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Exploring Depression, Self-esteem and Verbal Fluency with Different Degrees

of Internet Addiction among Chinese College Students

Article  in  Comprehensive psychiatry · January 2017

DOI: 10.1016/j.comppsych.2016.10.006

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Comprehensive Psychiatry 72 (2016) 114 – 120
www.elsevier.com/locate/comppsych

Exploring depression, self-esteem and verbal fluency with different

degrees of internet addiction among Chinese college students
Jia Nie a, b , Wei Zhang a, b,⁎, Ying Liu c
a
School of Psychology, Central China Normal University, Hubei, China
b
Key Laboratory of Adolescent Cyberpsychology and Behavior (CCNU), Ministry of Education, Wuhan, China
c
East Zhuyuan Primary School, Zhongshan, Guangdong, China

Abstract

Background: The aims of this study were to explore depression, self-esteem and verbal fluency functions among normal internet users, mild
internet addictions and severe internet addictions.
Methods: The survey sample consisted of 316 college students, and their internet addiction symptoms, depression and self-esteem symptoms
were assessed using the Revised Chen Internet Addiction Scale (CIAS-R), Zung Self-Rating Depression Scale (ZSDS), Rosenberg Self-
Esteem Scale (RSES), respectively. From this sample, 16 students with non-addictions, 19 students with mild internet addiction (sub-MIA)
and 15 students with severe internet addiction (sub-SIA) were recruited and subjected to the classical verbal fluency tests, including the
semantic and phonemic fluency task.
Results: The results indicated that severe internet addiction in the survey sample showed the highest tendency towards depressive symptoms
and lowest self-esteem scores, and sub-SIA showed poor performance on the semantic fluency task.
Conclusion: In conclusion, severe internet addiction was significantly associated with depression, low self-esteem and semantic verbal
fluency problems.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction Several studies have examined internet addicted users'

With the exponentially increased usage of internet
technologies in our lives and the easy access of internet,
overuse of the internet, particularly in teens and young
adults, has become a concern in recent years. The researchers
used different terms to describe this compulsive behavior
when referred to an overuse of the internet, such as internet
addiction [1,2], compulsive internet use [3], problematic
internet use [4], and pathological internet use [5]. This study
prefers the term ‘internet addiction’, which refers to an
individual's inability to control his or her own internet use
and leads to functional impairments of daily activities [6–8],
bearing many similarities to other types of behavioral
addictions and substance abuse [9–12].
We thank PhD Yanli Zhang-James for providing language help.
⁎ Corresponding author at: School of Psychology, Central China
Normal University, 152 Luoyu Street, Wuhan, Hubei, People's Republic
of China, 430079.
E-mail address: psyzhwccnu@126.com (W. Zhang).
http://dx.doi.org/10.1016/j.comppsych.2016.10.006
0010-440X/© 2017 Elsevier Inc. All rights reserved.
daily behaviors and their psychological characteristics.
Internet addicted users often showed poor academic
performance, avoided face-to-face communication, and so
forth [13,14]. Numerous research findings have revealed that
psychopathological factors, such as depression, and person-
ality factors, such as low self-esteem, were related to the
internet addicted behaviors [15,16]. However, it is not clear
whether the existing psychological or personality factors
were the causes for internet addiction, or it is the other way
around. A meta-analysis of recent literatures reported that
depression is one of the most co-morbid disorders with
internet addiction [17]. Low self-esteem, as a principal
component of depression, is described as the individual's
negative attitude towards themselves [18]. A previous study
found that adolescents with lower self-esteem were more
easily addicted to the Internet [19]. Internet addicted users
often considered the internet as a ‘haven’, a place where they
can gain more social support and ease pain from their daily
lives. However, these individuals often became even lonelier
and more depressed, rather than more socially connected and
 J. Nie et al. / Comprehensive Psychiatry 72 (2016) 114–120
happier [19,20], and often showed more deterioration in
daily communication skills or speech, and other executive
functions.
Studies of internet addition often utilized survey or
self-report questionnaires to assess the participants' addic-
tions levels [1,3,21]. However, mild internet addiction,
which was regarded as those users possibly or intermittently
addicted to the internet (a possible or intermittent use), may
have different psychological characteristics (i.e. depression
and self-esteem) compared with severely internet addicted
users. Therefore, it is important to utilize both traditional
diagnosis instruments (e.g. questionnaires) and major
quantitative measurement of internet addition (e.g. time
spent online) to better differentiate normal internet users,
mild and severe internet additions, and to quantitatively
compare the differences in the psychological characteristics
(i.e. depression and self-esteem) among the different
internet users.
