Accepted Manuscript

The Relationship Between Internet Addiction, Social Anxiety,

Impulsivity, Self-esteem, and Depression in a Sample of Turkish
Undergraduate Medical Students

Bengü Yücens , Ahmet Üzer

PII: S0165-1781(18)30612-7
DOI: 10.1016/j.psychres.2018.06.033
Reference: PSY 11508

To appear in: Psychiatry Research

Received date: 4 April 2018

Revised date: 12 June 2018
Accepted date: 12 June 2018

Please cite this article as: Bengü Yücens , Ahmet Üzer , The Relationship Between Internet Addiction,
Social Anxiety, Impulsivity, Self-esteem, and Depression in a Sample of Turkish Undergraduate Medical
Students, Psychiatry Research (2018), doi: 10.1016/j.psychres.2018.06.033

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 ACCEPTED MANUSCRIPT

Highlights

 Addictive internet use may be a way to diminish negative emotions.

 Internet addiction is related to social anxiety and depression.
 Social phobic avoidance predicts internet addiction.
 Impulsivity is not related to internet addiction.

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The Relationship Between Internet Addiction, Social Anxiety, Impulsivity, Self-esteem,

and Depression in a Sample of Turkish Undergraduate Medical Students

Bengü Yücens*, Ahmet Üzer

Department of Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar,

Turkey

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*Corresponding author:

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Bengü Yücens,

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Afyon Kocatepe University, Faculty of Medicine, Department of Psychiatry, Afyonkarahisar,
Turkey

Mobile phone: +90 505 2633138

E-mail address: dr.bengubaz@yahoo.com US

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Abstract
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Internet addiction (IA) is currently becoming a serious mental health problem. The aim of this
study was to estimate the prevalence of IA among undergraduate medical students and
evaluate the relationship of IA with social anxiety, impulsivity, self-esteem, and depression.
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The study included 392 undergraduate medical students. Evaluations were made with the
sociodemographic data form, the Internet Addiction Test (IAT), the Liebowitz Social Anxiety
Scale (LSAS), the Barratt Impulsivity Scale-11 (BIS-11), the Rosenberg Self-Esteem Scale
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(RSES), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). The
IA group had significantly higher scores on LSAS, BDI, BAI and lower scores on RSES than
the control group but the BIS-11 scores were similar among groups. IAT severity was
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positively correlated with LSAS, BDI, and BAI and negatively with RSES. No correlation
was observed between IAT severity and BIS-11. In the hierarchical linear regression analysis,
the avoidance domain of social anxiety was the strongest predictor of the severity of IA. The
present study suggests that undergraduate medical students with IA exhibit higher social
anxiety, lower self-esteem and are more depressed than those without IA, thus, indicating that
social anxiety, rather than impulsivity, seemed to play a prominent role in IA
psychopathology.

Keywords: internet, addictive behavior, social anxiety disorder, impulsivity, depression

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1. Introduction

1.1.Internet addiction
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Internet addiction, which is associated with an individual's loss of control over their internet
use, is considered to be a serious mental health problem. There has been an enormous use of
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the internet. The use of technology by health professionals for education and clinical care is a
topic of evolving interest, with the internet being used for social media, email and online
medical records (Torous et al., 2014). Egle et al. (2015) demonstrated that 58% of medical
students preferred electronic resources and utilized a variety of websites for medical
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information. Gedam et al. (2016) found that the overall prevalence of internet addiction
among medical students was 18.5%, with moderate and severe addiction at 17.3% and 1.2%
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respectively. In a study of undergraduate medical students in Turkey, 0.8% were determined

as addicted internet users and 5.2% of high-risk internet users (Ergin et al., 2013).

The underlying mechanisms of the phenomenon have not been clearly defined and there is no
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diagnostic classification in the Diagnostic and Statistical Manual of Mental Disorders IV-TR
(DSM-IV-TR) (American Psychiatric Association, 2000). Griffiths (2000) has described
internet addiction (IA) as a kind of technology addiction and a behavioral addiction similar to
a gambling habit and diverse addiction to the internet and addictions on the internet. In
addition, Shapira et al. (2000) suggested that problematic internet use could be conceptualized
as an impulse control disorder (ICD). Koronczai and colleagues (2011) put forward six
requirements for the instrument that assessing problematic online use (including internet
gaming): brevity (to make surveys as short as possible and help overcome question fatigue);
comprehensiveness (to examine all core aspects of internet gaming disorder (IGD) as
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possible); reliability and validity across age groups (e.g., adolescents vs adults); reliability and
validity across data collection methods (e.g., online, face-to-face interviews, and paper-and-
pencil); cross-cultural reliability and validity; and clinical validation. Subsequently, the
problem of internet overuse was included as „IGD‟ in DSM-5 section 3, which highlights the
need for more research to diagnose the formal disorders. According to the DSM-5 addiction
criteria, there is no difference between „chemical‟ and „behavioral‟ addiction and DSM-5
focuses on personal experiences rather than drug types (American Psychiatric Association,
2013).

