The risk factors of Internet addictionA survey of

university freshmen
Hsing Fang Tsai
a
, Shu Hui Cheng
a
, Tzung Lieh Yeh
a,b
, Chi-Chen Shih
c
,
Kao Ching Chen
a,b
, Yi Ching Yang
c,

, Yen Kuang Yang

a,b
a
Department of Psychiatry, National Cheng Kung University Hospital, Tainan, Taiwan
b
Department of Psychiatry, College of Medicine, National Cheng Kung University, Tainan, Taiwan
c
Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
Received 29 January 2007; received in revised form 16 January 2008; accepted 25 January 2008
Abstract
This study was designed to explore the risk factors of Internet addiction in 1360 freshmen of the National Cheng Kung
University in Taiwan in 2003. The test battery included a self-administrated structured questionnaire, the Chinese Internet
Addiction Scale-Revision (CIAS-R), the 12-item Chinese Health Questionnaire (CHQ-12), the Measurement of Support Functions
(MSF), and the neuroticism subscale of the Maudsley Personality Inventory (MPI). Of the total study population, there were 680
college freshmen (17.9%) in the Internet addiction group, as defined by high CIAS-R scores. Using logistic regression analyses, we
found positive relationships between Internet addiction and male gender, neuroticism scores and the CHQ score. In addition, the
freshmen who skipped breakfast and those who had poorer social support also had a higher probability of Internet addiction.
Internet addiction is prevalent among university freshmen in Taiwan. Risk factors included male gender, habit of skipping
breakfast, mental health morbidity, deficient social support; and neurotic personality characteristics.
2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Internet; Mental health morbidity; Social support function; Neuroticism
1. Introduction
The Internet is fast becoming a basic feature of global
civilization. Informative, convenient, and entertaining,
the Internet has changed the ways people work and spend
their leisure time. As of June 2007, 1.133 billion people
used the Internet according to the Internet World Stats.
However, uncontrolled Internet use may have negative
impacts on social, occupational, academic, marital and
interpersonal adjustment (Baruch, 2001; Parks, 2002;
Engelberg and Sjberg, 2004). Researchers have used
various terms to describe individuals who exhibit addic-
tive behaviors in their Internet use, including computer
dependency, online dependency, cyber addiction,
pathological Internet use, and Internet addiction
disorder (Whang et al., 2003; Lee and Shin, 2004;
Song et al., 2004). Addictive use of the Internet was
reported by Young (1996), who found that most people
with Internet addiction were young males with low
sociality and low self-esteem. Scherer (1997) reported
that persons who were over-involved with the Internet
Available online at www.sciencedirect.com
Psychiatry Research 167 (2009) 294299
www.elsevier.com/locate/psychres

Corresponding author. Department of Family Medicine, College of

Medicine, National Cheng Kung University, 138, Sheng Li Road,
Tainan 70428, Taiwan. Tel.: +886 6 2766165; fax: +886 6 2091433.
E-mail address: yiching2@giga.net.tw (Y.C. Yang).
0165-1781/$ - see front matter 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2008.01.015
exhibited symptoms of Internet addiction and might have
an increased risk of psychiatric morbidity. Chen et al.
(2003) also reported that people with addictive behaviors
were more likely to have health morbidity, socio-
economic problems and behavioral problems.
Certain personality traits should be considered when
assessing potential mental problems. In a study involving
a large sample, Breslau et al. (1991) reported that neuro-
ticism was one of the significant independent predictors
of post-traumatic stress disorder (PTSD). In Taiwanese
studies, a positive correlation between a personality trait
(namely, neuroticism) and psychiatric morbidity has also
been reported (Chen et al., 2001; Yang et al., 2003).
Therefore, we speculated that neuroticism is a possible
risk factor for Internet addiction.
Young people are generally believed to constitute the
majority of Internet users. An increasing number of
studies have revealed that some youngsters are compul-
sive in their use of the Internet and exhibit addictive
behaviors very similar to those related to alcoholism,
substance addiction and pathological gambling (Ng and
Wiemer-Hastings, 2005; Ha et al., 2006; Petry, 2006). In
Johansson and Gtestam's (2004) study, 1.98% of Nor-
wegian youth (aged 1218) were described as having an
Internet addiction according to the criteria of Young's
(1998b) diagnostic questionnaire.