In addition to depression and self-esteem, our study also
focused on cognitive dysfunction of internet addiction. Over
the years, extensive research has demonstrated deficits in
executive functioning, such as non-verbal working memory,
inhibition and decision-making tasks, in internet addiction
and its coexisting psychiatric disorders (e.g. pathological
gambling, problematic alcohol use and attention-deficit/
hyperactivity disorder) [22–24]. Verbal fluency was also
commonly used to evaluate cognitive functioning in
psychiatry disorders with impaired attention capacity, such
as pathological gambling, alcoholism, Parkinson's disease
and attention-deficit/hyperactivity disorder. Verbal fluency
is an important cognitive function that facilitates information
retrieval from memory and usually defined as the number of
words produced within a restricted category and limited
duration [25]. Assessments of verbal fluency are based on
two common parameters: semantic and phonemic fluency. In
general, phonemic fluency has been thought to be associated
with frontal-lobe functioning and is assessed by asking the
examinee to generate words beginning with a single given
letter. Semantic fluency has been thought to be associated
with temporal-lobe functioning and is tested by asking the
examinee to generate semantic category exemplar [26,27].
Many internet users reported that they had fewer opportu-
nities to write by hand and had forgotten how to write words
when picking up a pen. Interestingly, an early study showed
that patients with depression produced fewer words on the
semantic fluency test than controls, but performed normally
on the phonemic fluency test [28]. Taking into account that
depression is one of the most commonly coexisting
psychiatric disorders with internet addiction [17], it is
reasonable to hypothesize that internet addicted users may
also have impaired verbal fluency function, either directly
due to internet addiction, or influenced by depression.
Taken together, our study addresses several key issues
regarding internet addition. First, we try to better differen-
tiate normal internet users, mild and severe internet additions
by using both the scores of a traditional diagnosis
115
questionnaire of internet addiction and a major quantitative
parameter, the time spent online per day. Time spent online
per day was proven to be a well-validated indicator for
differentiating normal everyday users from mild and severe
internet addictions [29–31]. Several studies have shown
3–6 h per day was the time cutoff for diagnosing internet
addicted individuals [30,32–35]. Second, we used two
standard scales to quantify the depression and self-esteem
levels and to provide post hoc statistical analyses among
normal internet users, and individuals with mild or severe
internet additions. Third, we applied the classical verbal
fluency tests to determine if three different groups of Internet
users perform differently in verbal fluency and if the internet
addition-associated impairments are semantic or phonemic.
Finally, we focus on college students who usually have
considerable freedom to spend a large amount of time online
and their significant increase of internet use in college is
worrisome [36].
2. Method
2.1. Participants
Based on the report that internet addicted students often
showed poor academic performances [13,14], we selected a
university, whose admission criteria are lower than other
schools located in Wuhan city, as the source population of
participants recruited in our study. After obtaining the
approval from the university, trained research assistants
visited 8 randomly-selected classes and explained the
purpose of the study to the students. 320 students agreed
to participate and filled out a set of self-reported question-
naires, consisting of five components: (1) demographic
information; (2) the scope and daily average hours of internet
use; (3) the Revised Chen Internet Addiction Scale; (4) the
Zung Self-Rating Depression Scale; and (5) the Rosenberg
Self-Esteem Scale.
The participants can report their scope of internet usage
by selecting one or more answers from a multiple-choices
question: (1) downloading or retrieval of information from
the mass media (e.g. news or journals app); (2) retrieval of
information related to academic assignments and education;
(3) online shopping; (4) social network sites; and (5)
entertainment (e.g. watching videos or playing online
game). Average daily hours of internet use were assessed
by selecting one of the three different levels: (1) 0–3 h; (2)
3–6 h; and (3) N6 h.
Internet addiction was further assessed by the Revised
Chen Internet Addiction Scale (CIAS-R), a commonly used
self-rated questionnaire for Chinese's population [37]. The
CIAS-R contains 26-items on a 4-point Likert scale ranging
from 26 to 104. The internal reliability of the CIAS-R scale
and the subscales in the original study ranged from 0.79 to
0.93 [38]. The higher CIAS-R scores indicate more severe
addiction. The diagnostic cut-off point of 63/64 or more and
the screening cut-off value of 57/58 or less in the CIAS-R
116 J. Nie et al. / Comprehensive Psychiatry 72 (2016) 114–120
were used to distinguish those who were pathological users
of the Internet or normal Internet users [39]. Combining with
the daily online hours, our differential criteria for three
different groups of internet users are: (1) non-addictions:
individuals with CIAS-R scores ≤ 57, or those with CIAS-R
score 57–64, but have 0–3 h daily use; (2) Mild Internet
addiction (MIA): individuals with CIAS-R score 57–64 and
3–6 h of daily use or those with CIAS-R N 64, but 0–3 h of
daily use; and (3) severe Internet addiction (SIA):
CIAS-R N 64 and spending more than 3 h daily online.
