Original Research

The Shorter PROMIS Questionnaire and the

Internet Addiction Scale in the Assessment
of Multiple Addictions in a High-School
Population: Prevalence and Related Disability
By Stefano Pallanti, MD, PhD, Silvia Bernardi, MD, and Leonardo Quercioli, MD

ABSTRACT
Needs Assessment
Objective: Taking into account the importance Adolescence is a critical period of vulnerability to both substance and non-sub-
stance addictions. The investigation of the prevalence of multiple subthreshold
of act prevention on the development of addic- addictions in this age group may be helpful in identifying predictive and risk factors.

tions, we assessed the presence of multiple Learning Objectives

At the end of this activity, the participant should be able to:
addictions in an adolescent high-school popula- • Define the most frequent appetitive behaviors in adolescents.
• Identify which of these are the more frequent source of disability and in
tion, also assessing the prevalence of Internet which field.
• Consider the high disability of behavioral addictions apparently not as dangerous
abuse and the impact on disability. as Internet addictions.

Introduction: Adolescence seems to be a criti- Target Audience: Neurologists and psychiatrists

CME Accreditation Statement
cal period of addiction vulnerability, based on This activity has been planned and implemented in accordance with the Essentials
and Standards of the Accreditation Council for Continuing Medical Education
social but also neurobiological factors. The ear- (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and
MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by
lier onset of behavioral/substance dependence the ACCME to provide continuing medical education for physicians.
seems to predict greater addiction severity, mor- Credit Designation
The Mount Sinai School of Medicine designates this educational activity for a
bidity, and multiple addictive disorders. maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
Methods: Data were collected from a sam-
Faculty Disclosure Policy Statement
ple of 275 students in Florence, Italy, high It is the policy of the Mount Sinai School of Medicine to ensure objectivity,
balance, independence, transparency, and scientific rigor in all CME-sponsored
schools through surveys distributed in classes. educational activities. All faculty participating in the planning or implementation
of a sponsored activity are expected to disclose to the audience any relevant
The sample had an average age of 16.67±1.85 financial relationships and to assist in resolving any conflict of interest that may
arise from the relationship. Presenters must also make a meaningful disclosure
years (52.4% males, 47.6% females). To assess to the audience of their discussions of unlabeled or unapproved drugs or devices.
This information will be available as part of the course material.
multiple addiction we used the 16 subscales This activity has been peer-reviewed and approved by Eric Hollander, MD, chair
at the Mount Sinai School of Medicine. Review date: November 13, 2006. Dr.
of the Shorter PROMIS Questionnaire, to Hollander does not have an affiliation with or financial interest in any organi-
zation that might pose a conflict of interest.
assess Internet addiction prevalence we used
To Receive Credit for This Activity
the Internet Addiction Scale, and to quantify Read the three CME-designated articles, reflect on the information presented, and
then complete the CME quiz. To obtain credits, you should score 70% or better. The
disability symptoms, we used the Sheehan estimated time to complete all three articles and the quiz is 3 hours.Release date:
December 2006. Termination date: December 2008.
Disability Scale.

Dr. Pallanti is associate professor of psychiatry in the Department of Psychiatry and the director of the Institute for Neuroscience at the Florence
University of Medicine in Italy, and adjunct associate professor of psychiatry at the Mount Sinai School of Medicine (MSSM) in New York
City. Dr. Quercioli is medical surgeon and specialist in psychiatry at the Institute for Neuroscience. Dr. Bernardi is post-doctorate fellow in the
Department of Psychiatry at the Università degli Studi di Firenze in Florence.
Disclosures: Drs. Pallanti, Bernardi, and Quercioli do not have an affiliation with or financial interest in any organization that might pose a
conflict of interest.
Submitted for publication: August 11, 2006; Accepted for publication: November 13, 2006.
Please direct all correspondence to: Stefano Pallanti, MD, PhD, Institute for Neuroscience, viale Ugo Bassi 1, 50137, Firenze, Italy; Tel:
39-055-587889, Fax: 39-055-581051; Email: s.pallanti@agora.it.
CNS Spectr 11:12 © MBL Communications Inc. 966 December 2006
 Original Research

