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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 2  |  Page : 87-94

A study of impulsivity, compulsivity, and dysfunctional belief among medical undergraduate students with problematic internet use


1 Department of Psychiatry, Christian Medical College, Ludhiana, Punjab, India
2 Department of Psychiatry, SRM Medical College, Chennai, Tamil Nadu, India

Date of Submission01-Sep-2021
Date of Decision06-Jan-2022
Date of Acceptance21-Jan-2022
Date of Web Publication13-Jan-2023

Correspondence Address:
Dr. Pallavi Abhilasha
Department of Psychiatry, Christian Medical College, Gateway Terrace No. 12, Doctors Campus, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_201_21

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  Abstract 


Background: Internet addiction has been described as an emerging behavior related to the development of new technologies. Impulsivity is a risk factor for addictive behaviors. Maladaptive use of the Internet has been coined as compulsive Internet use. Dysfunctional belief is an irrational thinking pattern where there is a negative view of self, the outer world, and future. Aim: The present study aims to assess the role of impulsivity, compulsivity, and dysfunctional belief leading to problematic Internet use. Materials and Methods: A total of 300 undergraduate medical students were assessed on this cross-sectional scale. Demographic details, Internet Addiction Test, Urgency Perseveration Premediation Sensation Seeking Positive Urgency Scale, Compulsive Internet Use Scale, and Dysfunctional Attitude Scale were filled by the participants using Google Forms. One hundred students could not be assessed due to nonresponse. Results: This study had a response rate of 66.6%, and of the respondents, 74.4% were mild, 25.2% were moderate, and 0.76% were severe in nature. A positive correlation was observed between Internet addiction and compulsive Internet use. There was a positive correlation between Internet addiction and lack of perseverance and positive urgency. There is an overall significance between level of dependency, achievement, and self-control in problematic and nonproblematic users. Conclusions: In the emerging era of Internet use, we must learn to differentiate excessive Internet use from addiction and be vigilant about psychopathology.

Keywords: Compulsivity, dysfunctional Internet use, impulsivity, Internet addiction, problematic Internet use


How to cite this article:
Abhilasha P, Haryal A, Malhotra M, Reddy M, Moorthy T, Singla M. A study of impulsivity, compulsivity, and dysfunctional belief among medical undergraduate students with problematic internet use. J Mental Health Hum Behav 2022;27:87-94

How to cite this URL:
Abhilasha P, Haryal A, Malhotra M, Reddy M, Moorthy T, Singla M. A study of impulsivity, compulsivity, and dysfunctional belief among medical undergraduate students with problematic internet use. J Mental Health Hum Behav [serial online] 2022 [cited 2023 Jan 27];27:87-94. Available from: https://www.jmhhb.org/text.asp?2022/27/2/87/362704




  Introduction Top


The Internet has become an important part of our life and plays a major role in many of our day-to-day activities. Net-based activity is time intensive yet essential for work done by most professionals including medical professionals. A whole new world of possibilities has opened with the net availability. The other side of the issue is the use of the Internet for leisure activities. It has replaced books, older visual media in entertaining. With the launch of any new gadget the risk of misuse is always present along side it's usefulness.

Internet addiction, defined as excessive,inappropriate usage of the world wide web where an individual's productivity level is reduced along with fall in their activity of daily living. There have been growing concerns worldwide. It has been labeled as “Internet addiction” which was originally propounded by Goldberg.[1]

Griffith considered it as a subclass of behavioral addiction that meets the six core features of addiction, i.e., mood modification, salience, tolerance, withdrawal, conflict, and relapse. Extensive research has been conducted on Internet addiction.[2],[3] It has been questioned to whether people are addicted to the content of the Internet or to the platform.[4] According to the study, various types of Internet addiction are cyber-sexual addiction, cyber-relationship addiction, net compulsions, information overload, and computer addiction.

In 2013, the American Psychiatric Association determined that Internet gaming disorder (IGD) requires further research and data accumulation, and so included IGD in Section III of the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition.[5] The 11th final revision of the International classification of Diseases (ICD 11) and Impulse control disorder (ICD) and Impulse control disorder (ICD) which included gaming disorder was released in June 2018.[6] According to ICD-11, to be officially diagnosed with gaming disorder, a patient must exhibit three symptoms which is impaired control over gaming, increasing priority given to gaming, continuation, or escalation of gaming despite the occurrence of negative consequences.[6]

There has been an explosive growth in the use of the Internet not only in India but also worldwide. Reports reveal that there were about 137 million Internet users in India in 2013 and further suggest India as the world's second largest in Internet use after China in the near future. According to the Internet and Mobile Association of India and Indian Market Research Bureau, out of 80 million active Internet users in urban India, 72% have accessed some form of social networking in 2013,[7] and predicted to touch around 420 million by June 2017.