Four students who did not complete all components of
the self-completed questionnaires were excluded from the
study. The response rate was 98.75% (n = 316). The
percentage of non-addicted, MIA, and SIA students was
53.1% (n = 168), 30.1% (n = 95), and 16.8% (n = 53) in
this survey sample, respectively. There were no significant
differences among the participants regarding age and gender
(mean age, F = 0.26, p = 0.773, df = 2; gender, χ 2 = 0.90,
p = 0.637, df = 2).
A total of 50 students also agreed to participate in the
verbal fluency experiment and their informed consent were
obtained prior to the tests. Those included the sub-MIA
group of 19 students who met the criteria for MIA, and the
sub-SIA group of 15 students who met the criteria for SIA,
and a randomly selected 16 non-addicted students (the
sub-non-addicted group), who were age- and gender-
matched with the two addiction groups (mean age, F =
0.69, p = 0.505, df = 2; gender, χ 2 = 2.65, p = 0.266, df =
2). A short interview with a child psychiatrist and two
trained research assistants was conducted for the three
subgroup participants to ensure that they are free of clinically
diagnosed neurological diseases, the substance dependence,
learning disabilities, conduct disorder, oppositional defiant
disorder, current or past history of psychosis, and have not
been treated with any medications or psychotherapy. All
participants of the subgroups were right-handed native
Chinese speakers.
2.2. Measures
2.2.1. Zung self-rating depression scale (ZSDS)
ZSDS is a commonly used 20-item self-reported tool for
measuring depressive symptoms [40,41]. It includes ten
positive items (e.g., I find it easy to do the things I used to)
and ten negative items (e.g., I am restless and can't keep
still). The ZSDS score on a 4-point Likert-type scale ranges
from 20 to 80 with the higher scores indicating more severe
depressive symptoms.
2.2.2. Rosenberg self-esteem scale (RSES)
RSES was utilized to assess participants' current explicit
self-esteem [42]. The RSES contains 10 items that were
measured on a 4-point scale. A total self-esteem score ranged
from 10 to 40 with higher scores indicating higher
self-esteem. The internal reliability of the scale ranged 0.74
to 0.86 in the previous studies [42,43].
2.2.3. Verbal fluency tests
Verbal fluency (VF) tests are commonly used for
assessments of executive functioning on language, which
are divided in two parts: semantic and phonemic fluency. In
the semantic fluency task, participants were asked to give as
many Chinese words from a given category as possible in
3 min, such as ‘vegetables’, ‘stationeries’ and ‘transportation
vehicles’. They were instructed not to provide the same word
twice, or words from the same family (e.g., ‘bicycle’, ‘bike’,
etc.). In the phonemic fluency task, participants were asked
to generate as many distinct Chinese characters as possible
that began with a specific initial consonant within 1 min.
Three initial consonants – ‘b’, ‘m’ and ‘f’ – were tested for
one minute each; and participants were instructed not to
provide the same character twice.
Short task instructions were provided orally by the
researcher before the experiment. VF tests started with a
3-min phonemic fluency task, followed by 3–5 min of rest
and ended with a semantic fluency task. All answers were
reviewed by a Chinese literature expert and three trained
researcher assistants. The generated Chinese words were
marked as either correct or incorrect responses based on the
Modern Chinese Dictionary. Only the numbers of correct
words were taken as dependent variable in VF tests. Scores
were obtained for each verbal fluency test.
2.2.4. Overall procedure and statistical analysis
At the beginning of this study, self-completed question-
naires were distributed to 320 students at their respective
classrooms; 316 students completed these questionnaires and
were given a simple gift as a reward. A total of 50 students
agreed to also participate in the VF tests and received
monetary compensation upon the completion.
Scores were analyzed using SPSS 17.0 statistical software
package (SPSS Inc., Chicago, IL, USA). Group differences and
subgroup differences were tested using analysis of variance
(ANOVA) test for continuous variables and the Pearson
chi-squared test for categorical variables, respectively. Post-hoc
analysis with Fisher's least significant difference (LSD) was
used to correct for multiple comparisons. For VF tests, a
one-way ANOVA was used to explore between-subgroups
differences in performance on the semantic and phonemic
fluency task, respectively. Pearson's correlations were used to
assess the relationships among CIAS-R, ZSDS, and RSES
scores. We used a two-sided type I error rate 0.05.