1.2. Internet addiction and social anxiety

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Social anxiety and depression have been repeatedly reported to be associated with IA in

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adolescents (Wei et al., 2004; Yen et al., 2007a). In a prospective study of Taiwanese
adolescents, the incidence of social phobia and depression were found to predict the

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occurrence of IA (Ko et al., 2009). Online communication may be a safety behavior that
allows socially anxious subjects to communicate with others as they report experiencing
greater ease interacting on the internet compared to face-to-face (Erwin et al., 2004; Shepherd

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and Edelmann, 2005). The self-medication hypothesis is a general model of addiction that
posits that people use substances as a strategy to cope with disordered emotions, self-care,
self-esteem, and personal relationships triggering painful and threatening emotions. Main
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propositions of this hypothesis is that a person‟s choice of substances is intimately tied to the
particular distressing emotional state that they are trying to manage (Khantzian, 2013).
According to the self-medication hypothesis of addiction, IA emerges as a result of the
individual attempting to „self-treat‟ their stress, anxiety, and depression (Khantzian, 1997). In
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IA, individuals discover internet that relieves anxious states that they can not tolerate. In a
study by Lai et al. (2015), the suggestion that depression and social anxiety act as antecedents
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of IA supports this hypothesis.

1.3. Internet addiction and impulsivity

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Impulsivity is characterized by the tendency to act prematurely, without foresight, despite

adverse consequences (Robbins et al., 2012). Impulsive people are less able to control their
internet use, so impulsivity may be a risk factor for the occurrence of IA (Meerkerk et al.,
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2010). Theorists have argued that IA is more similar to an ICD such as gambling and eating
disorders rather than substance use disorders so IA can be considered a complex phenomenon
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that involves many different types of behaviour (Armstrong et al., 2000). Lee et al. (2012)
found that the severity of IA was positively correlated with the level of trait impulsivity in
patients with IA and stated that IA can be conceptualized as an ICD and that trait impulsivity
is a marker for vulnerability to IA.

1.4. Internet addiction and self-esteem

Self-esteem is described as a person‟s attitude to himself and reflects how an individual

evaluates her/his self concept (Aydın and Sar, 2011). Previous studies have revealed a
relationship between addiction and self-esteem (Greenberg et al., 1999). In those studies, it is
stated that different levels of self- esteem lead to self-distrust, addicted personality, sense of
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loss of control and a sense of failure. Similarly, Meerkerk et al. (2010) found that compulsive
internet users were lonelier, less satisfied with life, experienced more depressive moods and
had lower self-esteem. Therefore, it is thought that the self-esteem level of an individual may
be a significant determinant of IA.

1.5. Internet addiction, depression and anxiety

In studies analyzing psychiatric comorbidity in IA, it has been found that psychopathologies
such as adult attention deficit hyperactivity disorder, depression, schizophrenia and obsessive-
compulsive disorder accompany IA (Ko et al., 2008). Depression is the most common
comorbid disorder with internet addiction (Yen et al., 2007a). In studies on IA, addiction

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scores have shown a positive correlation with depression and anxiety scores (Müller et al.,

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2014) and individuals with IA had higher depression and anxiety scores (Lee and Stapinski,
2012; Tonioni et al., 2012). In a study by Ko et al. (2014), resistant depressive symptoms

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were seen to accompany IA, and following treatment of IA, depression, social anxiety and
aggressive behaviors diminished in internet addicts. In fact, psychiatric symptoms may lead to
the onset or persistence of IA or IA may precipitate psychiatric symptoms.

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The aim of this study was to estimate the prevalence of IA in a sample of Turkish
undergraduate medical students and to investigate the relationship of IA with social anxiety,
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impulsivity, self-esteem and depression. Undergraduate medical students appear to be a group
of particular concern because of the amount of time they spend on the internet for academic
purposes and on account of easy access. The results of this study may contribute to the
conceptualisation of internet addiction, which represents a behavioral addiction.
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2. Methods
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2.1. Participants

The study was conducted in Afyon Kocatepe University with 627 students of the Faculty of
Medicine in 2017-2018 that were able to approach and agreed to participate in the study. Of
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the total participants, the data of 53 students were excluded from the study as they were
incorrect or incomplete and 182 students withdrew from the study because they could not be
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contacted to complete the scales. Thus, a total of 392 students were included for evaluation in
the study. The necessary permissions to conduct the study were received from the Afyon
Kocatepe University School of Medicine Ethics Committee prior to the initiation of the
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research. Participation in the study was on a voluntary basis, and consent for participation was
obtained from each student assessed. There was no reward for participation. The inclusion
criteria were use of the internet on a regular basis and the exclusion criterion was refusal to
participate in the study.

2.2. Procedure

The study completed in person and the students were assessed in groups in the classrooms.
The students were initially given the required information and they were evaluated with
respectively, a sociodemographic data form, the Internet Addiction Test (IAT), the Liebowitz
Social Anxiety Scale (LSAS), the Barratt Impulsivity Scale-11 (BIS-11), the Rosenberg Self-
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Esteem Scale (RSES), the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory
(BAI). The participants spent 30 minutes in the session of assessment and there was one break
to the students have a rest.

2.3.Measures

2.3.1. Sociodemographic form

The form was developed by the researchers to collect the sociodemographic data from the
participants as age, sex, birthplace, living place, people living together, monthly income of the
family, online time in relation to the aim of the study.

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2.3.2. Internet Addiction Test (IAT)

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This is a 20-item, 5-point Likert scale, developed by Dr. Kimberly Young. It is a self-report

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questionnaire, including psychological dependence, compulsive use, and withdrawal, as well
as the related problems of school or work, sleep, family, and time management (Young,
2009). The scale was translated into Turkish by Bayraktar (2001) and in the present study the

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internal consistency (Cronbach‟s alpha coefficient) for the IAT was 0.90. The students were
divided into three levels based on their scores, i.e., <50 as normal, 51–69 as moderate and
>70 as high severe addicts. In the literature, it is generally assumed that the cut-off score 50 in
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Young‟s IAT, in order to provide information compatible with the literature (Bhagyalakshmi,
2013; Gedam et al., 2016), and between 50-70 scores are admitted as the mild IA, 50 is
accepted as a cut-off score. In the present study, the participants were separated into two
groups according to the IAT scores, as the IA group (moderate/high severe IA group with a
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cutoff score of 50) and the non-IA group (score <50) as the control group.