However, few studies have explored the correlation
between lifestyle habits, mental health and Internet
addiction in young people. Compared with other young
people, college students may be more involved with the
Internet (Kandell, 1998; Young, 2001). The aim of this
study was to investigate risk factors associated with
Internet addiction among university freshmen. We
hypothesized that risk factors related to personality
traits, lifestyle habits, interpersonal relationships and the
potential of psychiatric morbidity might be elevated in
those who are Internet addicted.
2. Methods
2.1. Subjects
A total of 4710 freshmen of the National Cheng Kung
University were recruited in 2003. Subjects were enrolled
during the routine health examination that was part of
freshmen orientation. They were invited to participate in
this study in which they would complete a self-admin-
istered questionnaire about their personal lifestyle habits
and online behaviors. Before the study began, informed
consent was obtained from all of the study participants.
Since they only agreed to have their questionnaire data
and related examination results analyzed anonymously,
any identifying information was kept confidential. The
Ethical Committee for Human Research at the National
Cheng Kung University Medical Center approved the
study protocol.
2.2. Assessment of personal lifestyle habits
Through a self-reported questionnaire, the demo-
graphic characteristics, personal history, family history,
lifestyle habits, and various medical problems were
evaluated. The 14-item questionnaire contains questions
about the following systemic diseases: hypertension,
diabetes mellitus, tuberculosis, asthma, renal disease,
polycystic kidney disease, proteinuria, hematuria, urin-
ary stone, arthritis, epilepsy, systemic lupus erythema-
tosus, polio, and hyperlipidemia. The personal lifestyle
habits investigated included breakfast skipping, coffee
drinking, alcohol drinking and cigarette smoking.
Breakfast skipping was defined in our questionnaires
as eating breakfast fewer than three times per week.
Similarly, coffee drinking was defined as drinking coffee
on more than 4 days per week. In addition, former and
current alcohol drinkers were assigned to the alcohol
group. Similarly, former and current smokers were
assigned to the smoking group. As for the amount of
smoking, the number of packs of cigarettes smoked per
year was calculated. The number of packs of cigarettes
smoked per year was determined by multiplying the
number of packs (one pack is equal to 20 cigarettes)
smoked per day by 365 days per year and by the duration
of smoking in years.
2.3. Measurement of psychological symptoms
The instruments in this domain included the Chinese
Internet Addiction Scale-Revision (CIAS-R) (Chen et al.,
2003), the 12-item Chinese Health Questionnaire (CHQ)
(Chong and Wilkinson, 1989), the Measurement of Sup-
port Functions (MSF) (Lin et al., 1999; Berkman and
Glass, 2000), and the 24-itemNeuroticismsubscale of the
Maudsley Personality Inventory (MPI) (Eysenck and
Eysenck, 1975).
The CIAS-R is a 4-point, 26-item self-rated measure
with good reliability and validity (Chen et al., 2003). This
test, which has been used to measure the severity of
adolescent Internet addiction, includes 26 questions about
the core symptoms and the related problems of Internet
addiction, and five background questions about basic
demographics, weekly online hours, habitual domains,
and experience of Internet utilization (Chen et al., 2003).
The core symptoms of Internet addiction included
tolerance (four questions), compulsive use (five questions)
295 H.F. Tsai et al. / Psychiatry Research 167 (2009) 294299
and withdrawal (five questions). The related problems
included negative impact on their social activities, inter-
personal relationships and physical conditions (seven
questions) and time management (five questions). The
total scores of the CIAS-R range from 26 to 84, with
higher CIAS-R scores indicating increased severity of
addiction to Internet activity. The cut-off score of 64 or
more in the CIAS-R (Ko et al., 2005) was used to identify
those who had Internet addiction. This diagnostic cut-off
value of 63/64 has been demonstrated to have a high
sensitivity rate (86.6%) and an excellent diagnostic accu-
racy rate (87.6%). This discriminative potential makes
the scale a reliable diagnostic tool in an epidemiological
survey, as it can provide the estimated prevalence rate and
identify the target case group.
