European Psychiatry 27 (2012) 18

Review

The association between Internet addiction and psychiatric disorder:

A review of the literature
C.-H. Ko a,b,c, J.-Y. Yen b,c,d, C.-F. Yen b,c, C.-S. Chen b,c,d, C.-C. Chen b,c,e,*
a
Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
b
Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
c
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
d
Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
e
Department of Psychiatry, Kai-Suan Psychiatric Hospital, 130, Kai-Suan 2RD, Ling-Ya District, Kaohsiung 802, Taiwan, ROC

A R T I C L E I N F O A B S T R A C T

Article history: Internet addiction is a newly emergent disorder. It has been found to be associated with a variety of
Received 24 January 2010 psychiatric disorders. Information about such coexisting psychiatric disorders is essential to understand
Received in revised form 24 April 2010 the mechanism of Internet addiction. In this review, we have recruited articles mentioning coexisting
Accepted 25 April 2010
psychiatric disorders of Internet addiction from the PubMed database as at November 3, 2009. We
Available online 6 December 2011
describe the updated results for such disorders of Internet addiction, which include substance use
disorder, attention-decit hyperactivity disorder, depression, hostility, and social anxiety disorder. We
Keywords:
also provide discussion for possible mechanisms accounting for the coexistence of psychiatric disorders
Internet addiction
Substance use disorder
and Internet addiction. The review might suggest that combined psychiatric disorders mentioned above
Comorbidity should be evaluated and treated to prevent their deteriorating effect on the prognosis of Internet
ADHD addiction. On the other hand, Internet addiction should be paid more attention to when treating people
Depression with these coexisting psychiatric disorders of Internet addiction. Additionally, we also suggest future
Social anxiety necessary research directions that could provide further important information for the understanding of
Hostility this issue.
2010 Elsevier Masson SAS. All rights reserved.

1. Introduction addiction disorder [23], pathological Internet use [64], and

In recent years, the Internet has become one of the most
important academic and recreational tools for adolescents and
adults. It provides an easy and immediate way for people to
explore information and communicate with other people over the
world. However, a loss of control over Internet use might lead to
negative impacts on daily life function, family relationships, and
emotional stability [1,38,47,65]. This phenomenon has been
described as Internet addiction or problematic Internet use
[23,50], and is suggested to be one type of behavioral addiction
[18]. In recent years, Internet addiction has been reported in both
Western and Eastern societies among adult and adolescent groups
[5,39,53,61]. It has become an important global mental health
problem and further attention should be paid to it.
1.1. The concept and denition of Internet addiction
The clinical features of behavioral problems related to Internet
use have been described in various ways, including Internet
* Corresponding author. Tel.: +886 7 7513171; fax: +886 7 7712494.
E-mail addresses: ccchen@mail.khja.org.tw, cyberko@seed.net.tw (C.-C. Chen).
problematic Internet use [50]. Several researchers have tried to
construct diagnostic criteria for this clinical issue. Young modied
the diagnostic criteria of pathological gambling in the Diagnostic
and Statistical Manual of Mental Disorders 4th edition (DSM-IV)
[2] to construct diagnostic questionnaires for pathological Internet
use. He has dened pathological Internet use as having ve or more
of eight characteristic symptoms including preoccupation, toler-
ance, withdrawal, failure to control, use longer than intended,
functional impairment, lying, and escape [64]. Shapira et al. have
also proposed diagnostic criteria for problematic Internet use
according to the concepts of impulse-control disorder in DSM-IV-
TR [3,50], and suggested that it is necessary to exclude behavioral
changes secondary to mania [50]. Under the concept of these two
denitions, Internet addiction was classied as impulse-control
disorder.
Anderson used the seven true-false questions that most closely
paralleled the diagnostic criteria of substance dependence in DSM-
IV to dene Internet dependence [1]. Ko and his colleagues had
proposed two diagnostic criteria of Internet addiction in adoles-
cents and college students based on data collected by systemic
diagnostic interview [23,29]. These criteria (of Ko et al.) had
provided data of sensitivity and specicity, and were composed of