3. Results
3.1. Demographic characteristic and questionnaires scores
in the survey sample
The proportions and means of the demographic information
for this survey sample (n = 316) are shown in Table 1. There
were no significant differences in age and gender composition
among MIA, SIA and their non-addicted counterparts. With
respect to the scope of the internet usage, the most often used
 J. Nie et al. / Comprehensive Psychiatry 72 (2016) 114–120 117

Table 1
Participant demographics characteristics of the survey sample (n = 316).
Non-addictions (n = 168) MIA (n = 95) SIA (n = 53) Total (n = 316) χ 2 or F df p
Age, mean years (SD) 20.13 (1.18) 20.03 (1.14) 20.15 (1.08) 20.10 (1.15) 0.26 2 0.773
Gender
Male, n (%) 56 (33.3) 27 (28.4) 15 (28.3) 98 (31.0)
0.90 2 0.637
Female, n (%) 112 (66.7) 68 (71.6) 38 (71.7) 218 (69.0)
Scope of internet activities used
Download, n (%) 130 (77.4) 72 (75.8) 32 (60.4) 234 (74.1) 6.28 2 0.043
Education, n (%) 95 (56.5) 48 (50.5) 16 (30.2) 159 (50.3) 11.20 2 0.004
Shopping, n (%) 79 (47.0) 43 (45.3) 24 (45.3) 146 (46.2) 0.10 2 0.952
Social network site, n (%) 149 (88.7) 84 (88.4) 41 (77.4) 274 (86.7) 4.84 2 0.089
Entertainment, n (%) 141 (83.9) 82 (86.3) 48 (90.6) 271 (85.8) 1.49 2 0.475
Average daily hours of internet use
0–3 h, n (%) 84 (50.0) 9 (9.5) 0 (0.0) 93 (29.4) 74.55 2 b0.001
3–6 h, n (%) 58 (34.5) 38 (40.0) 13 (24.5) 109 (34.5) 3.60 2 0.165
N6 h, n (%) 26 (15.5) 48 (50.5) 40 (75.5) 114 (36.1) 75.19 2 b0.001
MIA, mild Internet addiction; SIA, severe Internet addiction; CIAS-R, the Revised Chen Internet Addiction Scale; ZSDS, the Zung Self-Rating Depression
Scale; RSES, the Rosenberg Self-Esteem Scale.

internet service type was social network sites (86.7%),
followed by entertainment (85.8%), download or retrieval of
information (74.1%), retrieval of information related to
education (50.3%) and online shopping (46.2%).
One-way ANOVA revealed significant differences among
groups in ZSDS (F (2, 313) =29.74, p b 0.001) and RSES
scores (F (2, 313) =26.37, p b 0.001). CIAS-R, ZSDS and
RSES scores were reported in Table 2. Post-hoc analyses
revealed that SIA had the highest ZSDS scores for depression,
followed by MIA (p b 0.001) and non-addictions (p b 0.001);
and MIA had higher ZSDS scores than non-addictions (p =
0.002). Post-hoc tests also showed that non-addiction group
had the highest RSES self-esteem scores, followed by MIA
(p b 0.001) and SIA (p b 0.001); and MIA had lower RSES
scores than non-addictions (p = 0.004). In addition, CIAS-R
scores was significantly correlated with ZSDS scores
(r(316) = 0.473, p b 0.001) and RSES scores (r(316) =
−.373, p b 0.001).
3.2. Scores of VF tests in the subsample
The demographics characteristic and questionnaire scores
for the subsample (n = 50) are shown in Table 3. There were
no differences between subgroups in age, gender, or scope of
internet activities usage. One-way ANOVA revealed signif-
icant differences among subgroups in ZSDS (F (2, 47) =7.23,
p = 0.002) and RSES scores (F (2, 47) =4.57, p = 0.015).
