Patterns of Internet Addiction in an Italian sample:

100% of the sample experience Nomophobia

Federica Marcolini

University of Bologna
Gabriele Buffa
University of Bologna
Silvia Tempia Valenta
University of Bologna
Diana De Ronchi
University of Bologna
Anna Rita Atti
University of Bologna

Study protocol

Keywords: Internet Addiction Disorder, Nomophobia, Situational Phobia, Impulsiveness.

Posted Date: March 22nd, 2024

DOI: https://doi.org/10.21203/rs.3.rs-4130604/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
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Additional Declarations: No competing interests reported.

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Abstract
Background and Objectives: Internet Addiction Disorder, a concept introduced for the first time by Ivan
Goldberg in 1995, is one of the most recently identified forms of addiction, but already considered a real
psychosocial phenomenon, capable of having a profound impact on different aspects of social and
psychological life of individuals. One of its most recently identified manifestations is Nomophobia, a
neologism formed from the combination of terms such as "no mobile", "phone" and "phobia”, that can be
understood as the fear of feeling disconnected. It is today considered a situational phobia, characteristic
of contemporary times. The most common symptoms include excessive cell phone use, and constant
anxiety at the thought of losing the internet connection. Others are, for example, the “Ringxiety”, or ringing
anxiety, or the “phantom vibration syndrome”.

This study aims to examine the spread of Nomophobia in the Italian population, evaluating
psychopathological correlations that can explain its diffusion.

Methods: Between January and May 2023, an anonymous online questionnaire was randomly sent to the
general population. Alongside with tests to evaluate psycho-social features, the instrument used to study
Nomophobia was the Nomophobia Questionnaire(NMP-Q), in its Italian version.

Results: The sample consists of 253 people (145 F, 108 M), with an average age 33.5 years (sd 14). In our
sample, 100% of the subjects tested positive for Nomophobia. Values indicating a state of severe
Nomophobia are found in 11.5% of the sample (F 57.9%, M 24.1%). The young population, between 18
and 25 years old, represents 46.6% of the affected population, but more than 55.2% of severe cases. The
severe cases correlate positively (p<0,05) with findings of high impulsiveness. There are no other studies
that investigate the psychopathological correlates of Nomophobia among Italians.

Conclusions: Despite possible biases, the data obtained are an alarming sign of the spread of internet
addiction that characterizes our times, of which the excessive use of cell phones in the form of
Nomophobia is an expression. Despite their now undisputed usefulness, mobile devices are capable of
causing the onset of serious health problems, starting from exposure to radiation capable of causing
dermatitis. Furthermore, they dramatically interfere with driving safety, becoming a major cause of road
accidents. Considering these consequences, it appears to be extremely important to characterize the
phenomenon, as well as its psychosocial determinants, in order to proceed with its better definition and
prevention.

Introduction
In the 21st century, the influence of modern technology is something we have to be keenly aware of, since
it impacts on all aspects of life. Day by day it is developing and, simultaneously to technological
progress, new risks are coming to light on a regular basis. The mobile phone has become “the 21st
century icon”(1). It is ubiquitous in the modern world: as a communication device, an internet and social
networking portal, a financial and work organizer, and so forth. It is an undeniable fact that mobile phone
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is an essential tool nowadays, nevertheless, it also has been found to be a possible cause of serious
health problems, including effects on the cardiovascular system, sleep and cognitive function,
genotoxicity potential, neurohormonal secretion and tumor induction(2)−(3)−(4)−(5). Moreover, cell phone
radiation (radiofrequency electromagnetic waves; RF-EMW) exposure seems to decrease the semen
quality in men by decreasing the sperm count, motility, viability and normal morphology, making cell
phone a factor which can contribute to male infertility(6)−(7). Mobile phone may also have an important
impact on driving performance, being an important cause of car crash(8), which is a critical public health
issue(9).