Results: Caffeine abuse, sex, relationship Young 13 and Griffiths 14 first described the
submissive, gambling, food starving, and food addictive use of the Internet and conceptualized
pathological Internet use as a category of behav-
bingeing have raised highest scores. 5.4% of the ioral addiction and proposed diagnostic criteria.
students were found to be Internet addicted similar The clinical features of behavioral problems
to other countries. Disability seemed strongly cor- related to Internet use have been described in
various ways. “[P]roblematic Internet use” 15 or
related to the subscale of alcohol, gambling, sex,
“pathological Internet use”16 were some of the
tobacco, food starving and food bingeing, shop- early definitions of the disorder in psychiatric lit-
ping, exercise, and Internet addiction. Gambling, erature. The disorder was described at that time
on the basis of the Diagnostic and Statistical
sex, caffeine abuse, compulsive help dominant,
Manual of Mental Disorders, Fourth Edition-Text
work, Internet addiction, relationship dominant, Revision (DSM-IV-TR)17 definition for substance
and relationship submissive in this sample were dependence and pathological gambling, as the
individual’s inability to control his/her use of
strongly related to substance dependence.
the Internet, with related marked distress and/
Conclusion: Level of concerns unexpected or functional impairment. In 1998, Young16 pro-
compared to the level reported in other coun- posed diagnostic criteria for Internet addiction
as an adaptation of pathological gambling DSM-
tries for the behavioral compulsions, have been
IV-TR criteria, while Shapira and colleagues 15
highlighted. Behavioral addictions are multiple, a suggested criteria according to impulse-control
source of disability, and they are related to sub- disorder DSM-IV-TR nosology, which included
the need to exclude a current manic episode.
stance abuse. It has yet to be clarified if they are
Regardless of the controversy involved in the
a temporary phenomenon occurring in adoles- nomenclature of problematic Internet use, there
cents or if they are a stable trait, accounting as are no doubts about the increasing pervasive-
ness of this condition.
marker for the development of substance abuse.
Internet addiction can be found at any age and
CNS Spectr. 2006;11(12):966-974 in any socioeconomic condition,18 but the research’s
major attention has been focused on adolescents.
INTRODUCTION Most of the epidemiological studies19-22 have been
“Advances in the knowledge about the reward conducted in college populations, taking into
system of the human brain, much sustained account the importance of act prevention on the
through refined brain scan technologies, suggest development of the illness the fact that Internet use
that a reward constitutes a reward, regardless of is growing mainly in adolescent populations, and
whether it comes from a chemical variation or the possibility of multiple addictions.
an experience. And every time there’s a reward, In fact, the prevalence of problem gambling
there’s the associated risk for the brain of getting as been found to be two or four times higher in
trapped in a compulsion.” 1 Functional similari- adolescents than in adulthood, just as tobacco,
ties between substance-related and behavioral drug, and alcohol abuse have higher prevalence
addictions have been observed at the biological, in adolescent population.23-26
psychological and social levels of analysis.2 Anthony and colleagues’ epidemiological data27
It has been observed that even non-substance showed that an earlier onset of substance use
dependence can produce physiological arousal: the seems to predict greater addiction severity, mor-
heart rates of pathological gamblers increase dur- bidity, and multiple substance use disorders. This
ing a gambling session,3 altered dopaminergic and pattern seems to be true even for behavioral addic-
serotonergic functions have also been observed.4,5 tion: early age onset of gambling has been asso-
Other processes usually associated with addic- ciated with greater gambling-related problems
tive psychoactive substance use have been later in life.28,29 Adolescence seems to be a critical
observed in excessive engagement in sex,6 work, period of addiction vulnerability. This increased
and gambling,7 shopping,8 exercise,9 the playing vulnerability of the adolescent population can be
of video games,10 excessive consumption of food,11 explained by cultural and neurobiological factors.
tobacco, and caffeine.12 Chambers and colleagues30 suggested that the