The CHQ, which is a 12-item questionnaire, can be
considered a culturally sensitive tool for detecting po-
tential psychiatric morbidity among Chinese individuals.
The CHQ-12 is a standardized self-reported screening
instrument. The CHQ-12 has been used in surveys of
minor psychiatric morbidity in three communities in
Taiwan (Cheng, 1988). It can be used to identify a
probable clinical case on the basis of a cut-off score. In
addition, it can be used to determine the severity of
morbidity on the basis of the total score, which ranges
from zero to 12. Higher scores indicate more severe
psychiatric morbidity. The sensitivity and specificity in
predicting cases of psychiatric morbidity were 69.6% and
98.4%, respectively, in a community study (cut-off =2/3)
(Cheng, 1988), and 78%and 77%, respectively, in general
health clinics (cut-off =3/4) (Chongand Wilkinson, 1989).
In our study, a probable case of psychiatric morbidity was
defined using a cut-off value of 3/4. A probable case of
psychiatric morbidity was defined as having a score of 4 or
higher on the CHQ-12 (Yang et al., 2003).
The MSF has four subscales, including perceived
crisis support (PCS), perceived routine support (PRS),
received crisis support (RCS), and received routine sup-
port (RRS) (Lin et al., 1999). Perceived versus received
support focuses on the subjective versus the objective
continuum of support (Turner and Marino, 1994). Per-
ceived support refers to the perception of the availability
of support when it is needed, the appraisal of its adequacy,
and the quality of such support. Received support refers
to the nature and frequency of specific support transac-
tions. The other major dimensions are routine versus
crisis supports. Routine support is the process by which
support is received or perceived relative to day-to-day
activities, whereas crisis support reflects the process by
which support is perceived or received when the ego is
confronted with a crisis situation or event. In order to
further assess the relationship between Internet addiction
and support functions, each of these four subscales was
further divided into three categories, including low (24
points), moderate (2534 points), and high (35 points)
scores.
The MPI allows simple investigation of neurotic
tendencies and deceptive behaviors. In accordance with
Table 1
Differences between the Internet addiction and non-addiction groups.
Predictors Internet non-addiction Internet addiction Chi-square test for predictor
N=680 (%) N=680 (%)
2
df P-value
Demographic and health variables
Sex (Male) 463 (68.1) 483 (71.0) 1.39 1 0.23
History of systemic disease
a
(yes) 116 (17.1) 132 (19.4) 1.26 1 0.26
Coffee drinking (yes) 89 (13.1) 65 (9.6) 4.22 1 0.04
Alcohol drinking (yes) 10 (1.5) 13 (1.9) 0.40 1 0.52
Smoking (yes) 24 (3.5) 23 (3.4) 0.02 1 0.88
Breakfast eating (yes) 382 (56.2) 281 (41.3) 30.02 1 b0.0001
Assessments
b
MPI_Neuroticism (25) 128 (18.7) 315 (46.3) 118.47 1 b0.0001
PCS_MSF (low, moderate) 28, 546 (4.1, 80.3) 46, 533 (6.8, 78.4) 4.66 2 0.09
RCS_MSF (low, moderate) 125, 285 (18.4, 41.9) 149, 323 (21.9, 47.5) 12.52 2 0.002
PRS_MSF (low, moderate) 38, 411 (5.6, 60.4) 53, 466 (7.8, 68.5) 9.97 2 0.007
RRS_MSF (low, moderate) 38, 411 (5.6, 60.4) 53, 446 (7.8, 65.6) 9.97 2 0.005
CHQ (4) 61 (9.0) 140 (20.6) 36.44 1 b0.0001
a
The systemic diseases included hypertension, diabetes mellitus, tuberculosis, asthma, renal disease, polycystic kidney disease, proteinuria,
hematuria, urinary stone, arthritis, epilepsy, systemic lupus erythematosus, polio and hyperlipidemia.
b
MPI: Maudsley Personality Inventory; PCS_MSF: perceived crisis support; RCS_MSF: received crisis support; PRS_MSF: perceived routine
support; RRS_MSF: received routine support; CHQ: 12-item Chinese Health Questionnaire.