Park et al reveals that those who use Internet excessively showed greater impulsivity as compared to the normal users and shows a strong relationship between the excessive internet use and impulsivity. Understanding how college students resist or fail to resist this temptation might shed light on Internet addiction.[8] Researchers have widely reported that internet addiction leads to anxiety, depression, strained family relationships.[9],[10],[11] They tend to become lonely and develops social anxiety and endorse more socially deviant attitudes which leads to lower academic performance and at times display other risky behaviours such as illicit drug use, smoking and risky sex.[12],[13]

Impulsive individuals have problems in managing their behavior. Some core indicators of behavioral addiction are identical to those of chemical or substance addiction.[14] Impulsivity is defined as lack of planning or forethought, reduced perseverance and seeking novel experience.[15] There is a lack of control while engaging in this behavior. A large body of the literature in this area concerns impulsiveness impacting the addictive tendencies.[16],[17] Both behavioral and substance addictions are marked by an inability to stop. One of the most valid methods of intervening those addictions is by identifying and reducing the negative catalysts and strengthening the positive aspects. This pertains much to high impulsivity in addicts, also to Internet addiction.[18]

Compulsive Internet use has been defined as feeling discomfort when the Internet is unavailable, continuous use of the Internet although the individual wants to cut down the Internet to avoid unpleasant feelings, allowing Internet use to dominate one's behaviors and thinking pattern which results in conflicts with others or the self.[19] In practice, clinicians usually debate as to whether Internet addiction should be regarded as an independent psychiatric disorder or a manifestation of an underlying psychiatric disorder. Many researchers are of the view that Internet addiction is a form of impulse control disorder as patients experience it as “ego dystonic” corresponding to pleasure and euphoria. This is in contrast to obsessive compulsive disorder which has also been co-related with internet addiction, wherein obsessions are regarded as “ego dystonic” which leads to significant distress and anxiety. In addition, some clinicians are of the view that internet addiction is an impulsive-compulsive spectrum disorder. Another feature that distinguishes OCD from ICD is that in ICD, acting on the “impulses” causes pleasure or gratification while performance of compulsions in OCD is to prevent or reduce anxiety.[20],[21]

Dysfunctional beliefs are irrational thinking patterns wherein there are negative attitudes about self, the outer world, and future. In the literature, there is only one study investigating dysfunctional attitude in Internet Addiction. This study found that dysfunctional attitude scores are high in people with Internet addiction, and perfectionist attitude is an important predictor of Internet addiction.[22] In another study investigating only perfectionism and problem Internet use, perfectionism was similarly found to be a significant predictor of Internet addiction.[23] At this point, we can assume that more studies are needed to enlighten the interaction between Internet addiction, dysfunctional attitude, and psychopathologic features.

Aim

The present study aims to assess the role of impulsivity, compulsivity, and dysfunctional belief leading to problematic Internet use.


  Materials and Methods Top


Ethics

The study was approved by the Institutional Ethics Committee via REF: IECCMCL/08-6452020. Online written informed consent was obtained from all potential participants.

Study design and eligibility criteria

This was a cross-sectional, observational study carried out on 300 undergraduate medical students in a tertiary care referral hospital in North India. A Google document form was made and shared with all the students from the first year to the final year through E-mail address and WhatsApp group. The Google document contained a structured questionnaire in different parts: (1) demographic details of the students, (2) Internet Addiction Test (IAT), (3) Urgency Perseveration Premediation Sensation Seeking Positive Urgency Scale (UPPS-P), (4) Compulsive Internet Use Scale (CIUS), and (5) Dysfunctional Attitude Scale (DAS). An outline semi-structured questionnaire was developed with a consent form attached to it. The questionnaire was in English language, As medical students can comprehend English, questionnaires were provided in English language language. Participants who gave the consent and submitted the completed forms were included in the study; participants who did not respond to the questionnaire were sent three reminders at a gap of 3 days. Out of 300 undergraduate students, 200 students responded for the study through goggle forms.

Ethical approval was taken from the Institutional Ethical Committee.

Inclusion criteria

  • Those who are pursuing undergraduate medical education
  • Age range of 17–28 years
  • Students who are willing to participate.


Exclusion criteria

  • Those who have known psychiatric illness
  • Those who are not willing to participate.