2.3.3. Liebowitz Social Anxiety Scale (LSAS)

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The self-report version of the LSAS is a scale that measures fear/anxiety and avoidance of
social situations (Rytwinski et al., 2009). It consists of 11 items relating to social interaction
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and 13 items related to public performance. Participants were given 24 statements describing
various social situations (e.g., “meeting strangers”) and asked to rate their level of fear on a 4-
point scale from 0 (none) to 3 (severe), and avoidance in the last week from 0 (never avoided
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this activity) to 3 (usually avoided this activity). In the present study the Cronbach‟s alpha
coefficient for the LSAS total score was 0.92.
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2.3.4. Barratt Impulsivity Scale-11 (BIS-11)

The BIS-11 is a 30-item, self-report questionnaire on which participants rate their frequency
of several common impulsive or non-impulsive behaviors/traits on a scale from 1
(rarely/never) to 4 (almost always/always). It has been reported that three factors are
determined: attentional impulsiveness, motor impulsiveness and non-planning impulsiveness.
(Patton et al., 1995). Higher scores of the scale indicate greater impulsivity. In the present
study, the Turkish version of BIS-11 (Güleç et al., 2008) was used to examine impulsivity and
the Cronbach‟s alpha coefficient for the BIS-11 was 0.80.
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2.3.5. Rosenberg Self-Esteem Scale (RSES)

This is a 63-item self-report, 4-point Likert scale to measure global feelings of self-worth or
self-acceptance. Higher scores on the scale items indicate higher levels of self-esteem
(Rosenberg, 1965). The scale consists of 12 sub-categories. The aim of the current study was
considered, and the first 10 questions of the original scale that measure self-esteem were used.
The correlation between the scale and psychiatric interview results was found to be 0.71 in the
Turkish validity and reliability study (Çuhadaroğlu, 1986) and the Cronbach‟s alpha
coefficient for the RSES was 0.84 in the present study.

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2.3.6. Beck Depression Inventory (BDI)

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This is a 21-item self-report scale measuring the emotional, cognitive, somatic, and
motivational symptoms of depression (Beck et al., 1961). Each item is scored on a scale from

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1 to 3, and total scores are calculated by summing the scores on all items. In the Turkish
version of this test (Hisli, 1989), a score of 17 is considered the cut-off point for validity and
reliability. In the present study the Cronbach‟s alpha coefficient for the BDI was 0.88.

2.3.7. Beck Anxiety Inventory (BAI) US

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This is a 21-item self-report inventory that measures the severity of anxiety in psychiatric
populations (Beck et al., 1988). Each item is rated on a 4-point scale ranging from 0 (not at
all) to 3 (severely - I could barely stand it). In the present study the Cronbach‟s alpha
coefficient for the BAI was 0.91.
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2.4. Statistical analysis

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IBM SPSS 22 was used for all statistical analyses. Group differences in sociodemographic
variables were computed through the Chi-square test. Normal distribution of the data was
evaluated with the Kolmogorov–Smirnov distribution test. The Independent samples test was
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used to compare the quantitative variables that were normally distributed. In all tables, the
numerical variables are presented as mean ± standard deviation (SD) and the categorical
variables are presented as numbers of observations and percentages (%). Correlations between
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IAT and LSAS, BIS-11, RSES, BDI, BAI scores were assessed using Pearson correlations
analysis. Significance levels were set at p < 0.05 and p < 0.001. Hierarchical linear regression
analysis was used to determine the predictors of IAT severity.
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3. Results

In the present study, 27% (n=106) of the participants were categorized in the IA group and
73% (n=286) were categorized in the non-IA group. 3.3% (n=13) of the IA group were high
and 23.7% (n=93) were moderate-severe internet addicted. In the sociodemographic features,
only the mean age and monthly income of the family were significantly different between
groups. There was no statistically significant difference in the sex distributions, usage of
nicotine/alcohol, the resource of homework used and internet time use/week between groups.
The sociodemographic and clinical characteristics of the study sample are shown in Table 1.
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The results showed that the IA group obtained higher scores than the non-IA group for LSAS-
total, LSAS-anxiety, LSAS-avoidance, BDI, and BAI mean scores, whereas the non-IA group
had higher scores than the IA group for RSES mean scores, but there was no significant
difference between groups in respect of the BIS-11 mean scores (Table 2). The severity of IA
was positively correlated with LSAS-total (r= 0.47, p< 0.001), LSAS-anxiety (r= 0.14, p <
0.01), LSAS-avoidance (r= 0.66, p < 0.001), BDI (r= 0.37, p < 0.001), and BAI (r= 0.29, p <
0.001); whereas it was negatively correlated with RSES (r = -0.31, p < 0.001). Other than
these, BIS-11 showed no significant correlation (not shown).