0924-9338/$ see front matter 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.eurpsy.2010.04.011
2 C.-H. Ko et al. / European Psychiatry 27 (2012) 18
criteria A, B, and C. Criterion A contains nine characteristic
symptoms of Internet addiction, including preoccupation, uncon-
trolled impulse, usage more than intended, tolerance, withdrawal,
impairment of control, excessive time and effort spent on the
Internet, and impairment of decision-making ability. Six or more
symptoms should be fullled in Criterion A. Criterion B describes
functional impairment secondary to Internet use. Criterion C lists
the exclusive criteria including psychotic disorder, bipolar I
disorder, and other impulse-control disorder. People fullling
criteria A, B, and C would be diagnosed as having Internet
Addiction. Based on these criteria and termination, Internet
addiction was dened as a behavior addiction and by the criteria
similar to substance use disorder.
Until now, whether Internet addiction is classied as impulse-
control disorder or a behavior addiction has not been conrmed.
Furthermore, the operational denition of Internet addiction has
not been conclusively developed and is not included in the DSM-
IV-TR. However, the prevalence of Internet addiction has caught
the attention of researchers and it has been suggested that Internet
addiction should be included in DSM-V [8]. The DSM-V work group
has proposed that pathological gambling would be reclassied
from impulse-control disorders not elsewhere classied to
substance-related disorders, which will be renamed addiction
and related disorders. In addition, the report of the DSM-V
Substance-Related Disorders Work Group has also suggested that
Internet addiction might be one of the candidates for a possible
Non-substance addictions category as is pathological gambling.
However, the diagnostic criteria for Internet addiction was not
provided by the DSM-V work group. More empirical data focusing
on Internet addiction is necessary to support the denition and
classication for Internet addiction.
2. The possible mechanism underlining the coexisting
psychiatric disorders of Internet addiction
Shaffer et al. have criticized the fact that there is not yet
adequate evidence demonstrating that Internet addiction is a
primary disorder, and state that Internet addiction might be better
explained by the results of other primary disorders [48]. This might
suggest that understanding the association between Internet
addiction and other psychiatric disorders might shed light on the
mechanism of Internet addiction.
The comorbidity between addictive and other psychiatric
disorders has been repeatedly reported and reviewed [21,44].
The comorbidity between two disorders indicates that the
association between the two disorders is higher than expected
by chance. Thus, it usually suggests a mechanism or mechanisms
exist to contribute to the association, and it is therefore important
to understand such mechanisms and develop effective treatment
for both disorders. Four possible mechanisms have been described
to explain the association between addictive behaviors and
psychiatric disorders. Firstly, the psychiatric disorder results in,
contributes to, or deteriorates the symptoms or course of the
addictive disorder. Secondly, the addictive disorder leads to,
contributes to, or further deteriorates the symptoms or course of
other psychiatric disorders. Thirdly, there are underlying biologi-
cal, psychological, or sociological mechanisms shared by addictive
and psychiatric disorders. Lastly, other factors related to sampling,
assessment, investigation, study design, or analysis result in
inappropriate over-estimation of the comorbidity [41,44].
Thus, a very complex and comprehensive design is necessary to
conrm or test the hypothesis for the above four mechanisms;
however, it might be very difcult in situations with limited
resources. On the other hand, much previous research has focused
on the issue of coexisting psychiatric disorders of Internet
addiction, and the results have shed light on understanding the
possible mechanism(s) of Internet addiction. Accordingly, it is
necessary to carry out further review of previous studies in order to
provide updated information to clinicians and provide a direction
of future study for researchers.
In this review, we have recruited articles mentioning coexisting
psychiatric disorders of Internet addiction from the PubMed
database as at November 3, 2009. All articles that could be
recruited from PubMed with the key words of Internet addiction
and that were associated with coexisting psychiatric disorders of
Internet addiction.
3. The epidemiology of Internet addiction
The epidemiological ndings of Internet addiction is summa-
rized in Table 1. Based on the Internet addiction test [IAT], Lam
et al. found 10.8% of 13- to 18-year-olds were moderately to
severely addicted to the Internet in China [35]. Cao and Su had
reported 18.2% of junior high school students in China were
classied as Internet addicts based on the same test [10]. Further,
IAT had also revealed that 6.44% of rst-year university students
were addicted to the Internet [42]. Kim et al. found that 38% of
adolescents were classied as possible Internet addicts and 1.6% of
adolescents were diagnosed as Internet addicts in Korea [22].
Furthermore, Park et al. found that 10.7% of adolescents in Korea
had Internet addiction according to the Internet addiction scale
[45]. Moreover, Jang et al. found that 4.3% of adolescents showed
Internet addiction in Korea respectively [20]. In Italy, Milani et al.
found that 36.7% of adolescents aged 1419 years had signs of
problematic Internet use, which was dened as scoring more than
50 in IAT [39]. Canan et al. had reported that 11.6% of adolescents
aged 1419 years were classied as Internet addicts based on the
cut-off point of the Turkish version of the Internet addiction scale
[9]. Three different cut-off points, 50, 70, and 81, of IAT might be
one of the possible factors for the inconsisted results (Table 2).
By using Youngs Diagnostic Questionnaire [YDQ], Siomos et al.
found that 11% of 12- to 18-year-old adolescents had fullled the
criteria of Internet addiction in Greece [51]. Bakken et al. found
4.1% of females and 19% of males among a group aged 16 to 29 were
classied as having Internet addiction or at-risk addiction in
Norway [5]. Cao and Su found 2.4% of adolescents were classied as
having Internet addiction in China [10]. In China, Huang and Leung
also found 9.8% of teenagers had Instant Messaging addiction
(which is a subtype of Internet addiction) [19]. Shek et al. reported
that 19.1% of Hong Kong Chinese adolescents were found to have
Internet addiction [51].
In Taiwan, the most popular assessment tool for Internet
addiction is the Chen Internet Addiction Scale (CIAS) [12]. The
CIAS provides a clear cut-off point with good specicity and
adequate sensitivity to determine Internet addiction in adoles-
cents [24] and college students [29], based on the developed
diagnostic criteria of Internet addiction [23,29]. By using the
questionnaire, 18.8% of high school students [30], 17.9% of senior
high school students [59], 10.8% of grade 7 students [31] and 12.9%
of college students [61] were classied as Internet addiction. Until
now, no study has evaluated the prevalence based on psychiatric-
interview diagnosis.
In these studies, we found that Internet addiction was prevalent
across Eastern and Western societies. This might indicate the
disorder is a globalizing disorder worthy of more attention.
Furthermore, Internet addiction has been reported in adolescents
[30], college students [61], and adults [7]. However, most reports
focused on adolescents and young adult groups those who had
grown up in an environmental with a well-developed Internet.
Moreover, many reports were investigated in Asia countries in
which the Internet had been rapidly developed in recent years.
It might suggest that early exposure to the Internet and
 C.-H. Ko et al. / European Psychiatry 27 (2012) 18 3