Description of measures used

The first section was about the sociodemographic variable – age, gender, religion, type of family, source of accessibility, and money spent per month. The second section consists of the following scales used in the study.

Internet Addiction Test

IAT was developed by Dr. Kimberly Young and consists of 20 items associated with online Internet use, including psychological dependence, compulsive use, and withdrawal, as well as the related problems of school or work, sleep, family, and time management. For each item, a graded response is selected from 1 = “rarely” to 5 = “always” or “does not apply.” Those who scored more than 50 were thought experiencing occasional or frequent problems because of the Internet. Those who scored more than 50 were termed to be Internet addicts. The content and convergent validity and internal consistency was α = 0.88, test–retest was reliability (r = 0.82), and bisection (r = 0.72) were determined, and all were acceptable, regarding results.

Urgency Perseveration Premediation Sensation Seeking Positive Urgency Scale

The UPPS-P was developed by Whiteside and Lynman, 2001, which is a 59-item self-report that assesses five subscales (urgency, premeditation, perseverance, sensation seeking, and positive urgency) that are used to measure five distinct dimensions of impulse behavior in adolescents and adults (ages 12 and older). It is designed to measure impulsivity across dimensions of the four factors. Participants were asked to rate their behavior and attitudes on a 4-point scale, in which 1 – agree strongly, 2 – agree some, 3 – disagree some, and 4 – disagree strongly. The internal consistency was 0.74–0.88 across subscales and inter-scale correlations of the full UPPS-P. Here, the negative urgency refers to the tendency to experience strong impulses under conditions of negative affect. Positive Urgency refers to the tendency toward rash action in response to very positive mood. Lack of premeditation means the tendency to fail to think and reflect on the consequences of an act before engaging in that act. The lack of perseverance means difficulties remaining focused on a task that may be long, boring, or difficult. Sensation seeking encompasses two aspects: (a) the tendency to enjoy and pursue exciting activities and (b) an openness to trying new experiences that may or may not be dangerous.

Compulsive Internet Use Scale

Developed by Meerkerk, this scale measures excessive use. The original CIUS measures compulsive Internet use and consists of 14 items, which are rated on a 5-point scale from 0 to 4 (never, seldom, sometimes, often, and very often). A sum score is calculated, which ranges from 0 to 56. There are 5 domains, namely loss of control (items 1, 2, 5, and 9), preoccupation (items 4, 6, and 7), withdrawal symptoms (item 14), coping or mood modification (items 12 and 13), and conflict (items 3, 8, 10, and 11). Higher the value, higher is the compulsivity. The scale has good split-half reliability, r = 0.89, and good convergent validity with time spent online, 0.33< r <0.68, excellent test–retest reliability, r = 0.83, and excellent internal consistency, a = 0.90.

Dysfunctional Attitude Scale

The scale was developed by Wiess and Beck to assess the dysfunctional attitudes. The scale consists of 24 items; every item is scored on two extremes +7 to +1. Three factors of the original DAS-24 were categorized as achievement, self-control, and dependency and consists of 8 items each. The representative items for each subscale are as follows: “I must be a useful, productive, creative person or life has no purpose” for achievement, “If others dislike you, you cannot be happy” for dependency, and “If I try hard enough, I should be able to excel at anything I attempt” for self-control. Participants evaluated the degree to which they agree with each statement on a 7-point scale ranging from 1 (totally disagree) to 7 (totally agree). In the participants of the present study, Cronbach's alphas for the achievement, dependency, and self-control subscales were 0.79, 0.61, and 0.74, respectively.

Sample size was calculated by complete enumeration technique.

Data were analyzed using SPSS 16.0 (IBM Corp., Armonk , New York, USA) statistical package.

Chi-square test was applied to assess the association between sociodemographic factors and pattern of problematic Internet use.


  Results Top


There were a total of 118 males and 82 females who participated in the study. The highest age range of the student was 28 and the lowest range was 17 years. Fifty-nine percent were males and 41% females. There were 48 (24%) Hindus, 2 (1%) Muslims, 126 (63%) Christians, 22 (11%) Sikhs, and 2 (1%) from other religions who participated in the study. One hundred and eight-four (92%) belonged from a nuclear family and 15 (7.5%) from the joint family and 1 (0.5%) from other backgrounds. One hundred and eight-nine (94.5%) students mostly used mobile as it is easy to use while 11 (5.5%) used Wi-Fi as a source of accessibility of the Internet. 101 students were seen to be spending 250 to 500 rupees on the internet, 23 students were spending 500 to 750 rupees on the Internet, 3 students were spending 750-1000 rupees on the Internet and only one among them were spending more than 1000 rupees for internet accessibility. 98.5% did not have any psychiatric illness. There was a significant difference between type of family and religion with impulsivity.