296 H.F. Tsai et al. / Psychiatry Research 167 (2009) 294299
the criteria of the MPI, subjects scoring 25 points or
higher were categorized as abnormal.
2.4. Statistical methods
Group differences in categorical variables were
analyzed using the Chi-square test. Subsequently,
logistic regression was used to analyze the association
between the multiple risk factors and Internet addiction.
Variables with Pb0.05 in univariate analyses were
included in the multivariate models. The two-tailed
significance level was set at 0.05. All of the analyses
were carried out using the SPSS software (Version 11,
SPSS Inc., Chicago, IL, U.S.A.).
3. Results
Questionnaires were completed by 3806 of the
participants completed the questionnaires (response
rate =80.81%), and 67.7% of them were male
(males =67.7%). There were 680 (17.9%) freshmen
who were classified as possible cases of Internet
addiction. Furthermore, in order to analyze the possible
risk factors of Internet addiction, these 680 Internet
addiction students and 680 randomly selected non-
Internet addiction students from the non-Internet addic-
tion group were included.
The distinguishing characteristics of the Internet ad-
diction and non-addiction groups are shown in Table 1.
Coffee-drinking and breakfast-eating habits were sig-
nificantly less common among the students with Internet
addiction. Of the psychological symptoms, neuroticism
and psychiatric morbidity were significantly associated
with Internet addiction. Relative to a high score on the
MSF, lower support functions of received crisis, perceived
routine and received routine were more prevalent in the
Internet addiction group.
Because sex was a predictor of Internet addiction in
some previous studies (Young, 1996), we selected it and
other significant variables to enter in the multiple logistic
regression model. As shown in Table 2, male gender
increased the risk of Internet addiction by 1.3-fold, and
breakfast skipping increased that risk by 1.8-fold. Among
the various assessments of psychological symptoms,
scores on the neuroticism subscale of the MPI, support
functions of received crisis, and the CHQ-12 were sig-
nificant predictors of the risk of Internet addiction.
4. Discussion
The prevalence rates of Internet addiction seemto vary
with different study populations. Pallanti et al. (2006)
reported that 5.4% of Italian high-school students could
be characterized as suffering from Internet addiction as
defined by the Internet Addiction Scale criteria. Using the
Pathological Internet Use Scale, Morahan-Martin and
Schumacher (2000) found that 8.1% of U.S. College
students had symptoms related to pathological Internet
use. In this study, 17.9% of hr Taiwanese university
students were found to be Internet addicted. Owing to the
differences in target populations, social and cultural
contexts, and screening tools, it is difficult to compare
these findings directly.
Internet addiction was found to be associated with
male gender, habit of skipping breakfast, minor mental
health morbidity, poor social support function, and
neurotic personality characteristics. Some of these
findings are consistent with those of other studies on
Table 2
Risk factors of Internet addiction based on the logistic regression analyses (N=1360).
Predictors
a
df P-value O.R.
b
95% C.I.
b
Demographic and health variables
Sex (male vs. female) 1 0.28 0.03 1.32 1.031.70
Breakfast eating (no vs. yes) 1 0.56 0.00 1.75 1.392.19
Assessments
c
MPI_Neuroticism (25 vs.b25) 1 0.08 0.00 1.08 1.071.09
RCS_MSF score
Low vs. high 1 0.32 0.05 1.37 1.001.88
Moderate vs. high 1 0.30 0.02 1.35 1.051.75
CHQ (4 vs. b4) 1 0.40 0.03 1.49 1.042.12
Constant 1 1.12 0.33
2 Log likelihood=1722.51, Nagelkerke R square=0.15.
a
The non-significant predictors (coffee, PRS_MSF, and RRS_MSF) in the model are not shown here.
b
O.R.: Odds ratios; 95% C.I.: 95% confidence interval.
c
MPI: Maudsley Personality Inventory; RCS_MSF: received crisis support; CHQ: 12-item Chinese Health Questionnaire.