In the linear regression model when the IAT score was taken as a dependent variable and age,

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sex, BIS-11, LSAS-total, BDI, BAI, and RSES were taken as independent variables, only
LSAS-total (B=0,248, SE=0,032, β=0.383, t=7,775, p<0.001), BDI (B=,281, SE=,067, β=.207,

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t=4,208, p<0.001) and RSES (B=-,460, SE=,138, β=-.153, t=-3,342, p=001) were determined
as predictors (F=24,810, p=0.000, Adjusted R2=0.299) (not shown). Two hierarchical linear

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regression models with the stepwise method were used to determine the predictors of the IAT
score. In the first model, the LSAS-total score was entered as an independent variable and in
the second model, the LSAS anxiety and avoidance domains were entered as independent

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variables. The results revealed that in the first model, the LSAS-total score, BDI, and RSES
predicted the IAT (Adjusted R2=0.291). In the second model, step 1 (LSAS-avoidance)
explained 43.6% of IAT scores (Adjusted R2=0.436), step 2 (LSAS-avoidance and BDI)
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explained 45.7% of IAT scores (Adjusted R2=0.457), and step 3 (LSAS-avoidance, BDI, and
RSES) explained 46.4% of IAT scores (Adjusted R2=0.464) (Table 3). Thus, the association
of social anxiety with IA seems to be more prominent than the association between IA and
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depression or self-esteem. The avoidance domain of social anxiety, in particular, had a salient
predictor effect on IA as it explained 43% of the total variance in IA scores alone.
Nevertheless, although the severity of IA was related with the avoidance domain of social
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anxiety in the present study, because of the cross-sectional design, it was not possible to make
conclusive statements about the temporal order between the measures of psychiatric
symptoms and IA.
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4. Discussion
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The overall prevalence of internet addiction among medical students was found to be 27%,
with moderate and high severe addiction at 23.7% and 3.3% respectively. Of the
sociodemographic features, only the mean age and monthly income of the family revealed a
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statistically significant difference between groups. Although there was a minimal difference
between the mean ages of groups this difference was statistically significant as the age of the
participants was in a narrow range. The mean age of the non-IA group was found to be higher
than that of IA group. The reason for this is thought to be the decrease in the social avoidance
behaviors of senior students with older age because of they have become familiar with each
other for years and the fact that the concentration of preparatory studies on specialization
exam. Also, this result gives rise to the thought that the students with high monthly income of
the family can get the money for a variety of activities to enjoy, but for those with low
monthly income of the family merely internet is cheap and easy to access. Another interesting
finding was that the online time per week was similar between the groups. Online time is not
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a criterion for IA, but further work could be done in future studies to examine when and
where people with IA are using the internet such as during times when they could be sleeping
or engaging with others, or listening in class, etc. Additionally, Caplan et al. (2009) found that
while only 2% of the variance in problematic internet use was explained by online activities,
36% of the variance was accounted for by the individual‟s psychological profile. So it can be
concluded that online time may not be significantly related to problematic internet use such as
online activity.

A clinically significant finding of the present study was that the subjects who were more
socially avoidant scored higher on the IAT, and while social anxiety related avoidance

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predicted 43% of the variance, when combined with depression, this rate was 45%. Social
anxiety has been previously reported to be positively associated with internet use in

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adolescents (Shepherd and Edelmann, 2005), although few studies have examined the factors
that may account for this relationship. Socially anxious individuals show differences in the

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expectation of negative evaluation from an online compared to the offline audience and the
need to reduce their anxiety motivates them to minimize their chances of making undesired
impressions on others (Caplan, 2007). Online communication may provide a means of

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avoiding threatening face-to-face interactions and be one of many safety behaviors employed
to neutralize or avoid threatening social interactions (Lee and Stapinski, 2012), as was
determined in the present study. While online communication appears to reduce or regulate
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social anxiety in the short term (Campbell et al., 2006), confidence to communicate with
others beyond the online context may be undermined if successful online interactions are
attributed to the unique aspects of the internet rather than personal attributes in the longer
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term (McKenna et al., 2002).

The present study showed that the severity of IA among undergraduate medical students was
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not correlated with impulsivity. This result is consistent with the findings of Armstrong et al.
(2000), who found that impulsivity was not a good predictor of IA and showed no relationship
to IA. In contrast, Dalbudak et al. (2013) found that the severity of IA was related to
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impulsivity and impulsiveness was the significant predictor of Internet Addiction Scale (IAS)
score. Similar research in other countries has also indicated this relationship (Cao et al., 2007;
Mazhari, 2012) but it has not determined whether impulsivity is a risk factor for IA or a result
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of IA. Related to these conflicting findings, it is possible that the study sample in the present
study may include conservative students (e. g. low rate of drug abuse/addiction), therefore, no
relationship with impulsivity was found. When the students of the Faculty of Medicine are
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considered in terms of career choices, they can be predicted to be more responsive and less
impulsive. In addition, the prevalence of severe IA in this study was lower than has been
reported in other studies (Dalbudak et al., 2013) with sampling from the general population of
university students. As a result, the IA may be thought as a behavioral expression of other
psychopathological diseases that varies according to the characteristics of the population.

Additionally, self-esteem has emerged as a factor associated with problematic internet use
(Kim and Davis, 2009). The internet is a suitable environment for people with low self-
esteem, low motivation, fear of rejection, and need for approval. Internet use is highly
associated with its perception as a coping style and way of a compensation of some
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deficiencies such as low self-esteem (Griffiths, 2000). In the current study, the addicted group
has significantly lower self-esteem than the non-addicted group and self-esteem was
correlated with IA but the variance explained by the self-esteem measures was mild. Aydın
and Sar (2011) found that self-esteem was a significant predictor of IA among adolescents
and suggested that when individuals evaluate themselves in a negative way, they may
perceive the internet as a way to compensate for these negations and increasing internet use
may turn into a dependent relationship. Armstrong et al. (2000) found that self-esteem was a
good predictor of IA although Niemz et al. (2005) reported that self-esteem did not predict
pathological internet use. Alternatively, it could be argued that IA leads people to become
socially avoidant and they are no longer able to socialize in a normal way.