  • The average age of the respondent was 20.96 years, minimum age being 17 years and maximum age being 28 years [Table 1]. 74.04% have mild Internet addiction, 25.2% have moderate Internet addiction and 0.76% have severe Internet addiction [Table 2]. There is a positive correlation between internet addiction and compulsive use [Table 3]. There is a negative correlation between Internet addiction and impulsivity. There is a positive correlation between compulsive use of the Internet and the Internet. There is a negative correlation between compulsive use of the Internet and impulsivity.
Table 1: A study of impulsivity,compulsivity and dysfunctional belief among medical undergraduates with problematic internet use to explore subjects

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Table 2: Classification according to Internet Addiction Test

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Table 3: Correlation matrix

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There is a negative correlation between compulsive use of the Internet and dysfunctional use. There is a positive correlation between impulsivity and dysfunctional use of the Internet. There is a negative correlation between impulsivity and Internet addiction and compulsive Internet use. There is a negative correlation between dysfunctional use of the Internet and the Internet and compulsive use of the Internet. Addictive behaviour is positively corelated with more compulsivity. The 100 students who did not respond to the study were not taken into consideration for the study and were not assessed for the study.

As per [Table 4] there is a significant difference between the two groups in terms of negative urgency, and the mean score is high in nonproblematic users. There is a significant difference between two groups in terms of lack of perseverance where mean score is higher in problematic Internet users. There is a significant difference between the two groups in terms of positive urgency where mean score is higher in nonproblematic users. [Table 5] shows overall significance between level of dependency, achievement, and self-control in problematic and non- problematic users.
Table 4: Difference between problematic and nonproblematic users and facets of impulsivity

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Table 5: Difference between problematic and nonproblematic users and facets of Dysfunctional Attitude Scale-24 items

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  Discussion Top


This study is an attempt to assess the extent of IA among college students in India. The IAT is the only validated instrument which identifies the high, low, and average users of the Internet. Our study had a response rate of 66.6%, and of the respondents, 74.4% were mild, 25.2% were moderate, and 0.76% were severe in nature. Our study reports higher IA than the study done in Chile among medical students where the estimated prevalence rate of IA was 11.5%.[24] Our results are very much similar to the study done in Turkey.[25] Most Internet users are males.[26] In addition, problematic Internet use is more common among males.[27] This trend was reported in the current study. Some studies, however, report no difference between genders.[28] Impulsivity is broadly defined as the tendency toward rapid, poorly considered, and disinhibited decisions and actions, despite negative consequences. Impulsivity is increasingly conceptualized as multidimensional. Problematic use of the Internet is often conceptualized as behavioral addiction due to emerging evidence suggesting some overlap in underlying psychological and neurobiological mechanisms. In this study, we focus on the UPPS-P model, which captures the multidimensional nature of impulsivity.[29] Studying these relationships during adolescence and young adulthood is of particular importance, because this is when substance use is usually initiated with simultaneous increase in impulsive behavior. Literature on the UPPS-P model in compulsive use of Internet gaming and pornography is limited. In our study, we examined associations between impulsivity traits and problematic Internet use. Our results are similar to the study done by Taymur et al.[25] There is a significant relationship between Internet addiction and compulsive Internet use which is similar to a study done by Guertler et al.[30] In our study, problematic Internet users compared to nonusers are more prone to impulses while having low mood, anxiety, or stress compared to nonusers. Problematic users are more prone to rash decisions involving behaviors which are seen when you are happy and impulsively take decision based on them. This could mean overspending, excessive shopping, and wasteful expenditure. These people also have problems being patient and sticking to tasks which involve patience. All these together could increase the risk of impulse control disorders and recklessness. Billieux et al. conducted a study on problematic involvement in multiplayer online playing games which showed problematic Internet use and significantly predicted high negative urgency levels in the participants.[31] Our study showed a significant relationship between Internet addiction and lack of perseverance and positive urgency which is not similar to the study done by Billieux et al. Most of the time, the classes for medical students tend to be long and monotonous which leads them to shift their focus toward the Internet and surfing. At times, students are prone to problematic Internet use as they are free with no underlying stressors, when life is near to ideal or when they have achieved something worthwhile. However, further studies are required to investigate the various psychological mechanisms underlying the facets of impulsivity that predict problematic involvement in problematic Internet use.[31] Our study showed a significant difference between the mean scores between problematic Internet use and nonproblematic users when compared with facets of DAS. The representative items for each subscale are as follows: “I must be a useful, productive, creative person or life has no purpose” for achievement, “If others dislike you, you cannot be happy” for dependency, and “If I try hard enough, I should be able to excel at anything I attempt” for self-control. The person with achievement group originally has core beliefs of negative self but tries to obtain a positive self-regard by behaving according to achievement self-schemas. Dysfunctional attitude means negative core beliefs of the underlying self. The study shows that there is a significant difference between level of dependency and achievement in problematic and nonproblematic Internet users which is similar to the study done by Senormancı et al.[22] Dependency here relates to verbal signals of social approval and sentiment. Immediate and predictable achievement from Internet activity such as gaming or surfing provides satisfactory sources for novelty and esteem without unpredictable frustration. Consequently, low reward dependence predicted the development of Internet addiction. There is an overall significance between level of dependency, achievement, and self-control in problematic and nonproblematic users. People want to create a perfect persona at least in the virtual world. People think that if they do not portray themselves as a creative or innovative person, they would not be loved as a person which leads to low mood, self-doubt, sadness, and anxiety. Individuals feel that if they do not post or update about the daily activities, they feel they are left out. People tend to check on the likes and comments on various social networking sites for their approval and validation. The relationships between low self-esteem that may be related to the need for approval and Internet addiction have been known well. The Internet has a suitable environment for people with low self-esteem, low motivation, fear of rejection, and need for approval. They can explain themselves by taking less risk than “real life.” Internet is a kind of safety tool for them. The Internet is a narcissist's paradise. Various Internet platforms, such as blogs, chat rooms, and forums, provide an ideal environment for narcissists to reinforce the sense of their own importance; they can focus on themselves and describe to all who care to listen what they've seen, heard, and felt. Social networks, for example, are another place where narcissists can present and “sell” themselves. Narcissists tend to use social networks as a way of cultivating their own standing among others. They take selfies (self-captured photos of themselves), and continuously upload them; they invest a great deal of time in improving their personal profiles; they deliberate at length as they choose pictures, and their posts tend to focus on how “I did…, I do…, I am…”[32]