297 H.F. Tsai et al. / Psychiatry Research 167 (2009) 294299
social impairment and mental morbidity in excessive
Internet users (Shapira et al., 2000; Pratarelli and
Browne, 2002; Nalwa and Anand, 2003).
The personality trait of neuroticism (as defined by the
MPI neuroticism score) was associated with Internet
addiction (as defined by the CIAS-R) in the freshmen in
this study. These students may prefer to do something
alone to avoid feeling anxious. Although several previous
studies have proposed that the subjects with Internet
addiction had distinctive personality characteristics such
as depressed, lonely, lowin self-esteem, anxious, and bold
as well as assertive (Young, 1998a; Beard and Wolf,
2001), Engelberg and Sjberg (2004) concluded that
frequent use of the Internet could not be linked to any
specific personality dimension. However, Lee et al.
(2005) reported that neuroticismscores may be associated
with D
2
/D
3
receptor availability in healthy individuals. It
is well known that the dopaminergic system may be
implicated in the most important systems involved in
addiction behaviors (Nisell et al., 1995). In light of these
findings, the association between neuroticism scores and
Internet addiction may seem plausible.
Male gender was another risk factor for Internet
addiction in this study. This observation validates the
findings of Young (1998b) and Greenfield (1999). A
study on gender differences in sexual arousal found that
men tend to be more visual with respect to sexual fantasies
while women are more process or verbally oriented (Buss,
1999). As the cost of bandwidths decreased drastically in
recent years, the Internet has become more abundant with
graphical information. The increased availability of
pornography in cyberspace may be one of the reasons
for the higher prevalence rate of Internet addiction in
males. Estimates suggest that one in five Internet addicts
are engaged in some form of online sexual activity
(primarily viewing cyberporn and/or engaging in cyber-
sex). Studies also show that men are more likely to view
cyberporn. Cooper et al. (2000) studied cybersex
compulsives and found that the group was 79% male.
The cybersex compulsive group consisted of those who
met the criteria for both sexual compulsivity on the Sexual
Compulsivity Scale (Kalichman et al., 1994) and who
spent more than 11 h a week online engaged in sexual
pursuits. However, not all studies about cyber sex
addiction agree about the male dominance of the group
(Griffiths, 2004). Further studies are thus needed to
conclusively validate the link between male gender and
Internet addiction.
In a survey of Internet addiction in students in India,
Nalwa and Anand (2003) found that Internet-dependent
users often spend excessive amounts of time online,
delaying work and losing sleep due to late-night log-ons.
The disrupted sleep patterns due to late-night Internet
sessions may lead to excessive fatigue and thus impair
functioning in the academic and occupational realms. In
our study, the habit of skipping breakfast is one of the
risk factors of Internet addiction. This finding seems
reasonable since Internet addicts stay up late at night and
may get up too late for breakfast.
Nalwa and Anand (2003) also reported that the higher
the scores on the loneliness scale, the more dependent on
Internet usage the subjects are. Furthermore, Young
(1996) demonstrated that addictive use of the Internet led
directly to social isolation, depression, familial discord,
divorce, academic failure, financial indebtedness, and job
loss. These results may suggest a relationship between a
poor social support system and Internet addiction.
However, further studies are needed to explain why
only the RCS score is related to Internet addition.
There are several limitations in our study. First of all,
we did not conduct individual interviews to confirm the
diagnoses of Internet addiction and psychiatric morbid-
ity. Secondly, we only found an association between
the risk factors and Internet addiction, but did not clarify
the mechanism of these risk factors. Thus the causal
relationship cannot be confirmed. Lastly, excluding the
freshmen who did not complete all questionnaires from
our analyses might have influenced the power of the
findings.
In conclusion, our findings indicate that Internet
addiction is prevalent among university freshmen and
certain lifestyle habits and mental health problems are
related to Internet addiction. We recommend integrating
long-term follow-ups into the associated mental health
programs of university freshmen to monitor the devel-
opment of Internet addiction, as well as prioritizing
Internet addiction for further research.
Acknowledgments
The authors thank Miss Shu Chuan Lin, Miss Ching
Lin Chu, Miss Linda J. Chang, Miss Yun-Hsuan Chang
and students of the National Cheng Kung University
who participated in the study.
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