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Lai et al. (2015) found significant associations of IA with social anxiety and depression then

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suggested that internet use as a coping strategy may leave adolescents even worse off if the
underlying social anxiety and depression is left untreated at the developmental period of

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identity formation and this increases the risk of excessive and addictive use of the internet.
Previous studies have stated that increased levels of depression are associated with the risks of
becoming addicted to the internet (Ha et al., 2006; Yen et al., 2007b). However, Dong et al.

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(2011) suggested that depression was an outcome of IA and not a precursor. There are two
possibilities to explain this result; first, that internet use leads to depression resulting in a
negative effect on psychological well-being, and second, that individuals with depression may
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adjust their emotional condition through internet use, which is less harmful and more
available than illegal substances. Davis described distal and proximal factors associated with
internet use. According to Davis (2001), distal factors associated with internet use refer to the
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underlying psychopathology as depression, social anxiety and other dependencies and

proximal factors refer to the maladaptive cognitions as a negative evaluation of self and the
world. From a different point of view, the maladaptive distorted cognitions in IA, social
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anxiety and depression might be related to some other underlying constructs, such as
personality traits and transdiagnostic constructs of cognitive distortions (Kuru et al., 2018).
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Whether the relationship is cause or consequence is not clear and social anxiety and
depression should be taken into account in the assessment of IA and these characteristics must
not be disregarded in the treatment process. It has been concluded that cognitive behavioral
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therapy (CBT) is effective in the treatment of IA, with improvements seen in time
management skills and positive effects on emotional, cognitive and behavioral symptoms
(Young, 2007).
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The current study has some limitations. The use of self-rating measurement to detect internet
addiction can be considered a limitation of the study. The study was cross-sectional so a
causal relationship could not be established. The students spent a lot of time studying online
and it would be considered as normal internet use and not as internet addiction. Therefore, due
to the specificity of the sample studied, online time per week for studying purposes only
should be asked in the sociodemographic data form and this was another limitation of the
study. As the current study only included undergraduate medical students, the results cannot
be generalized to university students. Also, the total number of medical schools is 84 and
there are approximately 75,000 undergraduate medical students in Turkey so that this study
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sample can represent so much of the general medical students. However, it is not
unreasonable to speculate that similar cognitive processes are at work in the broader
population of heavy internet users. Future studies should seek to confirm the findings with a
more diverse sample. These findings will help to identify the factors related to IA. A causal
relationship between psychopathology and IA needs to be further analyzed in order to
determine whether internet use causes psychiatric problems or exacerbates existing
symptoms. There is a need for similar studies to be conducted with larger samples from
different colleges so that the results can be generalized.

5. Conclusion

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The current study demonstrated a strong correlation between IA and social phobic avoidance

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suggesting that social anxiety has a role in IA. Internet addiction may be linked to underlying
psychiatric problems that may contribute to the development of the disorder, or worsen the

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symptoms. Nevertheless, unlike other addictions and specific impulse control disorders, no
relationship was found between impulsivity and IA. Rather, the association with social
anxiety and IA suggested that internet addicts are using the internet as a way of escaping their

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negative emotions and finding an alternate virtual world in which they are not threatened or
challenged. Follow-up prospective studies to monitor both the social phobic anxiety and
avoidance behaviors and IA are recommended, to be able to gain more insight to the
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progression of this particular addiction.
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References
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American Psychiatric Association, 2000. American Psychiatric Association: Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Am. Psychiatr. Assoc.
doi:10.1176/appi.books.9780890423349
PT

American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental

Disorders, 5th Edition (DSM-5). Diagnostic Stat. Man. Ment. Disord. 4th Ed. TR. 280.
CE

doi:10.1176/appi.books.9780890425596.744053

Armstrong, L., Phillips, J.G., Saling, L.L., 2000. Potential determinants of heavier Internet
AC

usage. Int. J. Hum. Comput. Stud. 53, 537–550. doi:10.1006/ijhc.2000.0400

Aydın, B., Sar, S.V., 2011. Internet addiction among adolescents: The role of self-esteem.
Procedia Soc and Behav Sci. 15, 3500–3505. doi:10.1016/j.sbspro.2011.04.325

Bayraktar, F., 2001. The role of Internet usage in the development of adolescents. Master‟s
thesis. Ege University Social Sciences Institute Psychology Department, İzmir.

Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An Inventory for
measuring depression. Arch. Gen. Psychiatry 4, 561–571.
doi:10.1001/archpsyc.1961.01710120031004
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Beck, A.T., Epstein, N., Brown, G., Steer, R.A., 1988. An inventory for measuring clinical
anxiety: Psychometric properties. J. Consult. Clin. Psychol. 56, 893–897. doi:10.1037/0022-
006X.56.6.893

Bhagyalakshmi, V., 2013. Correlation between affect and Internet addiction in undergraduate
medical students in Mangalore. J. Addict. Res. Ther. 05. doi:10.4172/2155-6105.1000175

Campbell, A.J., Cumming, S.R., Hughes, I., 2006. Internet use by the socially fearful:
addiction or therapy? CyberPsychology Behav. 9, 69–81. doi:10.1089/cpb.2006.9.69

Cao, F., Su, L., Liu, T.Q., Gao, X., 2007. The relationship between impulsivity and Internet

T
addiction in a sample of Chinese adolescents. Eur. Psychiatry 22, 466–471.

IP
doi:10.1016/j.eurpsy.2007.05.004

Caplan, S.E., 2007. Relations among loneliness, social anxiety, and problematic Internet use.