For scores of semantic fluency task (sub-non-addictions,
8.06 ± 0.90; sub-MIA, 7.49 ± 1.58; sub-SIA, 6.27 ± 1.22),
a one-way ANOVA revealed significant differences in
semantic fluency score among subgroups (F (2, 47) =7.86,
p = 0.001, η 2p = 0.251). Post-hoc tests indicated that in the
semantic fluency task, sub-SIA performed significantly
poorer than sub-MIA (p = 0.008) and sub-non-addictions
(p b 0.001); however, there was no significant difference
between sub-non-addictions and sub-MIA (p = 0.196). By
contrast, there were no significant differences in phonemic
fluency scores among three subgroups (sub-non-addictions,
9.06 ± 2.71; sub-MIA, 9.33 ± 2.87; sub-SIA, 8.11 ± 1.78;
F (2, 47) =1.03, p = 0.365). After controlling for depressive
symptoms by including ZSDS score as a covariate, the
significant difference among subgroups in semantic fluency
score remained (F (3, 46) =6.99, p = 0.002, η 2p = 0.233);
however, there were still no significant difference in
phonemic fluency score among sub-groups (F (3, 46) =
1.34, p = 0.271).

Table 2
Questionnaire scores for the three groups in the survey sample (n = 316).
Non-addictions (n = 168) MIA (n = 95) SIA (n = 53) F df p
CIAS-R, mean scores(SD) 48.37 (9.34) 61.46 (2.76) 71.60 (6.97) 224.24 2 b0.001
ZSDS, mean scores(SD) 36.16 (6.16) 38.69 (6.05) 43.60 (6.45) 29.74 2 b0.001
RSES, mean scores(SD) 32.47 (4.61) 30.02 (3.83) 27.89 (3.97) 26.37 2 b0.001
MIA, mild Internet addiction; SIA, severe Internet addiction; CIAS-R, the Revised Chen Internet Addiction Scale; ZSDS, the Zung Self-Rating Depression
Scale; RSES, the Rosenberg Self-Esteem Scale.
118 J. Nie et al. / Comprehensive Psychiatry 72 (2016) 114–120

Table 3
Participant demographics characteristics and questionnaire scores in the subsample (n = 50).
Sub-Non-addictions (n = 16) Sub-MIA (n = 19) Sub-SIA (n = 15) Total (n = 50) χ 2 or F df p
Age, mean years (SD) 20.69 (1.49) 20.74 (1.85) 20.13 (1.36) 20.54 (1.59) 0.69 2 0.505
Gender
Male, n (%) 12 (75.0) 11 (57.9) 7 (46.7) 30 (60.0)
2.65 2 0.266
Female, n (%) 4 (25.0) 8 (42.1) 8 (53.3) 20 (40.0)
Scope of internet activities used
Download, n (%) 14 (87.5) 16 (84.2) 9 (60.0) 39 (78.0) 4.10 2 0.129
Education, n (%) 8 (50.0) 11 (57.9) 5 (33.3) 24 (48.0) 2.06 2 0.356
Shopping, n (%) 8 (50.0) 12 (63.2) 5 (33.3) 25 (50.0) 2.98 2 0.225
Social network site, n (%) 11 (68.8) 15 (78.9) 9 (60.0) 35 (70.0) 1.45 2 0.484
Entertainment, n (%) 13 (81.3) 18 (94.7) 15 (100.0) 46 (92.0) 4.01 2 0.135
Average daily hours of internet use
0–3 h, n (%) 10 (62.5) 3 (15.8) 0 (0.0) 13 (26.0) 17.38 2 b0.001
3–6 h, n (%) 5 (31.3) 1 (5.3) 1 (6.7) 7 (14.0) 5.83 2 0.054
N6 h, n (%) 1 (6.3) 15 (78.9) 14 (93.3) 30 (60.0) 29.05 2 b0.001
Questionnaire scores
CIAS-R, mean (SD) 48.75 (9.51) 62.26 (2.66) 70.40 (6.67) 60.38 (10.92) 41.66 2 b0.001
ZSDS, mean (SD) 35.75 (5.47) 37.16 (5.39) 42.87 (5.74) 38.42 (6.19) 7.23 2 0.002
RSES, mean (SD) 33.63 (7.20) 29.21 (3.88) 28.53 (3.91) 30.42 (5.55) 4.57 2 0.015
MIA, mild Internet addiction; SIA, severe Internet addiction; CIAS-R, the Revised Chen Internet Addiction Scale; ZSDS, the Zung Self-Rating Depression
Scale; RSES, the Rosenberg Self-Esteem Scale.

4. Discussion
The current study showed that 30.1% of college students
had mild Internet addiction. This observed prevalence was
similar to that reported in previous studies in that intermittent
internet addiction was possibly encountered in 30.3%–
30.5% of Korean adolescents [29,44]. In this study, 88.4%
(n = 84) of MIA reported that they have used social network
sites more than other four internet activities; however, 90.6%
(n = 48) of SIA reported more use of entertainment
categories than that of the social network sites (77.4%,
n = 41). This result is inconsistent with a previous study,
which reported that the usage of chatting or social media was
an independent factor related to transition from intermittent
internet addiction to addiction [29]. One of the possible
reasons for the discrepancy is that internet service type in the
previous study only consisted of three subtypes: information
searching, chatting and gaming.