It can be conceptualized in a way that narcissists are completely focused about themselves and other people's opinion does not matter to them. Studies indicate that narcissism is a constantly increasing tendency; more and more people are feeling self-important with increasingly disproportionate egos. Some studies reveal that there is a steep drop in empathy toward people. Hence, overall there is a complete deterioration in the self-esteem of a patient which leads to various psychiatric comorbidities. This would be crucial in the future design of therapeutic and preventive strategies. Internet dependency is a psychological and physical disorder which has symptoms of endurance, emotional disturbances, separation, and social disruption. Internet dependency is a maladaptive pattern of behavior which leads to considerable discomfort and disorder causing educational, psychological, occupational, and behavioral problems in an individual. Different studies across the globe have shown how Internet dependency has led to harmful psychological and behavioral effects among teenagers leading to their decline in academic performances, anxiety, depression, ADHD, decreased social relationships, sleep disorders, avoidance of activity in life, anger, irritability, and aggression which are among the known complications of Internet dependency. However, this study is completely novel in terms of exploring the factors to why people fall into the niche of Internet addiction. This would be crucial in the future design of therapeutic and preventive strategies.


  Conclusions Top


Overall, the results of this study indicate a significant outbreak of problematic Internet use mostly among male medical students. It highlights that students are more impulsive to using their Internet when faced with adversities or when they are free with no underlying stressors. Considering the fact that Internet use is common in medical students, it is necessary to carry out Workshops should be held for the medical students as it is very essential for them to know the pros and cons of internet use and how important it is to use screen time judiciously. These findings are very relevant for medical schools to be aware of this emerging phenomenon, especially because early detection and treatment could not only help students in the way they relate to new technologies but also help treat underlying psychiatric comorbidities.

Limitations of the study

Our results should be interpreted in light of limitations. First, all our investigations relied on self-reported data from adolescents. It has been seen that low mood or stressors are frequently associated with excessive time spent in online activities. The other limitation could be single-center experience. It will give us a better result if we take multiple institutions into consideration. There is also a potential response bias because there are around 100 students who did not respond. Thus, it can be possible that some individuals suffering from comorbid psychiatric disorders in real life are more prone to addiction. It would have been better if large sample size would have been collected to know more about the various psychological mechanisms underlying the facets of impulsivity, compulsivity, and dysfunctional use of the Internet.

Acknowledgment

We would like to thank Dr. Rajkumar Ramanathan Prof and HOD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
Introduction
Materials and Me...
Results
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