CR
CyberPsychology Behav. 10, 234–242. doi:10.1089/cpb.2006.9963

Caplan, S., Williams, D., Yee, N., 2009. Problematic Internet use and psychosocial well-being
among MMO players.
doi:10.1016/j.chb.2009.06.006
Comput.
US Human Behav. 25, 1312–1319.

Çuhadaroğlu F., 1986. Adolesanlarda benlik saygısı. Uzmanlık Tezi, Hacettepe Üniversitesi
AN
Tıp Fakültesi, Ankara.

Dalbudak, E., Evren, C., Topcu, M., Aldemir, S., Coskun, K.S., Bozkurt, M., Evren, B.,
M

Canbal, M., 2013. Relationship of internet addiction with impulsivity and severity of
psychopathology among Turkish university students. Psychiatry Res. 210, 1086–1091.
doi:10.1016/j.psychres.2013.08.014
ED

Davis, R.A., 2001. Cognitive-behavioral model of pathological Internet use. Comput. Human
Behav. 17, 187–195. doi:10.1016/S0747-5632(00)00041-8
PT

Dong, G., Lu, Q., Zhou, H., Zhao, X., 2011. Precursor or sequela: Pathological disorders in
people with internet addiction disorder. PLoS One 6. doi:10.1371/journal.pone.0014703
CE

Egle, J.P., Smeenge, D.M., Kassem, K.M., Mittal, V.K., 2015. The internet school of
medicine: use of electronic resources by medical trainees and the reliability of those
resources. J. Surg. Educ. 72, 316–320. doi:10.1016/j.jsurg.2014.08.005
AC

Ergin, A., Uzun, S.U., Bozkurt, A.İ., 2013. Tıp fakültesi öğrencilerinde internet bağımlılığı
sıklığı ve etkileyen etmenler. Internet addiction prevalence and contributing factors in the
medical faculty students. Pamukkale Tıp Derg. 6, 134–142.

Erwin, B.A., Turk, C.L., Heimberg, R.G., Fresco, D.M., Hantula, D.A., 2004. The Internet:
home to a severe population of individuals with social anxiety disorder? J. Anxiety Disord.
18, 629–646. doi:10.1016/j.janxdis.2003.08.002
 ACCEPTED MANUSCRIPT

Gedam, S.R., Shivji, I.A., Goyal, A., Modi, L., Ghosh, S., 2016. Comparison of internet
addiction, pattern and psychopathology between medical and dental students. Asian J.
Psychiatr. 22, 105–110. doi:10.1016/j.ajp.2016.06.007

Greenberg, J.L., Lewis, S.E., Dodd, D.K., 1999. Overlapping addictions and self-esteem
among college men and women. Addict. Behav. 24, 565–571. doi:10.1016/S0306-
4603(98)00080-X

Griffiths, M., 2000. Does Internet and computer “addiction” exist? Some case study evidence.
CyberPsychology Behav. 3, 211–218. doi:10.1089/109493100316067

T
Güleç, H., Tamam, L., Güleç, M.Y., Turhan, M., Karakuş, G., Zengin, M., Stanford, M.S.,

IP
2008. Psychometric properties of the Turkish version of the Barratt impulsiveness scale-11.
Klin. Psikofarmakol. Bul. 18, 251–258.

CR
Ha, J.H., Yoo, H.J., Cho, I.H., Chin, B., Shin, D., Kim, J.H., 2006. Psychiatric comorbidity
assessed in Korean children and adolescents who screen positive for internet addiction. J.
Clin. Psychiatry 67, 821–826. doi:10.4088/JCP.v67n0517

US
Hisli N.,1989. Reliability and validity of Beck Depression Inventory among university
students. Turk J Psychol. 7, 3-13.
AN
Khantzian, E.J., 1997. Self-regulation factors in cocaine dependence- a clinical perspective.
Subst. Use Misuse 32, 1769–1774. doi:10.3109/10826089709035579
M

Khantzian, E.J., 2013. Addiction as a self-regulation disorder and the role of self-medication.
Addiction. doi:10.1111/add.12004
ED

Kim, H.K., Davis, K.E., 2009. Toward a comprehensive theory of problematic Internet use:
Evaluating the role of self-esteem, anxiety, flow, and the self-rated importance of Internet
activities. Comput. Human Behav. 25, 490–500. doi:10.1016/j.chb.2008.11.001
PT

Ko, C.-H., Yen, J.-Y., Chen, C.-S., Chen, C.-C., Yen, C.-F., 2008. Psychiatric comorbidity of
internet addiction in college students: an interview study. CNS Spectr. 13, 147–53.
CE

doi:10.1017/S1092852900016308

Ko, C.-H., Yen, J.-Y., Chen, C.-S., Yeh, Y.-C., Yen, C.-F., 2009. Predictive values of
psychiatric symptoms for internet addiction in adolescents: a 2-year prospective study. Arch.
AC

Pediatr. Adolesc. Med. 163, 937–943. doi:10.1001/archpediatrics.2009.159

Ko, C.H., Liu, T.L., Wang, P.W., Chen, C.S., Yen, C.F., Yen, J.Y., 2014. The exacerbation of
depression, hostility, and social anxiety in the course of Internet addiction among adolescents:
a prospective study. Compr. Psychiatry. doi:10.1016/j.comppsych.2014.05.003

Koronczai, B., Urbán, R., Kökönyei, G., Paksi, B., Papp, K., Kun, B., Arnold, P., Kállai, J.,
Demetrovics, Z., 2011. Confirmation of the three-factor model of problematic Internet use on
off-line adolescent and adult samples. Cyberpsychology, Behav. Soc. Netw. 14, 657–664.
doi:10.1089/cyber.2010.0345
 ACCEPTED MANUSCRIPT