The growing use (or misuse) of mobile phones over the past few decades has provoked massive
neuropsychological consequences(1). The pervasiveness and intrusiveness of these devices could lead
to mental health issues such as problematic use, distress, and compulsive usage, which could end up
resulting in what is termed as “smartphone dependence” or “smartphone addiction”(10)−(11). According
to Shambare et al. (2012) mobile phone usage is “possibly the biggest non-drug addiction of the 21st
century”(1). When analyzing excessive usage of mobile phones and the internet, several terms appear in
scientific literature, such as internet addiction, compulsive internet use, nomophobia, internet
pornography addiction, online gaming disorder, online gambling disorder, and so on(12). Although there
is widespread consensus regarding the various addictive applications available on the internet (e.g.,
gaming and gambling, pornography, shopping sites, and so forth), only Internet Gaming Disorder has
been added to the DSM-5 appendix(13). This demonstrates the need for more research on this
phenomenon to gather proof of its clinical significance and underlying mechanisms(14).

The term NOMOPHOBIA (NO MObile PHone PhoBIA) is used to describe a psychological condition when
people have a pathological fear of being detached from mobile phone connectivity(15). The term was
coined only in 2008 by the English Post Office, regarding the results of an epidemiological research they
launched, aimed at examining how many citizens experienced mobile phone-related anxiety in their daily
lives(30). It was reported that nearly 13 million citizens described themselves as anxious to be without a
telephone, 53% of the sample(30). Anxiety was referred to various scenarios, such as losing or forgetting
the phone, finding oneself with a flat battery, losing the internet connection, finding oneself in a broad
sense without the possibility of receiving calls, messages, or emails(30). Thanks to this episode, it
becomes clear how society itself can be ahead of science in identifying a new phenomenon, impactful
enough to raise concerns among the general population.

Nomophobia is considered a disorder of the contemporary digital and virtual society and refers to
discomfort and anxiety that arise from being disconnected from a mobile device(16). It is a consequence
of technological progress that enable virtual communication, making the mobile phone an ideal
representation of "a paradox of technology," having the ability to both free and enslave people(17). The
clinical features of nomophobia can be various, such as spending considerable time on the mobile
phone, using it in an impulsive way, and always carrying a charger with them(18). It also includes having
their phone switched on all the time (24 hours a day), sleeping with their phone in bed, and having few
social encounters with people in person, which can cause stress and anxiety, preferring to communicate
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via technological devices(18). Nomophobia can include the so-called “Ringxiety”: to constantly check the
phone's screen to see if there are any new calls or messages(16). Ringxiety may manifest in a variety of
sometimes remarkable and unique clinical ways, such as the feeling of hearing "phantom ring tones" or
"false mobile sounds," mistaking the sound of a ringing cell phone for another similar sound, or
impulsively reaching for one's own phone after hearing or presuming to have heard a ring tone(16).

Since nomophobia is a modern-day problem, there is still limited scientific literature on the subject.
According to the first study conducted in this field, nearly 53% of British citizens who used mobile phones
reported to be anxious when losing their mobile or forgetting to take the phone with them (15). According
to more recent studies, the prevalence of nomophobia could be higher and might be susceptible to
variation depending on gender and age differences(19).

As reported by previous studies, there are psychological risk factors related to Internet-related addictions,
such as self-esteem, extroversion and personality traits(20, 21). Addictive behaviors of all types are also
associated with the trait of impulsivity(22). Impulsivity can be defined as the tendency to react quickly to
a situation in a reward-driven manner, without premeditation or consideration of consequences(23).
Impulsivity is a multifaceted construct, commonly conceptualized and evaluated in addiction research as
consisting of four key aspects: lack of planning, lack of perseverance, sensation seeking, and emotion-
driven rash actions(24).

First of all, this study aims to examine the spread of Nomophobia in a sample of the Italian population,
defining its epidemiological characteristics. Secondly, it tries to evaluate some possible
psychopathological correlations that can try to explain its spread. There are no other studies that
investigate the psychopathological correlates of Nomophobia among Italians. Considering, according to
literature, this phenomenon as an addictive behavior, we choose to evaluate specifically the correlation
with the impulsivity trait.