Table 1
Review of the prevalence of Internet addiction.

Age (n) Country Assessment tool Denition Rate (%) Publishing Author
date

1419 y/o (292) Turkey Internet addiction scale Cut-off score: 81 11.6 2009/12 Canan et al.
(Turkish version)

1318 y/o (1618) China Internet Addiction Test Moderately to severely 10.8 2009/12 Lam et al.
addicted to Internet

1113 y/o (2162) Taiwan Chen Internet addiction scale Cut-off score: 64 10.8 2009/10 Ko et al.

1419 y/o (98) Italy Internet Addiction Test Cut-off score: 50 36.7 2009/12 Milani et al.

1219 y/o (330) China Youngs diagnostic questionnaire 5 or more 9.8 2009/12 Huang et al.
of Internet addiction

1216 y/o (9405) Taiwan Chen Internet addiction scale Cut-off score: 64 18.8 2009/6 Ko et al.

First-year university students (3557) China Internet Addiction Test Cut-off score: 50 6.44 2009/6 Ni et al.

University students (2453) Taiwan Chen Internet addiction scale Cut-off score: 68 12.3 2009/4 Yen et al.

High school students (903) South Korea Internet Addiction Scale Cut-off score: 70 10.7 2008 Park et al.

1218 y/o (2200) Greek Youngs diagnostic questionnaire 5 or more 8.2 2008/12 Siomos et al.
of Internet addiction

Junior high school students (686) South Korea Internet Addiction Scale Cut-off score: 50 18.2 2008/12 Cho et al.