Kuru, E., Safak, Y., Özdemir, Tulacı, R.G., Özdel, K., Özkula, N.G., Örsel, S., 2018.
Cognitive distortions in patients with social anxiety disorder: Comparison of a clinical group
and healthy controls. Eur. J. Psychiatry. doi:10.1016/j.ejpsy.2017.08.004

Lai, C.M., Mak, K.K., Watanabe, H., Jeong, J., Kim, D., Bahar, N., Ramos, M., Chen, S.H.,
Cheng, C., 2015. The mediating role of Internet addiction in depression, social anxiety, and
psychosocial well-being among adolescents in six Asian countries: a structural equation
modelling approach. Public Health 129, 1224–1236. doi:10.1016/j.puhe.2015.07.031

Lee, B.W., Stapinski, L.A., 2012. Seeking safety on the internet: relationship between social
anxiety and problematic internet use. J. Anxiety Disord. 26, 197–205.

T
doi:10.1016/j.janxdis.2011.11.001

IP
Lee, H.W., Choi, J.-S., Shin, Y.-C., Lee, J.-Y., Jung, H.Y., Kwon, J.S., 2012. Impulsivity in

CR
Internet addiction: a comparison with pathological gambling. Cyberpsychology, Behav. Soc.
Netw. 15, 373–377. doi:10.1089/cyber.2012.0063

Mazhari, S., 2012. Association between problematic Internet use and impulse control

US
disorders among Iranian university students. Cyberpsychology, Behav. Soc. Netw. 15, 270–
273. doi:10.1089/cyber.2011.0548
AN
McKenna, K.Y.A., Green, A.S., Gleason, M.E.J., 2002. Relationship formation on the
Internet: What‟s the big attraction? J. Soc. Issues 58, 9–31. doi:10.1111/1540-4560.00246

Meerkerk, G.J., Van Den Eijnden, R.J.J.M., Franken, I.H.A., Garretsen, H.F.L., 2010. Is
M

compulsive internet use related to sensitivity to reward and punishment, and impulsivity?
Comput. Human Behav. 26, 729–735. doi:10.1016/j.chb.2010.01.009
ED

Müller, K.W., Beutel, M.E., Wölfling, K., 2014. A contribution to the clinical characterization
of Internet addiction in a sample of treatment seekers: validity of assessment, severity of
psychopathology and type of co-morbidity. Compr. Psychiatry 55, 770–777.
PT

doi:10.1016/j.comppsych.2014.01.010

Niemz, K., Griffiths, M., Banyard, P., 2005. Prevalence of pathological Internet use among
CE

university students and correlations with self-esteem, the General Health Questionnaire
(GHQ), and disinhibition. CyberPsychology Behav. 8, 562–570. doi:10.1089/cpb.2005.8.562
AC

Patton, J.H., Stanford, M.S., Barratt, E.S., 1995. Factor structure of the Barratt impulsiveness
scale. J. Clin. Psychol. 51, 768–774. doi:10.1002/1097-4679(199511)51:6<768::AID-
JCLP2270510607>3.0.CO;2-1

Robbins, T.W., Gillan, C.M., Smith, D.G., de Wit, S., Ersche, K.D., 2012. Neurocognitive
endophenotypes of impulsivity and compulsivity: towards dimensional psychiatry. Trends
Cogn. Sci. doi:10.1016/j.tics.2011.11.009

Rosenberg, M., 1965. Rosenberg Self-Esteem Scale. W.W. Norton, New York. doi:/S0034-
98872009000600009
 ACCEPTED MANUSCRIPT

Rytwinski, N.K., Fresco, D.M., Heimberg, R.G., Coles, M.E., Liebowitz, M.R., Cissell, S., et
al., 2009. Screening for social anxiety disorder with the self-report version of the Liebowitz
Social Anxiety Scale. Depress. Anxiety 26, 34–38. doi:10.1002/da.20503

Shapira, N.A., Goldsmith, T.D., Keck, P.E., Khosla, U.M., McElroy, S.L., 2000. Psychiatric
features of individuals with problematic internet use. J. Affect. Disord. 57, 267–272.
doi:10.1016/S0165-0327(99)00107-X

Shepherd, R.-M., Edelmann, R.J., 2005. Reasons for internet use and social anxiety. Pers.
Individ. Dif. 39, 949–958. doi:10.1016/j.paid.2005.04.001

T
Tonioni, F., D‟Alessandris, L., Lai, C., Martinelli, D., Corvino, S., Vasale, M., et al., 2012.

IP
Internet addiction: hours spent online, behaviors and psychological symptoms. Gen. Hosp.
Psychiatry 34, 80–87. doi:10.1016/j.genhosppsych.2011.09.013

CR
Torous, J., Keshavan, M., Gutheil, T., 2014. Promise and perils of digital psychiatry. Asian J.
Psychiatr. doi:10.1016/j.ajp.2014.06.006

US
Wei, L., Zijie, H., Daxi, L., 2004. Internet use and depression, communication anxiety of
medical students. Chinese Ment. Heal. J. 18, 501–503.