Methods
Subject recruitment
Between January and May 2023, an anonymous online questionnaire was disseminated via a QR to the
general population of Bologna, city located in northern Italy. The questionnaire was created via the
Qualtrics Experience Management online platform, the use of which for research purposes was approved
by the Ethics Committee of the University of Bologna and by the Italian privacy law. We selected only
adult patients (age > 18 years, by Italian law). The Alma Mater Studiorum - Università di Bologna
bioethical committee approved the study (Prot. n. 0366672, 06/12/2022) and each participant signed an
online informed consent. All the study procedures followed the Helsinki Declaration of 1975 (as revised in
1983) for human experimentation.
Assessment tools
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Alongside with tests to evaluate the presence of nomophobia, psycho-social and demographic features
were included. To estimate the presence of nomophobia, the Nomophobia Questionnaire (NMP- Q), in its
Italian version, was used(25, 26).

The Nomophobia Questionnaire

It is a tool developed by Yildrim and Correia in 2015(25) which consists of 20 items, aimed at
investigating the presence of a certain degree of symptoms correlated to the picture of smartphone
addiction, evaluated by the patient in a ranking from 1 to 7 (from "completely disagree" to "totally agree”).
The total score is calculated by adding the answers reported in the individual items, resulting in a
possible range that moves between 20 and 140. The higher the result, the more it correlates with a greater
severity of the nomophobia picture. In particular, following the indications of the developers of the test
itself, the NMP-Q score is interpreted as follows: a value of 20 indicates a total absence of nomophobia; a
result greater than 20, but less than 60, corresponds to a low level of nomophobia; a moderate degree is
associated with a finding of values higher than 60 but lower than 100; a total score equal to or greater
than 100 corresponds, however, to a severe picture of nomophobia. The validated version in Italian
language, created by Adawi and colleagues in 2018, was submitted to the recruited individuals(26).
The Barratt Impulsiveness Scale
The Barratt Impulsiveness Scale (BIS), currently in its eleventh revision, is a tool designed to evaluate the
presence of impulsive patterns in the behavior and personality patterns of the individuals to whom it is
administered(27). The questionnaire consists of 30 questions, in the form of self-report, for which there is
a forced answer choice, in a range from "never" to “always”. It identifies three different constructs of
impulsivity: motor impulsivity, understood as motor instability and lack of perseverance, as well as acting
without premeditation; non-planning impulsivity, understood as the lack of self-control and intolerance to
cognitive complexity; attentional impulsivity, understood as inattention and cognitive instability,
manifests itself in the form of the inability to maintain an attentional focus and concentration. Following
the indications of the latest reviews on the topic, the normal range is considered to be that which sees BIS
values between 52 and 71(28). Values equal to or greater than 72 are associated with increased
impulsivity. For subscales, no thresholds cut offs are available in literature and observation on a linear
scale is recommended. To identify significant cases more easily, we set the value corresponding to the
75th percentile as the cut-off in identifying risk values, aware of the limit that this arbitrary evaluation
represents(28). The validated version in Italian language, by Fossati and De Ceglie dated 2001, was
submitted to the recruited individuals(29).

Statistical analysis
Firstly, we conducted descriptive analyses in our population, to describe it in terms of sociodemographic
characteristics. We then evaluated the distribution of results obtained in the administered questionnaires.
Thanks to contingency tables we highlighted the trend of the results obtained in the NMP-Q with age and
occupation. To evaluate significant correlations between impulsivity and nomophobia we used Pearson's
linear correlation. The null hypothesis predicts absolute equality between groups and asserts that the

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observed differences are due solely to chance. By setting a threshold for statistical significance p < 0.05,
the null hypothesis will be refuted as defined by the objectives.