1674 y/o (3399) Norwegians Youngs diagnostic questionnaire 5 or more 1 2009/4 Bakken et al.
of Internet addiction

1118 y/o (6121) Hong Kong Chinese of Internet addiction 3 or more (Goldberg) 22.9 (Goldberg) 2008 Shek et al.
(Goldberg) scale and Chinese Four or more (Young) 19.1 (Young)
Internet Addiction (Young) Scale

7th12th grades students (851) South Korea Internet Addiction Scale Cut-off score: 70 4.3 2008/3 Jang et al.

1516 y/o (1573) South Korea Internet Addiction Scale Cut-off score: 70 1.6 2006/2 Kim et al.

Senior high school (2114) Taiwan Chen Internet addiction scale Cut-off score: 64 17.9 2007/7 Yen et al.

1218 y/o (2620) China Youngs diagnostic Yes for 15 items and 2.4 2007/5 Cao et al.
questionnaire of one of 68 items
Internet addiction

environmental factors were important associated factors for 4.2. The association between Internet addiction and substance use
Internet addiction. disorders

4. The association between Internet addiction and psychiatric
disorders
4.1. The association between Internet addiction and mental health
Based on the Symptom Checklist-90-Revision, obsessive-
compulsive and depressive symptoms were found to be associated
with intermittent and unabated addiction to the Internet
respectively, in a Korean study [20]. Yang and colleagues also
noted that excessive Internet use on IAT was associated with
higher psychiatric symptoms on the Symptom Checklist-90-
Revision in Korea [58]. However, Niemz and colleagues did not
nd a signicant association between pathological Internet use
and the level of mental health on the General Health Questionnaire
[43]. Yen and colleagues evaluated psychiatric symptoms by using
the Brief Symptoms Inventory, and found that adolescents with
Internet addiction had higher psychiatric symptoms than those
without Internet addiction [60]. In that study, hostility and
depression were noted to be the most associated symptoms with
Internet addiction. It also suggested the possible bi-directional
interaction between Internet addiction and psychiatric symptoms.
On the one hand, heavy Internet use might be utilized to cope with
or relieve psychiatric symptoms. On the other hand, maladaptive
Internet use might also result in or further amplify psychiatric
symptoms. However, these mechanisms could not be proven by
the above cross-sectional studies.
Volkow and Li have suggested that addiction-prone pheno-
types for substance use disorders would also reect sensitivity to
other alternative reinforcers in the individuals environment [56].
Thus, if the Internet had the potential to be addictive, adolescents
or college students with vulnerability to substance use disorders
would be vulnerable to Internet addiction. Bai and colleagues rst
noted the high prevalence of substance use disorders among cases
of Internet addiction in a virtual clinic [4]. Lam and colleagues
stated that adolescents with alcohol drinking behavior are more
likely to have Internet addiction [OR = 1.7, 95% CI = 1.12.8] [35].
Ko and colleagues declared that adolescents with substance use
experience are more likely to have Internet addiction [25].
Furthermore, this article also noted that adolescents with Internet
addiction or substance use experience shared the same personal-
ity characteristics, including high novelty-seeking and low
reward dependence. However, adolescents with Internet addic-
tion had high harm avoidance, which was low among adolescents
with substance exposure [25]. Ko and colleagues also determined
that adolescents with problematic alcohol use were more likely to
have Internet addiction [27]. This study also ascertained that
psychosocial proneness, including high behavior activation, low
self-esteem, low family function, and low life satisfaction, were all
associated with both Internet addiction and problematic alcohol
use. Based on the results, the authors suggest that Internet
addiction could be included in the organization of a problematic
behavior model. Yen and colleagues further demonstrated that
4 C.-H. Ko et al. / European Psychiatry 27 (2012) 18

Table 2
Review for the coexisting psychiatric disorder of Internet addiction.