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 Original Research

immaturity of the frontal cortical and subcortical recreational drugs, prescription drugs, gam-
monaminergic system during normal neurode- bling, sex, caffeine, food bingeing, food starv-
velopment underlies adolescent impulsivity that ing, exercise, shopping, work, relationships
is to be considered as the foundation of disorders dominant and submissive, and compulsive
marked by disturbance in reward motivation.31 helping dominant and submissive.32 Each of the
Since adolescence seems to be the most vul- scales contained 10 items formatted as 6-point
nerable period of life for addiction, and given the Likert-type items, ranging from 0 (strongly dis-
tendency of every addiction disorder to co-occur, agree) to 5 (strongly agree) and had a global
especially in the early-onset forms,29 we decided scale point ranging from 0–50. The 160 items
to assess epidemiology of multiple behavioral related to the 16 scales are listed in random
addictions in this population. order. The first page of the questionnaire con-
The aim of the study was to evaluate the preva- tains instructions and a brief explanation of the
lence of behavioral addiction in adolescents using various substances and behaviors included in
the Shorter PROMIS Questionnaire (SPQ)32 and the scales. The original version was translated
the Internet Addiction Scale (IAS).18 The impact of to Italian by three psychiatrists fluent in English,
this psychopathology, since multiple addictions then revised, and reverse translated by a native
and early onset are associated with an increased English speaker.
morbidity and severity of symptomatology, was The Internet Addiction Scale
assessed by the Sheehan Disability Scale.33 The IAS is a modified version of that of
Moreover, we decided to investigate high- Young’s.18 Young16 has described Internet addic-
school adolescent students, trying to avoid tion as ‘‘an impulse-control disorder which
the bias that may occur in the college environ- does not involve an intoxicant.’’ The IAS exam-
ment. In fact, the college environment seems to ines the degree of pre-occupation, compulsive
promote the risk of addiction, even of Internet use, behavioral problems, emotional changes,
dependence, since it is often an integral part of and the impact on life related to Internet use.
a college student’s life. Italian high-schools stu- The 20 items of the IAS are calibrated scores
dents have limited or no Internet access. ranging from 1–5 (given a total score rang-
ing from 20–100), with higher scores reflect-
METHODS ing a greater tendency toward addiction. Three
types of Internet-user groups were identified in
Participants and Procedure accordance with the original scheme of Young:
The project was developed for adolescent Internet addicts, possible Internet addicts, and
students (school superior first- through fourth- non-addicts, whose scores on the IAS were
year classes) with the intent of investigating the >70, 40–69, and <39, respectively. Non-addicts
behavioral addiction phenomenon through the did not exhibit any disturbances in their daily
use of specific psychopathological instruments. lives as a result of Internet use. We defined the
Data were collected from a sample of 275 stu- participants with scores >70 as the addiction
dents in Florence high schools through surveys group, having problems with Internet use. In
distributed in class. All the students were living the current sample (N=275), the Cronbach’s a
away from school and their access to the Internet coefficient was 0.91.
was related to life activity outside of school time. The Sheehan Disability Scale
The sample had a average age of 16.67±1.85 The Sheehan Disability Scale 33 is a 3-item
years and consisted of 52.4% males and 47.6% self-report scale measuring the severity of
females. All subjects and their parents gave oral disability in the domains of work, family life/
consent to participate in this institutional review home responsibilities, and social/leisure activi-
board-approved study. In the interests of guaran- ties. Each of these three domains is scored on
teeing anonymity, we did not require any autobi- a 10-point Likert scale (0=not at all impaired,
ographical information other than age and sex. 5=moderately impaired, and 10=very severely
impaired). It provides a measure of total func-
Operational Measures tional disability (range: 0–30) and has been
The Shorter PROMIS Questionnaire shown to have adequate internal reliability
The SPQ consists of 16 scales, each assess- (Intra-class correlation ranging from r=.85 to
ing one addictive behavior: the use of nicotine, r=1.0) and construct/criterion-related validity.34

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968 December 2006
 Original Research

Data Analysis were used as appropriate used to test. All the

Prior to the undertaking of the study, ethi- tests were two-tailed and assumed a 5% sig-
cal approval was obtained from the principal nificance level.
of each high school. Researchers explained the
purpose of the study to the principal and class RESULTS
teachers and asked for their cooperation. When Results of the SPQ are summarized in Table 1.
their cooperation was confirmed, the researchers Significant differences between male and female
went to classrooms where they introduced the subjects were found in alcohol, drugs, prescribed
study’s purpose and explained how to respond drugs, gambling, sex work (males>females), and
to the questionnaires. They also explained that shopping and bingeing (females>males) sub-
the data would be used solely for the purpose of scales. The Figure shows the distributions of SPQ
the study and that their privacy and anonymity subscales scores, expressed as percents according
would be fully protected. The students filled in to the Christo and colleagues32 normative data.
the questionnaire in a self-reporting format, after Table 2 shows the results of the IAS in stu-
which the researchers collected the data along dents. Among the participants, 5.4% was found
with the written consents that the subjects had to be Internet addicted, as indicated by the
duly signed. All the data were analyzed using IAS. Male students had higher mean IAS total
SPSS for Windows.35 Descriptive analyses were scores compared with females. No signifi-
performed on all variables. cant differences in the distribution of Internet
Cross-tabulation, one-way analysis of vari- addicts, possible Internet addicts and non-
ance and Pearson correlation coefficients addicts between gender were found.