Results
The sample resulting from the dissemination of the questionnaires includes a total of 253 individuals. Of
these individuals, 145 (57.3%) reported their biological sex as female, while the remaining 108 (42.7%)
reported their assigned sex male. All subjects identify with the gender corresponding to their biological
sex. The age is between 18 and 68 years, for a mean value of 33.5 years (standard deviation of 14.2). As
regards work and education, the distribution occurs as shown in the graphs in the figures (Fig. 1 and
Fig. 2).

To evaluate the interviewees' relationship with technology and electronic devices, their habits in this
regard were analyzed. In particular, it appears that 88.1% of the sample has a personal computer or a
tablet and the 88.8% use the same to work or study. The presence of a stable internet connection at home
characterizes the 88.9% of the sample. We also investigated the most well-known and used social media
in Italy (Instagram, Facebook, Twitter, TikTok), finding that the 89.5% of the sample used at least one of
them on a daily basis.

To evaluate the presence of problems related to smartphone misuse in our population, we analyzed the
results obtained in the NMP-Q test(25). As shown in the following graphs, the results were analyzed
based on the limit values indicated by the test developers themselves. Following these interpretative
guidelines, a positive response to the phenomenon emerges in 100% of the population, while a moderate
state of Nomophobia characterizes the 54.2%. A state of severe Nomophobia is found in 11.5% (75.9% F;
24.1% M) of the recruited sample (Fig. 3). The young population, between 18 and 25 years old, represents
more than 55.2% of severe cases (95% confidence interval 50–65%) (Fig. 4). It is interesting to note how,
again considering the most severe cases, the representation of students and employees is equivalent
(44.8%) (Fig. 5).

Pearson linear correlation coefficient is calculated between quantitative variables of nomophobia and
impulsivity. Correlation coefficients with a p < 0.05 are considered significant. Specifically, a statistically
significant positive correlation was assessed with findings of increased impulsivity(27, 29). Severe cases
of nomophobia in our sample correlated positively with both general impulsivity (p < 0.027) and its motor
subclass (p < 0.006) (Fig. 6).

Discussion
Within this Italian sample the entire population was found to be positive for the phenomenon of
nomophobia. One out of ten participants (11.5% of cases) had a form defined as severe, according to the
criteria established by the test developers themselves. The majority of severe cases occurred in the
youngest age group (between 18 and 25 years).

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In the most recent systematic review on nomophobia prevalence, conducted by Leon-Mejıa and
colleagues in 2021, positivity to this phenomenon is estimated to affect up to 73% of the population(31).
The prevalence of this phenomenon appears destined to increase and become a major problem at a
social level, due to the constant massive use of telephones(32).

We chose to evaluate nomophobia with the aim of offering a small overview of the diffusion of this
emerging phenomenon in our local reality. Severe cases are the 11.5% and these values have a significant
correlation with impulsivity and, in particular, with its motor subcategory. Results pointing towards a
correlation between internet addiction or nomophobia and impulsivity are not totally unexpected.
Recently conducted studies had in fact found a relationship between telephone addiction and impulsivity
and sensation seeking(33, 34). This can be explained by the fact that nomophobia is characterized by the
tendency to engage in an activity, such as excessive smartphone use, without thinking about its
consequences, a characteristic that is often observed in individuals with high impulsivity(35).

A strong link is suggested between impulsive sensation seeking and the desire for new and exciting
experiences, which can intensify emotional attachment to mobile devices(36). Furthermore, the impulsive
nature of seeking immediate rewards or stimulation aligns with the constant connectivity offered by
mobile phones, potentially reinforcing dependency on these devices(37).

Despite this finding, the presence of nomophobia throughout the entire population presupposes
underlying elements that go beyond the problems linked to the impulsivity spectrum. How then can such
high prevalence levels be explained?