Author/Year/country Sample (n) Design Coexisting psychiatric Assessment tool Statistically

disorder analysis

Jang et al./2008/Korea Junior and senior high Cross-section Obsessive-compulsive Symptom Checklist-90-Revision Logistic
school (914) and depressive symptoms regression

Yang et al./2005/Korea Senior high school (328) Cross-section Psychiatric symptoms Symptom Checklist-90-Revision ANOVA

Niemz et al./2005/British University students (371) Cross-section Mental health General Health Questionnaire ANOVA

Yen et al./2008/Taiwan Junior and senior high Cross-section Psychiatric symptoms Brief Symptoms Inventory t test Logistic
school (3662) regression

Bai et al./2001/Taiwan visitors to the virtual Cross-section Substance use disorder Unknown Chi-square
clinic (251)

Lam et al./2009/China Junior and senior high Cross-section Drinking more than Questionnaire Logistic regression
school (1639) 2 times a week

Yen et al./2007/Taiwan Senior high school (2114) Cross-section ADHDa ADHDa t test Logistic
Depression Self-rated scale regression
Social anxiety The Center for Epidemiological
Hostility Studies Depression Scale
Social Phobia Inventory
The Buss-Durkee Hostility
Inventory-Chinese
Version-Short Form

Ko et al./2005/Taiwan Junior and senior high Cross-section Substance use experience Questionnaire Chi-square
school (3662)

Ko et al./2008/Taiwan Senior high school (2114) Cross-section Problematic alcohol use CRAFFT Chi-square

Yen et al./2009/Taiwan College students (2453) Cross-section Harmful alcohol use Alcohol Use Disorders Chi-square
Identication Test

Yoo et al./2004/Korea Element school (535) Cross-section ADHDa DuPauls ADHDa rating scale Correlation t test
a
Bernardi and Pallanti/2009/ Adult (50) Cross-section ADHD Diagnostic interviewing Just reporting
American Dysthymic disorders percentage
Social anxiety disorder
Hypomania

Ha et al./2006/Korea Children (455) and Cross-section ADHDa Psychiatric interviewing for Just reporting
adolescents (836) Depression 12 children and adolescents percentage

Yen et al./2007/Taiwan College students (2793) Cross-section ADHDa Adult ADHD Self-Report Scale t test Logistic
regression

Ko et al./2008/Taiwan College students (216) Cross-section Adult ADHD Psychiatric interviewing Chi-square
Depressive disorder
Social anxiety disorder

Ko et al./2009/Taiwan
Junior High School (2293)
Prospective ADHDa ADHDa Survival analysis
Depression Self-rated scale
Social anxiety The Center for Epidemiological
Studies Depression Scale
Hostility Negative self evaluation scale
The Buss-Durkee Hostility
Inventory-Chinese
Version-Short Form

Kim et al./2006/Korea High school students Cross-section Depression Korean version of the Diagnostic ANOVA
(1573) Interview Schedule for
Children-Major Depression
Disorder-Simple Questionnaire

Ko et al./2007/Taiwan Junior High School (517) Prospective Hostility Interpersonal Brief Symptoms Inventory t test
sensitivity
a
Attention-decit and hyperactivity disorder.

