signifi

Table 4.

Psychiatric disorders in relation to IA problematic use.

Significance P-value

IA problematic use

No Yes

NS >.05 5 (5.9%) 19 (6.7%) Depression

NS >.05 9 (10.5%) 22 (7.8%) Dysthemia

NS >.05 14 (17.1%) 35 (12.6%) Panic

NS >.05 21 (25.6%) 61 (21.9%) Agrophobia

NS >.05 29 (35.8%) 85 (30.7%) Anxiety

S <.05 8 (10%) 14 (5.1%) Social phobia

S <.05 14 (17.5%) 27 (9.8%) Specific phobia

NS >.05 6 (7.5%) 13 (4.7%) OCD

HS <.001 15 (18.8%) 21 (7.7%) Generalized anxiety

NS >.05 2 (2.5%) 5 (1.8%) ADHD

NS >.05 1 (1.3%) 5 (1.8%) ADHD hyperactivity

HS <.001 4 (5%) 1 (.4%) ADHD combined

S <.00 30 (37.5%) 69 (25.3%) Oppositional defiant

In an attempt to identify a relation between PIU and presence

of a psychiatric morbidity in the whole studied group, watching

movies (especially horror movies) was found to be of sig-

nificant relation to the occurrence of a psychiatric disorder (P

≤ .05).

Using binary logistic regression test indicated that female sex,

horror movies and internet problematic use are independent

predictors of psychiatric morbidity. On the other hand males,

private schools, high social class are considered independent

predictors for internet use problems (problematic/addiction) in

our sample. As shown in Table 5.

Discussion

For adolescents, the Internet serves as an inexpensive, readily

accessible platform for social interaction (Paul & Bryant, 2005)

and leisurely activities (Dannon & Iancu, 2007). With the

growing wealth of literature on PIU among adolescents, re-

searchers attempted to investigate the psychiatric morbidity in

PIU, and its possible risk factors.

Table 5.

Relation between psychiatric disorders, internet problematic use and

different variables by logistic regression.

Odd’s (95% CI)P-value Beta-coefficientIndependent predictors

Psychiatric disorder

1.7 (.4 - 7.8) <.05 .98 Female sex

1.2 (.4 - 6) <.05 .45 Horror movies

1.1 (.1 - 7) <.05 .42 IA (positive problem)

1.01 (.2 - 4.9) >.05 .19 Govern school

Internet problematic use

1.3 (.3 - 10.8) <.05 .56 Male sex

1.1 (.3 - 11.7) <.05 .33 Private school

1 (.4 - 7) <.05 .25 High social class

Although the internet enhances psycho-social development,

still pathological internet use encouraged researchers to monitor

this phenomena, European prevalence reported between 1 and

9% (Pallanti et al., 2006; Siomos et al., 2008; Villella et al., 2010),

Middle Eastern prevalence at between 1 and 12% (Ghassemzadeh

et al., 2008; Canbaz et al., 2009; Canan et al., 2010). And

prevalence in Asia reported between 2 and 18% (Ko et al., 2007;

Park et al.; 2008, Song et al., 2010). Variation in figures can be

explained by the different criteria used to identify internet

problematic use and/or addiction (pathological use), which was

evident in our study as 22.1% (n = 111) showed to have

problematic Internet use, and .8% (n = 4) proved to have

Internet addiction, in the current work both (problematic and

addictive users) were referred to as PIU.

Excessive and pathological Internet users are inevitably

making regular and intense use of the Internet, with regard to

both the frequency and duration of each Internet session,

especially for accessing e-mail, chat rooms, and Internet games

(Cak & Leung, 2004), which consistent with the current work,

as students with problematic internet users tend to login more

frequent and stay online for longer duration, as it is a major

contributor in defining PIU.

Psychiatric morbidity in adolescents with PIU has been

identified in several researches, (Ha et al., 2006; Ko et al.,

2008), in the current study PIU subjects showed higher

tendency in showing anxiety disorders i.e., social phobia,

specific phobia as well as generalized anxiety disorder, which is

in agreement with previous studies (Shapira et al., 2000; Milani

et al., 2009; Akin & Iskender, 2011). These findings could be

explained by the speculation that online social networking gives

adolescents the chance to form virtual friends they can’t face in

real world which positively affect social and moral knowledge

among adolescents.

Attention-deficit/hyperactivity disorder (ADHD), hostility,

depression, were correlated in other study to internet addiction

M. REDA ET AL.

(Ko et al., 2009), in the current study we could identify ADHD

(P ≥ .001) but failed to correlate with depression, this could be

explained by the outnumber of 295 male (59%) to 206 females

(41%). PIU is known for the multiple windows with different

activities, rapid responses and immediate reward which may

resembles symptoms of ADHD.

Using logistic regression to identify independent predictors

to psychiatric disorder; female gender and horror movies were

related, on the other hand, males, high social class, private

school were independent predictors to PIU, gender difference

was proven in previously conducted studies (Ceyhan, 2008;

Frangos & Sotiropoulos, 2011). These factors should be taken

with caution, and larger scale studies should be conducted, as

although in Egypt gender gap regarding internet use is 59%

males and 41% females (MCIT, 2010), still several barriers

exist such as basic computer illiteracy and high price of internet

service.

In conclusion PIU is not an uncommon problem among

Egyptian adolescents, potential risk factors identified in this

work include: high social class, male gender and availability of

access. Anxiety disorders and ADHD are the most prevalent

comorbid psychiatric disorders.

Limitations

The researchers admit having difficulties in obtaining higher

sample size due to refusal of few schools to participate, secondary

to denying approval for psychiatric assessment as well as

reluctance of adolescents to participate. Another limitation is

excluding smart phones as sample included students from low

economic families’.

Acknowledgements

Special thanks go to the subjects of the study, without them

this study wouldn’t be possible.

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