A recent meta-analysis conducted on the spread of nomophobia reports prevalence values close to 100%,
in a young population, between 18 and 25 years old(38). In particular, the study refers to the university
student population, which appears to represent the segment of the population most affected by the
phenomenon, especially in its serious manifestations. This trend is found also in our sample, with the
young population (18–25 years) representing 55.2% of cases with serious manifestations. However, it is
certainly interesting to note how, again in relation to the most serious cases, in our sample, students do
not represent the majority of cases, but are indeed equally represented compared to workers (both cover
44.8% of severe cases).

Since its inception, nomophobia has been considered as a branch or manifestation of social phobia
disorder, a chronic anxiety disorder characterized by the onset of intense anxiety triggered by social
situations that require interpersonal contacts and interactions(13). The DSM-5 emphasizes that at the
basis of the diagnosis there must be significant interference in at least one important area of the
individual's life, which can include work, social relationships but also studies or moments of leisure(13).
New technologies, from tablets to smartphones, have certainly contributed to the genesis of new and
constant comforts for users, as well as to an improvement in performance and effectiveness in personal,
interpersonal, and working life(39). But, at the same time, they have the ability to reinforce dysfunctional
behaviors, such as social isolation(39). The excessive use of mobile phones is identified by several
studies as one of the coping methods in managing anxiety and stress in daily life(40).
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A study, conducted on a sample of university students in 2012, evaluated peer relationship skills,
conducted both in person and online and demonstrated how the internet has excellent potential as a
mediator of relationships, representing a way viable alternative in the presence of social anxiety(41).
Individuals seem to prefer this indirect communication route and even appear more open and self-
confident through the use of it, as the screen probably constitutes a protective barrier towards the outside
from this perspective(42). This increases enormously when we consider the burgeoning reality of social
media, which is based first and foremost on the creation of an online universe, parallel to “real” life
situations and relationships, in which people choose what to show of themselves and how to show it(41).
This could mimic an individual overcoming introversion, anxiety, and low self-esteem, but in reality,
strengthening them and making them more debilitating when one returns to one's daily life(43). The
relationship between social anxiety and seeking refuge in the internet world is nothing new. The Internet
represents a cause of social withdrawal but also an alternative in interpersonal communication even in
the widely described phenomenon of Hikikomori(44, 45). Currently, the term Hikikomori is applied to
individuals who do not leave theirs rooms or homes and is often conceptualized as a “culturally
boundless syndrome of modern society”(46, 47). It is a condition that mainly affects adolescents or
young adults, who live isolated from the world, using the Internet profusely, considering it the only method
of interaction with others(48, 49). The fact that it is precisely the younger population groups that are more
familiar with the use of these modern tools could be one of the key elements in explaining the prevalence
distribution in our population, which sees the under 25 age group as particularly affected.

An interesting correlation with nomophobia, recently described for the first time, is that with
unsatisfactory sleep. Unsatisfactory sleep seems to be at the basis of both insomnia and
nomophobia(50). Furthermore, it is an element that historically has a positive correlation with various
psychiatric disorders such as depression and anxiety(51). The relationship between insomnia and
nomophobia is certainly bidirectional in nature, as, on the one hand, the lack of sleep and the need to fill
the night hours leads to the use of electronic devices more easily, but on the other, blue light emitted by
the devices themselves alters the functionality of the epiphysis, which produces melatonin and regulates
the circadian rhythm, altering our ability to fall asleep(50, 51).

Experts are starting to focus their attention on an additional factor that can play a role in the problematic
use of social media and electronic devices in general: FOMO(52). FOMO is an acronym that stands for
Fear Of Missing Out, therefore "fear of missing something", understood, in a very broad sense, as any
event or experience that happens around us and that could be within our reach(53). The definition, coined
in 2013, describes the phenomenon as "the pervasive apprehension that others may be having exciting
and/or satisfying experiences from which one is absent"(53). It is a condition that has been associated
with depression, anxiety, reduced levels of both physical and mental well-being, as well as problematic
sleep(54). Sleep would be affected by the need to avoid the feeling of missing typical of FOMO, especially
in the evening and night hours, satisfying one's need for autonomy, competence, and self-determination,
thus fomenting nomophobia(55). As in the previous case, here too the relationship can be of a bimodal
nature, because certainly the constant search for the telephone can depend on the fear of missing
something that is about to happen around us, but at the same time the massive use of the internet and
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social media does nothing but present new experiences lived by others and new possibilities that one was
not aware of, fomenting FOMO itself(52).