Our psychological analysis indicated that the internet
addicted groups showed higher depression scores and lower
self-esteem scores than the non-addictions. Correlational
analyses also showed that higher depression scores and
lower self-esteem scores were significantly associated with
more severe internet addiction scores, respectively. This is
supported by previous studies that reported higher depres-
sion scores and lower self-esteem scores in severely Internet
addicted individuals than the non-addicted and mildly
addicted individuals [29,45,46]. One possible reason is that
Internet may offer users an opportunity to express them-
selves in a way that they could not in real life and help them
to feel confident in the virtual worlds [39,47]. Internet may
also provide young adults with social support platform which
helps them to escape the emotional difficulties in the real
world [48]. Internet addicted individuals may encounter
more failures and difficulties in school and families than the
normal users, which may subsequently drive them to retreat
more to virtual worlds where they can become successful and
powerful. Indeed, internet addicted users may have virtual
emotional experiences and identities that are different from
those in the real word [49]. The contrast, however, may
exacerbate their failure and difficulties in the real world.
Such negative effect, if it exists, would be reversely
correlated with the amount of interact exposures. Indeed,
this hypothesis is supported by our findings that SIA had the
worst depression scores followed by the MIA groups when
compared with the non-addicted individuals.
Compared to sub-non-addictions, sub-SIA group per-
formed poorly on the semantic fluency task and normally on
the phonemic fluency task. A previous report claimed no
significant differences between the internet addicted group
and normal control group in verbal fluency test [22].
However, that study did not emphasize the difference
distinguishing the normal Internet use, mild and severe
internet addictions. More importantly, they used a simpler
verbal fluency task that does not separate the semantic and
phonemic fluencies. The poor performance of sub-SIA on
the semantic fluency task was similar to that of the
depressive patients in another study [28]. In order to clarify
if the impaired semantic fluency in severely Internet addicted
users was due to the internet addition itself or their comorbid
depressive symptoms, we added the ZSDS score as a
covariate in our subgroup analysis. Our results confirmed
that the poor semantic fluency in the sub-SIA groups was
still statistically significant compared with the non-addicted
group. Our findings did not showed any evidence of verbal
fluency impairments in the sub-MIA group, suggesting that
the semantic fluency task may be a marker related to
transition from mild to severe internet addictions. Future
 J. Nie et al. / Comprehensive Psychiatry 72 (2016) 114–120
studies to confirm this finding will be important because
MIA group may be an important target for prevention of
further development of severe internet addiction.
There are several limitations in the current study. The
cross-sectional research design limited the ability to draw
conclusions regarding the causal relationships between the
severity of internet addiction and those psychological
variables. The generalizability of our findings is also limited,
because the survey sample was recruited from a single
university and the subsample is inconsistent with the original
sample in demographic characteristics. Further studies with
larger sample sizes are needed to confirm our findings.
Another limitation is that we did not assess other major
internet activities (e.g. online gaming). It will be necessary to
include these additional types of internet usages in future
studies in order to better differentiate the different degrees or
types of Internet addictions, and to examine their impact on
depressive symptoms, self-esteem and verbal fluency.
Despite these limitations, there are several important
contributions that our study made to better understand the
Internet addiction and its neuropsychological correlates in
young adults. Our results clearly showed that the psycho-
logical mechanisms of depression, self-esteem and verbal
fluency may not be the same among normal Internet users,
mildly and severely internet addicted users. Our findings
suggest that impaired semantic fluency may be a stable and
useful marker associated with transition from mild internet
addiction to severe internet addiction.
In conclusion, our study showed that internet addictions are
associated with an increased likelihood of comorbid depres-
sion and low self-esteem. Severe addictions were also
associated with impaired semantic verbal fluency. Future
studies should focus on the interventions that prevent the
development of internet addictions, particularly those that
prevent the mildly addicted individuals to become more
severely addicted.
Acknowledgment
We thank PhD Yanli Zhang-James for providing
language help. This study was supported by The National
Natural Science Foundation of China Youth Science Fund
Project (31300865).
References
[1] Young KS. Internet addiction: the emergence of a new clinical
disorder. Cyberpsychol Behav 1998;1:237-44.