college students with harmful alcohol use were more likely to
have Internet addiction [62]. Besides, both harmful alcohol use
and Internet addiction were associated with high behavior
activation. These results might suggest the shared personality
characteristics play a role in the coexistence between Internet
addiction and substance use disorders. Furthermore, Ko and
colleagues demonstrated that cue-induced gaming urges activat-
ed similar brain areas corresponding to substance craving in a
functional magnetic resonance study [32]. However, more
neurobiological studies are necessary to test the hypothesis that
Internet addiction has similar neurocognitive mechanism[s] to
substance use disorders.
4.3. The association between Internet addiction and attention-decit
hyperactivity disorder (ADHD)
ADHD as dened by DSM-IV-TR manifests distractibility,
difculty focusing, excessive talking and restlessness, and affects
510% of children and 4% of adults [11]. Yoo and colleagues rst
reported the association between Internet addiction and ADHD in
 C.-H. Ko et al. / European Psychiatry 27 (2012) 18
elementary schoolchildren in Korea [63]. Bernardi and Pallanti
found that 14% of adults with Internet addiction were diagnosed
with ADHD [7]. Ha and colleagues had also reported that seven out
of 12 children with Internet addiction were diagnosed with ADHD
[16]. Yen and colleagues found that adolescents with Internet
addiction had signicantly higher ADHD symptoms than those
without Internet addiction and ADHD symptoms were the most
signicantly associated symptoms of Internet addiction [61]. In a
study among adults, Yen and colleagues also demonstrated the
association between Internet addiction and higher symptoms of
adult ADHD among college students. Among the manifesting
ADHD symptoms, attention decit was the most associated one
with Internet addiction, and the association was more prominent
among females [61]. Ko and colleagues conducted a diagnostic
psychiatric-interview study that found an association between
adult ADHD and Internet addiction [28]. This study also found that
adult ADHD was the most signicantly associated psychiatric
disorder of Internet addiction among college students. Although
the fact that ADHD had developed before 7 years of age provides
temporal information, the causal relationship between Internet
addiction and adult ADHD could not be conrmed in the cross-
sectional designed study. A recent two-year prospective study
found that adolescents with ADHD were more likely to become
Internet-addicted in the two-year follow-up [31].
Biopsychosocial mechanisms have been utilized to explain the
coexistence between Internet addiction and ADHD. Firstly, two
core symptoms reported in ADHD are being easily bored and
having an aversion for delayed reward [11,15], which usually
resulted in impaired academic function and difculties in
interpersonal relationships. Internet behavior is characterized by
rapid response, immediate reward, and multiple windows with
different activities, which may reduce the feeling of boredom or
provide immediate stimulation and reward for subjects with
ADHD.
Secondly, Koepp and colleagues have reported that striatal
dopamine is released during video gaming [33], which may help
the game players keep focused on gaming and have better
performance. Thus, adolescents with ADHD may utilize the
Internet to compensate for the frustration they feel in real-life
situations. Thirdly, research has found that adolescents with ADHD
have abnormal brain activities associated with impaired inhibition
[46]. This lack of self-control may cause individuals with ADHD to
have difculty in controlling Internet use and hence become
vulnerable to Internet addiction. Fourthly, motivation decit, an
anomalous reaction to reward and punishment, has been reported
to be an endophenotype of ADHD [11]. The decit includes rapid
habituation to repeated positive reinforcement and less arousal or
behavioral response to punishment [6]. Internet activities,
especially for online gaming, usually provide immediate response
and reward. Higher reward sensitivity might contribute to higher
vulnerability to Internet addiction. Lastly, impulsivity, hyperactiv-
ity, and inattention usually negatively inuence individuals
interpersonal relationships. However, these decits could be
masked well online. Thus, for people with ADHD, establishing
interpersonal relationships online is easier than in the real world.
Although these factors possibly explain why people with ADHD are
more likely to be addicted to the Internet, further research focusing
on these mechanisms is necessary to prove/disprove these
hypotheses.
In any case, the association between ADHD and Internet
addiction might suggest that people with ADHD should be an
important target group of preventive scheduling for Internet
addiction. Furthermore, ADHD should be well-evaluated and
treated among cases of Internet addiction. Han and colleagues
have found that methylphenidate could decrease online gaming
use among adolescents with ADHD and online gaming behaviors
5
[17]. These results suggest that treating the coexisting psychiatric
disorders could also benet Internet addiction. On the other hand,
whether Internet addiction would deteriorate or benet the course
of ADHD should be also researched by prospective studies.
4.4. The association between Internet addiction and major depressive
disorder
Bernardi and Pallanti have reported that 7% of adult cases of
Internet addiction had comorbid dysthymic disorder [7]. Ha and
colleagues discovered an association between Internet addiction