TABLE 1.
SPQ Subscale Scores in Male and Female Students

Male Female Total

SPQ Subscales (n=144) mean (n=131) mean (N=272) mean ANOVA-F (df=1.273)
Alcohol 17.39±11.64 13.53±10.74 15.54±11.37 8.12*
Drugs 10.16±12 5.41±9.33 7.88±11.04 13.24†
Prescribed drugs 6.58±7.47 4.14±5.7 5.41±6.79 9.14*
Tobacco 13.32±15 13.50±14.8 13.41±14.93 .01
Caffeine 8.88±7.36 7.66±7.15 8.30±7.28 1.94
Gambling 8.28±9.6 4.37±6.27 6.41±8.39 15.65†
Sex 12.16±10.6 6.05±8.2 9.23±10.01 28.18†
Relationship dominant 15.81±9.7 14.39±9.9 15.13±9.85 1.44
Relationship submissive 20.23±9.8 20.13±11.2 20.18±10.50 .01
Compulsive helping dominant 21.72±9.3 21.79±10.3 21.75±9.83 .01
Compulsive helping submissive 25.70±9.0 25.67±8.7 25.69±8.87 .01
Work 19.40±10.6 16.40±9.2 17.97±10.07 6.23*
Exercise 15.57±9.7 14.30±9.0 16.00±9.55 1.26
Shopping 17.17±8.7 19.35±9.0 18.22±8.91 4.17*
Food bingeing 14.60±9.6 18.83±11.1 16.63±10.58 11.48*
Food starving 15.60±9.6 17.76±9.11 16.64±9.44 3.65
* P<.05
† P<.001

SPQ=Shorter PROMIS Questionnaire; ANOVA-F=cross-tabulation, one-way analyses of variance.