[2] Huang C. Internet addiction: stability and change. Psychol Educ
2010;25:345-61.
[3] Meerkerk GJ, van Den Eijnden RJJM, Vermulst AA, Garretsen HFL.
The compulsive internet use scale (CIUS): some psychometric
properties. Cyberpsychol Behav 2009;12:1-6.
[4] Caplan SE. Problematic internet use and psychosocial well-being:
development of a theory-based cognitive–behavioral measurement
instrument. Comput Hum Behav 2002;18:553-75.
[5] Davis RA. A cognitive–behavioral model of pathological internet use.
Comput Hum Behav 2001;17:187-95.
119
[6] Chen K, Tarn JM, Han BT. Internet dependency: its impact on online
behavioral patterns in E-commerce. Hum Syst Manag 2004;23:49-58.
[7] Stanton JM. Company profile of the frequent internet user. Commun
ACM 2002;45:55-9.
[8] Young KS. Internet addiction a new clinical phenomenon and its
consequences. Am Behav Sci 2004;48:402-15.
[9] Lee HW, Choi J-S, Shin Y-C, Lee J-Y, Jung HY, Kwon JS. Impulsivity
in internet addiction: a comparison with pathological gambling.
Cyberpsychol Behav Soc Netw 2012;15:373-7.
[10] Ko CH, Yen J-Y, Yen CF, Chen CS, Weng CC, Chen CC. The
association between internet addiction and problematic alcohol use in
adolescents: the problem behavior model. Cyberpsychol Behav
2008;11:571-6.
[11] Grant JE, Chamberlain SR. Impulsive action and impulsive choice
across substance and behavioral addictions: cause or consequence?
Addict Behav 2014;39:1632-9.
[12] 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.
[13] Dhir A, Chen S, Nieminen M. Predicting adolescent internet addiction:
the roles of demographics, technology accessibility, unwillingness to
communicate and sought internet gratifications. Comput Hum Behav
2015;51:24-33.
[14] Stavropoulos V, Alexandraki K, Motti-Stefanidi F. Recognizing
internet addiction: prevalence and relationship to academic achieve-
ment in adolescents enrolled in urban and rural Greek high schools. J
Adolesc 2013;36:565-76.
[15] Orsal O, Orsal O, Unsal A, Ozalp SS. Evaluation of internet addiction
and depression among university students. Proc Soc Behav Sci
2013;82:445-54.
[16] Sariyska R, Reuter M, Bey K, Sha P, M L, Y-F C, et al. Self-esteem,
personality and internet addiction: a cross-cultural comparison study.
Personal Individ Differ 2014:61-2 [28–33].
[17] Ho RC, Zhang MWB, Tsang TY, Toh AH, Pan F, Lu YX, et al. The
association between internet addiction and psychiatric co-morbidity: a
meta-analysis. BMC Psychiatry 2014;14:1-10.
[18] Fennell MJ. Low self-esteem: a cognitive perspective. Behav Cogn
Psychother 1997;25:1-26.
[19] Chiang IP, Su YH. Measuring and analyzing the causes of problematic
internet use. Cyberpsychol Behav Soc Netw 2012;15:591-6.
[20] Morahan-Martin J, Schumacher P. Loneliness and social uses of the
internet. Comput Hum Behav 2003;19:659-71.
[21] Huang Z, Wang M, Qian M, Zhong J, Tao R. Chinese internet
addiction inventory: developing a measure of problematic internet use
for Chinese college students. Cyberpsychol Behav 2007;10:805-12.
[22] Choi J-S, Park SM, Roh M-S, Lee J-Y, Park C-B, Hwang JY, et al.
Dysfunctional inhibitory control and impulsivity in internet addiction.
Psychiatry Res 2014;215:424-8.
[23] Yao Y-W, Wang L-J, Yip SW, Chen P-R, Li S, Xu J, et al. Impaired
decision-making under risk is associated with gaming-specific
inhibition deficits among college students with internet gaming
disorder. Psychiatry Res 2015;229:302-9.
[24] Nie J, Zhang W, Chen J, Li W. Impaired inhibition and working
memory in response to internet-related words among adolescents with
internet addiction: a comparison with attention-deficit/hyperactivity
disorder. Psychiatry Res 2016;236:28-34.
[25] Patterson J. Verbal fluency. Encyclopedia of clinical neuropsychology.
Springer; 2011. p. 2603-6.
[26] Shin YS, Shin NY, Jang JH, Shim G, Park HY, Shin M-S, et al.