and depression among adolescents in a Korean sample [16]. Kim
and colleagues noted that Internet addiction was associated with
depression and suicide ideation [22]. Yen and colleagues demon-
strated the association between Internet addiction and depressive
symptoms under control of other psychiatric symptoms among
adolescents in Taiwan [59]. Another psychiatric diagnostic
interview study demonstrated the association between Internet
addiction and depressive disorders [major depressive disorder and
dysthymic disorder] in college students [28]. These cross-sectional
studies demonstrate the association between Internet addiction
and depression. However, the causal relationship between Internet
addiction and depression could not be proven.
Ko and colleagues conducted a prospective questionnaire study
to demonstrate that adolescents with depression are more likely to
become Internet-addicted in the two-year follow-up period. Since
the Internet provides adolescents with social support [55],
achievement [54], the pleasure of control [37], and a virtual world
in which they can escape from emotional difculty in the real
world, it appears reasonable that adolescents with depression
would be more likely to use the Internet to alleviate depression,
and would be more prone to subsequent Internet addiction than
are their unaffected peers. Kraut and colleagues [34] proposed a
rich get richer model where the Internet provides more benets
to those who are already well-adjusted, and by contrast, poorly
adjusted adolescents with depression may suffer more deleterious
effects from heavy Internet use, creating a vicious circle.
Additionally, previous research has found that the short alleles
of the 5HTTLPR polymorphism, which is associated with depres-
sion [57], is also associated with Internet addiction [36]. The
5HTTLPR gene is implicated in serotonin function; therefore, the
biological vulnerability to both depression and Internet addiction
might be linked to serotonin dysfunction, which in turn might
explain the relationship found in this study. Thus, depressive
disorders should be a target of preventive scheduling of Internet
addiction and should be assessed and treated among cases of
Internet addiction. On the other hand, the effect of Internet
addiction on the course or prognosis of depression has not been
thoroughly investigated. Further prospective studies to address
this important issue are necessary.
4.5. The association between Internet addiction and social anxiety
The Internet could provide non-face-to-face interaction with
anonymity and might attenuate anxiety when interacting.
However, whether Internet communication benets adolescents
with social phobia is still inconclusive [40,52]. Bernardi and
Pallanti found that 15% of adult cases of Internet addiction were
classied to have social anxiety disorder [7]. Milani and colleagues
reported that adolescents with symptoms of problematic Internet
use had worse interpersonal relationships [39]. In China, shyness
and alienation from family, peers, and school have been noted to be
associated with Instant Messaging addiction among teenagers
[19]. The association between Internet addiction and social anxiety
has also been found among adolescents in Taiwan [59]. Further-
more, this association was found in a psychiatric diagnostic
6 C.-H. Ko et al. / European Psychiatry 27 (2012) 18
interviewing study among college students [28]. Moreover, social
anxiety symptoms could predict the emergence of Internet
addiction in a two-year follow-up study [31]. Since Internet use
could provide social support [52], adolescents with social phobia
might benet from avoiding the stress caused by face-to-face
interaction with others. However, if their social difculties in the
real world did not improve, adolescents with social phobia might
receive social support predominantly from the Internet, and this
could decrease their motivation to meet others in the real world.
Then, the risk of becoming addicted to Internet use would increase.
However, we found that the predictive effect of social phobia was
insignicant after control of depression and ADHD [31]. This might
indicate that other psychiatric symptoms are more important
predictors of Internet addiction than social phobia. In any case,
social anxiety is an important psychiatric problem deserving more
attention when treating Internet addiction.
4.6. The association between Internet addiction and hostility, and
aggressive behavior
Yen and colleagues have noted that hostility was associated
with Internet addiction in adolescents [59,60]. Then, after one year
of follow-up, hostility could predict the persistence of Internet
addiction [26]. Moreover, Ko and colleagues determined that
adolescents with Internet addiction are more likely to manifest
aggressive behaviors [30]. All these studies demonstrate the strong
association between Internet addiction and hostility.
However, these previous studies could not conrm the causal
relationship suggested by the above hypothesis. On the other hand, a
prospective study demonstrates that adolescents with higher
hostility have higher risk of developing Internet addiction [31].
For adolescents, high hostility might result in interpersonal conict
or rejection. The Internet could provide a cheap, free, and virtual
world to escape from the interpersonal difculties of the real world,
as previously mentioned. In addition, many Internet activities,
especially online gaming, provide a world in which to express
hostility and perpetrate violence without restriction, but that does