Yen, J.-Y., Ko, C.-H., Yen, C.-F., Wu, H.-Y., Yang, M.-J., 2007a. The comorbid psychiatric
AN
symptoms of Internet addiction: Attention deficit and hyperactivity disorder (ADHD),
depression, social phobia, and hostility. J. Adolesc. Heal. 41, 93–98.
doi:10.1016/j.jadohealth.2007.02.002
M

Yen, J.-Y., Ko, C.-H., Yen, C.-F., Wu, H.-Y., Yang, M.-J., 2007b. The comorbid psychiatric
symptoms of Internet addiction: attention deficit and hyperactivity disorder (ADHD),
ED

depression, social phobia, and hostility. J. Adolesc. Health 41, 93–8.

doi:10.1016/j.jadohealth.2007.02.002
PT

Young, K., 2009. Internet addiction: Diagnosis and treatment considerations. J. Contemp.
Psychother. doi:10.1007/s10879-009-9120-x
CE

Young, K.S., 2007. Cognitive behavior therapy with Internet addicts: treatment outcomes and
implications. CyberPsychology Behav. 10, 671–679. doi:10.1089/cpb.2007.9971
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TABLES
Table.1 Sociodemographic features of the participants
Without IA IA Chi-
n=286 n=106 SquareTest
n (%) n (%) p
Sex Male 124 (43.4) 43 (40.6) 0.620
female 162 (56.6) 63 (59.4)
Birth place Rural 86 (30.1) 40 (37.7) 0.197
Urban 200 (69.9) 66 (62.2)
Make-up exam Existent 12 (4.2) 8 (7.5) 0.180
None 274 (95.8) 98 (92.5)
Usage of alcohol Existent 53 (18.5) 13 (12.3) 0.141

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None 233 (81.5) 93 (87.7)
Usage of nicotine Existent 51 (17.8) 14 (13.2) 0.274

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None 235 (82.2) 92 (86.8)
Living place Government dorm 62 (21.7) 31 (29.2) 0.290
Private dorm 87 (30.4) 29 (27.4)

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Lodging 105 (36.7) 39 (36.8)
Own house 32 (11.2) 7 (6.6)
People living together Family 49 (17.1) 22 (20.8) 0.373
Friends 168 (58.7) 65 (61.3)

Monthly income of the

family

Resource of homework
Alone
<1500 TL
1500-3000 TL
>3000 TL
Internet
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69 (24.1)
13 (4.5)
90 (31.5)
183 (64.0)
203 (71.2)
19 (17.9)
12 (11.3)
35 (33.0)
59 (55.7)
85 (80.2)
0.039*

0.183
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Library 24 (8.4) 5 (4.7)
Others 58 (20.4) 16 (15.1)
Mean±SD Mean±SD p
Age year 20.8±2.1 20.3±1.8 0.013*
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Online time hour/week 23.7±17.4 26.5±18.7 0.167

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p <0.05, n: number, %: percentage, SD: Standart Deviation, TL:Turkish Lira
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Table.2 Comparison of social anxiety, impulsivity, self-esteem, depression and anxiety

scores between IA and without IA groups
Without IA IA Independent
n=286 n=106 samples test
Mean±SD p
LSAS-total score 77.6±17.7 99.7±22.0 < 0.001*
LSAS-anxiety score 35.2±14.1 41.4±15.2 < 0.001*
LSAS-avoidance score 42.4 ±8.4 58.3±12.4 < 0.001*

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BIS-11 score 54.7±15.3 55.5±17.0 0.665

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RSES score 19.6±4.2 17.1±4.5 < 0.001*
BDI score 11.9±9.0 19.3±11.1 < 0.001*

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BAI score 11.5±8.9 19.8 ±13.4 < 0.001*
*
p <0.05, IA: Internet Addiction, SD: Standard Deviation, LSAS: Liebowitz Social Anxiety Scale, BIS-11: Barratt
Impulsivity Scale-11, RSES: Rosenberg Self-Esteem Scale, BDI: Beck Depression Inventory, BAI: Beck Anxiety Inventory

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Table.3 Hierarchical regression analysis results associated with the IAT scores.

B SE Beta t Sig. R2 adjR2 ΔR2 F

Model 1
Step 1
(Constant) 17.547 2.499 7.022 <0.001 0.222 0.220 0.220 110.970
LSAS-total 0.305 0.029 0.471 10.534 <0.001
Step 2
(Constant) 17.326 2.418 7.165 <0.001 0.273 0.269 0.049 73,008

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LSAS-total 0.253 0.030 0.391 8.528 <0.001
BDI 0.327 0.062 0.240 5.244 <0.001

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Step 3
(Constant) 29.020 4.008 7.240 <0.001 0.297 0.291 0.022 54.577

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LSAS-total 0.230 0.030 0.356 7.705 <0.001
BDI 0.289 0.062 0.213 4.644 <0.001
RSES -0.490 0.135 -0.163 -3.627 <0.001
Model 2
Step 1
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(Constant) 7.286 2.119 3.438 0.001 0.438 0.436 0.438 303.514
LSAS- 0.766 0.044 0.662 17.422 <0.001
avoidance
Step 2
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(Constant) 7.270 2.079 3.496 0.001 0.460 0.457 0.022 165.639

LSAS- 0.702 0.046 0.606 15.251 <0.001
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avoidance
BDI 0.217 0.054 0.159 4.006 <0.001
Step 3
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(Constant) 14.223 3.571 3.983 <0.001 0.468 0.464 0.008 113.661

LSAS- 0.673 0.047 0.582 14.251 <0.001
avoidance
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BDI 0.197 0.054 0.145 3.627 <0.001

RSES -0.283 0.119 -0.094 -2.388 0.017
Dependent Variable: Internet Addiction Test (IAT). SE: Standart Error, Sig.: Significance, adjR2: adjusted R2, LSAS: Liebowitz
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Social Anxiety Scale, BIS-11: Barratt Impulsivity Scale, RSES: Rosenberg Self-Esteem Scale, BDI: Beck Depression Inventory,
BAI: Beck Anxiety Inventory