Switching strategy underlies phonemic verbal fluency impairment in
obsessive–compulsive disorder. J Obsessive Compuls Relat Disord
2012;1:221-7.
[27] Troyer AK, Moscovitch M, Winocur G, Alexander MP, Stuss D.
Clustering and switching on verbal fluency: the effects of focal frontal-
and temporal-lobe lesions. Neuropsychologia 1998;36:499-504.
[28] Fossati P, Ergis A-M, Allilaire J-F. Qualitative analysis of verbal
fluency in depression. Psychiatry Res 2003;117:17-24.
120 J. Nie et al. / Comprehensive Psychiatry 72 (2016) 114–120
[29] Jang KS, Hwang SY, Choi JY. Internet addiction and psychiatric
symptoms among Korean adolescents. J Sch Health 2008;78:165-71.
[30] Tonioni F, D'Alessandris L, Lai C, Martinelli D, Corvino S, Vasale M,
et al. Internet addiction: hours spent online, behaviors and psycholog-
ical symptoms. Gen Hosp Psychiatry 2012;34:80-7.
[31] Bernardi S, Pallanti S. Internet addiction: a descriptive clinical study
focusing on comorbidities and dissociative symptoms. Compr
Psychiatry 2009;50:510-6.
[32] Cao H, Sun Y, Wan Y, Hao J, Tao F. Problematic internet use in
Chinese adolescents and its relation to psychosomatic symptoms and
life satisfaction. BMC Public Health 2011;11:802.
[33] Van Deursen AJAM, van Dijk JAGM, Peters O. Rethinking internet
skills: the contribution of gender, age, education, internet experience,
and hours online to medium-and content-related internet skills. Poetics
2011;39:125-44.
[34] Yang SC, Tung C-J. Comparison of internet addicts and non-addicts in
Taiwanese high school. Comput Hum Behav 2007;23:79-96.
[35] Hou S-I. Time spent online and online health-seeking related
behaviors. 142nd APHA annual meeting and exposition (November
15–November 19, 2014). APHA; 2014.
[36] Verhoeven JC, Heerwegh D, De Wit K. Information and communi-
cation technologies in the life of university freshmen: an analysis of
change. Comput Educ 2010;55:53-66.
[37] Mak K-K, Lai C-M, Ko C-H, Chou C, Kim D-I, Watanabe H, et al.
Psychometric properties of the revised Chen internet addiction scale (CIAS-R)
in Chinese adolescents. J Abnorm Child Psychol 2014;42:1237-45.
[38] Chen SHWL, Weng L, Su Y, Wu H, Yang P. Development of a
Chinese internet addiction scale and its psychometric study. Psychol
2003;45:279-94.
View publication stats
[39] Ko CH, Yen JY, Chen CC, Chen SH, Yen CF. Gender differences in
addiction to playing online games and related factors among
Taiwanese adolescents. J Nerv Ment Dis 2005;193:273-7.
[40] Zung WW. A self-rating depression scale. Arch Gen Psychiatry
1965;12:63-70.
[41] Biggs JT, Wylie LT, Ziegler VE. Validity of the Zung self-rating
depression scale. Psychiatry 1978;132:381-5.
[42] Rosenberg M. Society and the adolescent self-image. Princeton: NJ:
Princeton University Press; 1965.
[43] Li Z, Wu M. The relationship between college students' self-esteem
and social anxiety: the mediating effect of intolerance of uncertainty.
Spec Educ 2013;155:72-6.
[44] Yang CK. Sociopsychiatric characteristics of adolescents who use
computers to excess. Acta Psychiatr Scand 2001;104:217-22.
[45] Kormas G, Critselis E, Janikian M, Kafetzis D, Tsitsika A. Risk factors
and psychosocial characteristics of potential problematic and prob-
lematic internet use among adolescents: a cross-sectional study. BMC
Public Health 2011;11.
[46] Dowling NA, Quirk KL. Screening for internet dependence: do the
proposed diagnostic criteria differentiate normal from dependent
internet use? Cyberpsychol Behav 2009;12:21-7.
[47] Armstrong L, Phillips JG, Saling LL. Potential determinants of heavier
internet usage. Hum Comput Stud 2000;53:537-50.
[48] Tichon JG, Shapiro M. The process of sharing social support in
cyberspace. Cyberpsychol Behav 2003;6:161-70.
[49] Yen C-F, Chou W-J, Liu T-L, Yang P, Hu H-F. The association of
internet addiction symptoms with anxiety, depression and self-esteem
among adolescents with attention-deficit/hyperactivity disorder.
Compr Psychiatry 2014;55:1601-8.