not mean such violence is harmless according to the effect
mentioned above. However, whether online behavior or Internet
addiction would result in hostility or aggressive behaviors has not
been validated. It is necessary to evaluate whether people with
Internet addiction are more aggressive online than in the real world,
and whether this tendency would result in progression of hostility
and aggressive behavior in the real world.
4.7. The association between Internet addiction and other psychiatric
disorders
Internet addiction has also been reported to be associated with
many psychiatric disorders that have not been well or repeatedly
evaluated. Bernardi and Pallanti found that 7% of adult cases of
Internet addiction had hypomania [7]. Shapira et al. noted that a
signicant percentage of cases with Internet addiction in a clinical
setting were the cases of bipolar I disorder [49]. However, these
results could not demonstrate that Internet addiction was more
prevalent in those with bipolar I disorder than those without.
Bernardi and Pallanti found that 15% of adults with Internet
addiction had general anxiety disorder, 7% had obsessive-
compulsive personality, 14% had borderline personality disorder,
and 7% had avoidant personality disorder [7]. Furthermore, the
association between Internet addiction and dissociative symp-
toms was noted in the clinical [7] and nonclinical groups [14]. Choi
and colleagues found a signicant association between Internet
addiction and excessive daytime sleepiness among adolescents
[13]. Ha and colleagues also found an association between
Internet addiction and obsessive-compulsive symptoms [16].
Since heavy Internet use has been labeled as compulsive Internet
use, whether Internet addiction is associated with obsessive-
compulsive spectrum disorders is important but not demonstrat-
ed. These associations between Internet addiction and bipolar I
disorder, dissociative disorder, general anxiety disorder, and
obsessive-compulsive disorder should be evaluated by further
studies.
5. The clinical implication of comorbidity
The associations between Internet addiction and psychiatric
disorders provide important information for treatment and
prevention for Internet addiction. These psychiatric disorders,
including ADHD, depression, social anxiety disorder, substance
use disorder, and aggressive behaviors, should be thoroughly
assessed for cases of Internet addiction. To treat these disorders
concurrently might provide benet to intervention for Internet
addiction. Furthermore, since these disorders might predispose
Internet addiction, appropriate screening and treatment for these
disorders might prevent emergence of Internet addiction.
Moreover, since the Internet is one of the common leisure
activities, it might become a coping strategy for emotional or
social difculties. However, persistent coping use of the Internet
without effective intervention in the real world of some
maladaptive people might result in Internet addiction, which
leads to a vicious cycle. In such a condition, treatment focusing on
Internet addition without paying attention to psychiatric dis-
orders might result in failure of treatment. Lastly, the effect of
suggested preventing schedule and treating coexisting psychiat-
ric disorder for Internet addiction should be further evaluated in
future.
On the other hand, it is also necessary to evaluate the existence
of Internet addiction when treating people with ADHD, depres-
sion, social anxiety disorder, substance use disorder, and
aggressive behaviors, especially among adolescents. Lastly, the
association between Internet addiction and well-known psychi-
atric disorders might increase understanding toward Internet
addiction. For example, Ko and colleagues found that brain
activation of a cue-induced gaming urge was similar to that in
substance craving [32].
6. The questions deserve future study
Firstly, temporal relationships have not been properly
investigated in most studies. Whether psychiatric disorder
predicts Internet addiction or Internet addiction predicts psychi-
atric disorders is necessary to be evaluated. Secondly, how
comorbidity contributes to the prognosis of Internet addiction
and psychiatric disorders should be examined by follow-up
studies. Thirdly, the underling mechanism of the comorbidity has
not been studied well. Underling biological, psychological, and
social mechanisms that could explain the comorbidity should be
further studied. Lastly, whether the treatment for comorbidity can
benet the case of Internet addiction has not been systematically
evaluated.
7. Conclusion
Based on this review, Internet addiction is associated with
substance use disorder, ADHD, depressive disorder, social phobia,
and hostility. Furthermore, ADHD, depressive disorder, social
phobia, and hostility would predict the emergence of Internet
addiction. When treating subjects with Internet addiction, these
disorders should be properly assessed and treated at the same
time. Additionally, the comorbidity should be screened and
interventions developed to prevent the emergence of Internet
 C.-H. Ko et al. / European Psychiatry 27 (2012) 18
addiction. Lastly, it is also important to pay attention to Internet
addiction when treating people with these comorbid disorders.
Further research focusing on the mechanisms of the comorbidity of
Internet addiction is necessary.
Acknowledgments
This study was supported by a grant of the National Science
Council of Taiwan (NSC96-2413-H-037-003-MY2).
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