The relevance of the very concept of nomophobia and, consequently, of its study lies in its association
with mental health problems, such as increased stress, anxiety, irritability, insomnia, and depression. It
can also correlate with self-esteem problems, social self-isolation, loneliness and, in a broader sense,
unhappiness(56). It can also impair individuals' ability to concentrate on the activities they are carrying
out, leading to a tendency towards impulsive action. This is particularly relevant if we observe the
university population, for which an increased level of nomophobia is associated with difficulties in
cultivating interpersonal relationships and a reduction in academic performance(38). The lack of
concentration that can result from the use of technological means in cases of severe nomophobia is also
associated with an increase in harm to oneself and others, primarily being correlated to an increased risk
of road accidents(57).

It is easy to conclude by stating that we do not have certain answers at the moment in this area, which is
so innovative and dynamic that it is always one step ahead of research. In this discussion we asked
ourselves questions regarding the development of nomophobia, but to date research does not offer us
unequivocal answers, but mostly further questions.

Limits
The main limitation of the study is represented by the analysis of results relating to the abuse of internet
and mobile phone use through a questionnaire distributed via the internet itself, which therefore may
constitute a selection bias. It has to be also considered the small size of the sample, as well as the
restricted psychopathological area investigated, limited to the impulsivity trait. It may also be considered
appropriate to evaluate and discuss the sensitivity of the test, which could be called into question on the
basis of such high prevalence of the phenomenon itself.

Conclusions
The data that emerge from our analyses, despite the presence of limitations, are useful, on the one hand,
to frame the spread on a population scale of the problematic behavioral style known as nomophobia, and
on the other to raise awareness from the point of both a medical and social perspective on the prevention
and management of such behavior.

Given the very high incidence of nomophobia, we wonder whether it would be appropriate to evaluate its
inclusion within the official diagnostic categories, which did not happen with the introduction of the DSM-
5. Furthermore, educational and awareness programs aimed at disseminating the principles of the correct
use of technology, especially among the student population, should be considered and implemented.

Of interest for future research should be, first of all, the submission of the NMP-Q questionnaire in an
ever-increasing number of countries and to an ever-wider age range, in order to better characterize the
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phenomenon itself. Additionally, it would be useful to further study the phenomenon in clinical
populations by cross-linking it with general anxiety. Furthermore, we should collaborate to develop more
standardized ways of categorizing results, so that different studies conducted can be compared more
effectively.

Declarations
Author Contributions

The authors have accepted responsibility for the entire content of this manuscript and approved its
submission. Conceptualization, F.M. and A.R.A.; methodology, F.M. and A.R.A.; data curation, S.T.V., A.R.A.
and F.M.; writing-original draft preparation, G.B. and F.M., writing-review and editing, S.T.V. and A.R.A.;
supervision, A.R.A. and D.D.R. All authors have read and agreed to the published version of the
manuscript.

Ethical Considerations

Not applicable.

Funding

None declared.

Conflicts of Interest

The authors state no conflict of interest.

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Figures

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Figure 1

Current occupation distribution in the sample.

Figure 2

Level of education in the sample.

Figure 3

Results at the NMP-Q. A result >20 indicates a low level of nomophobia, >59 a moderate one, and >99 a
severe one.

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Figure 4

Crosstab of NMP-Q results and age groups of the sample.

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Figure 5

Crosstab of NMP-Q results and current occupational status of the sample.

Figure 6

Pearson linear correlation coefficient considered significant (p < 0.05).

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