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 Original Research

Table 3 shows the intercorrelation among SPQ the country of origin. Also gambling had a higher
subscale scores. There are many statistically sig- prevalence in our sample. This may be due to dif-
nificant correlations, and it could be explained as ference in age between the samples. In fact, our
a strong intercorrelation among addictive behav- sample’s age ranged from 14–19 years, while the
iors. However, it could also suggest that the data other studies utilizing the SPQ have been con-
from the SPQ can be simplified or explained by a ducted in adult populations, and gambling has a
lesser number of variables. higher prevalence in adolescents.26
Noteworthy, the range of the “extreme problem” Addictions are multiple and often seemed
that, according to Christo and colleagues,32 should related to each other in our data, consistently with
include 2.5% of a normal population, is reached in our the model of multiple dependences. Clusters of
sample in the areas of caffeine by 13% of the sample, emerging dependency in adolescents was linked
compulsive helping dominant by 12% of the sample, behavioral to substance addictions. Particularly,
compulsive helping submissive by 12% of the sam- gambling, caffeine abuse, sex, food starving, work,
ple, gambling by 16% of the sample, food bingeing compulsive help dominant, relationship domi-
by 7% of the sample, sex by 11% of the sample, and nant, and submissive in this sample were strongly
relationship submissive by 20% of the sample. related to substance dependence, such as alcohol-
The range of “serious problem“ (5% accord- ism or drug use.
ing to Christo and colleagues32) is reached in the In order to detect if any disability was expe-
areas of caffeine (15%), compulsive helping dom- rienced by the subjects we also considered the
inant (8%), prescribed drugs (7%), sex (6%), and disability impact of each SPQ items analyzing the
food starving (19%). correlations with the Sheehan Disability Scale. The
The range of “significant problem” (10% accord- disability impact was correlated with relationship
ing to Christo and colleagues32) is reached in: caffeine dominant and submissive, alcohol, gambling, sex,
(20% of our sample), compulsive helping dominant tobacco, food starving and food bingeing, shop-
(12%), exercise (13%), food bingeing (13%), food ping, and exercise. Internet abuse was significantly
starving (19%), gambling (11%) prescribed drugs correlated with family and relation impairment
(11%) relationship dominant (13%) and relationship (P<.001) and less strongly with the job session of
submissive (20%), and shopping (14%). Sheehan Disability Scale (P<.05).
Among students, social disability indicators While an elevated score in the substance sub-
seemed to be correlated to some of the SPQ sub- scale (alcohol, caffeine, prescribed drugs, and street
scales more significantly to gambling, food binge- drugs) was expected according to other epidemio-
ing, food starving, shopping, tobacco, and sex logical studies,37-39 the higher scores reported in
addictive behaviors. Strongly correlated to the social appetitive behaviors, such as gambling, sex, exer-
disability were mean scores on the IAS. (Table 4). cise, food starving, food bingeing, relationship sub-
missive, and shopping, was unexpected.
DISCUSSION According to IAS criteria, 5.4% of our sample was
To our knowledge, this is also the first assess- Internet addicted. In Italy, Internet use has had a
ment of multiple addictions in a non-clinical sample slower diffusion than in other countries. Prevalence
in Italy. Furthermore, this is the first application of of Internet use as a cause of concern in this high-
the SPQ in an Italian adolescent population. school students sample does not reach a significant
The average score in our high-school students difference compared with the prevalence reported
sample was higher in each scale compared with in other countries. To our knowledge, these are the
the normality range of each of the SPQ subscales first reports in Italy of the prevalence of Internet
assessed by Christo and colleagues 32 in a con- addiction. The epidemiology of Internet use is still
venience sample. The study results show how controversial, since the definition issued by Young13
caffeine abuse, gambling, food bingeing, sexual and Greenfield in 1999 40 suggests that ~5.7% of
addiction, submissive relationship style, compul- United States Internet users fulfilled the criteria of
sive helping dominant, and compulsive helping serious, compulsive Internet use.
submissive are reaching the level of “extreme Yang and colleagues41 published an epidemio-
problems” between Italian adolescents logical study assessing the excessive Internet use in
Caffeine was found to have a higher prevalence 4.9% of a Korean adolescent population, non-use in
in our sample than in the previous studies 36 but 18.0%, minimal use in 47.3%, moderate use 29.9%.
this could be explain by cultural difference from On the other hand, using the IAS in a large sample of

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 Original Research

Korean adolescents, Kim and colleagues42 reported true for other ailments. In this study, there were
60.5% of non-addicted patients, a 37.9% possible no psychopathological measures, therefore, we
addicted patients, and 1.6% of Internet-addicted did not assess the presence of clinical comorbid-
patients. The symptoms of Internet-addicted adoles- ity. Similar investigations should consider con-
cents usually reported were lying, difficulty in stop- ducting this assessment.
ping Internet use, irritation and anger, increasing
time invested in Internet use, difficulty in maintain-
ing steady study habits or everyday functions, and
TABLE 2.
the occurrence of health problems.43 Impairment
in family and social activity due to Internet abuse Internet Addiction Scale in Students:
have already been reported by Armstrong and col- Differences Between Gender in Total
leagues. 44 Indeed, other researchers 45 have sug- Score Mean, Number, and Percent of
gested an association between Internet use and IAs, PAs, and NAs
psychological states or mood: a significant correla- Statistics
tion between adolescent depression and suicidal Male Female Total (Male vs
ideation has been reported. (n=144) (n=131) (n=275) Female)
Depression, loneliness, social impairment, and IAS total 48.3±6.7 38.9±14.5 49.8± ANOVA-
distraction are a common features in substance score 12.4 F=49.03*
abusers and behavioral dependents. 46 Gambling (mean)
addiction has been reported to be a way to cope IAs, n 9 6 15
with depression for the addicted female popula- (% in (6.2) (4.6) (5.4)
tion.47 According to this point of view, Griffiths and gender)
Sutherland 48 suggested the addiction behavior PAs, n 45 (31.2) 34 (25.9) 79
χ2=0.6
provides a way to cope with suffering daily life (% in (28.7)
df=2†
gender)
and substance abuse.
It is not clear if mood disorders are consequences NAs, n 58 (40.3) 53 111
of life function and self-esteem deterioration (% in (40.5) (40.4)
gender)
induced by the “salience” toward the drug/behav-
* NS
ior, or if they are caused by dependence. † P<.001
That other illnesses lead to a misuse of the
IAs=Internet addicts; PAs=possible Internet addicts; NAs=non-addicts;
internet, as Mitchell49 has reported, is the main ANOVA-F=cross-tabulation, one-way analyses of variance.
argument against the hypothesis of Internet Pallanti S, Bernardi S, Quercioli L. CNS Spectr. Vol 11, No 12. 2006.
addiction as a separate disorder, but this is also

FIGURE.
Adolescent SPQ score percentages

100%
90%
Extreme Problem 80%
Serious Problem 70%
Significant Problem 60%
Cause of Concern 50%
High Range 40%
None-Average 30%
20%
10%
0%
A C CHD CHS D E FB FS G T PD RD RS S Sho W
SPQ=Shorter PROMIS Questionnniare; A=alcohol; C=caffeine; CHD=compulsive helping dominant; CHS=compulsive helping submissive; D=street drugs;
E=exercise; FB=food bingeing; FS=food starving; G=gambling; T=tobacco; PD=prescribed drug; RD=relationship dominant; RS=relationship submissive; S=sex;
Sho=shopping; W=work; S=sex.

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 Original Research

In future studies, it may also be interesting Brain structures supporting these functions are
to investigate the neurobiological mechanism mainly the prefrontal cortex and the dopamine
underlying the emerging appetitive behaviors, mesolimbic pathways.50
assessing the shared features or differences Substance use concern was more frequent in
during the developed in substance abuse and the male than in the female population as well
behavioral addictions. as problem gambling, sexual, and working prob-
For example, there are no data regarding the lems.51,52 Still, consistent with previous data,8,53
state of the cognitive functions, such as working shopping and food bingeing was typically more
memory and long-term memory in adolescents frequently reported in females.
with concerning behaviors. It may be inter-
esting to assess these functions, since there
are theories considering addiction a disease CONCLUSION
of learning processes, and memory, a patho- This study has the merit of highlighting a level of
logical usurpation of the neural mechanism in concerns unexpected for some features, particularly
normal circumstances serving this functions. for some substance abuse and for some behaviors.

TABLE 3.
Correlations Among SPQ Subscales in Students (Pearson-rho Coefficient)

FS FB Sho E W CHS CHD RS RD S G C T PD D IAS

Alcohol .183 *
.156 *
.266 †
.170 *
.212 †
.126 *
.222 †
.326 †
.326 †
.572 †
.376 †
.312 †
.459 †
.237 †
.576 †
.376†
Drugs .159* .002 .161* .095 .250† .016 .129* .188* .379† .558† .473† .252† .482† .281† 1 .524†
Prescribed .267 †
.203 *
.228 †
.092 .184 *
–.001 .103 *
.133 *
.290 †
.355 †
.473 †
.367 †
.160 *
1 .281 *
.134*
drugs
Tobacco .276† .118 .200* .046 .126* .069 .185* .206* .269† .331† .237† .269† 1 .160 .482† .298†
Caffeine .450 †
.334 †
.436 †
.134 *
.401 †
.153 *
.252 †
.281 *
.406 †
.394 †
.476 †
1 .269 †
.367 †
.252 †
.193*
Gambling .306† .226† .313† .091 .170* .079 .121* .193* .457† .557† 1 .476† .237† .437† .437† .394†
Sex .243† .122* .372† .277† .233† .088 .227† .298† .496† 1 .557† .394† .331† .355† .558† .252†
Relationship .432 †
.286 †
.524 †
.279 †
.410 †
.250 †
.517 †
.610 †
1 .496 †
.457 †
.406 †
.269 †
.290 †
.379 †
.121*
dominant
Relationship .446* .347† .530† .350† .480† .352† .714† 1 .610† .298† .193* .281† .206* .133* .188* .133*
submissive
Compulsive .436† .343† .474† .220† .435† .250† 1 .352† .517† .227† .121* .252† .185* .103 .129* .213†
helping
dominant
Compulsive .213† .203* .302† .165* .211* 1 .250† .480† .250† .088† .079* .153* .069 –.001 .016 .394†
helping
submissive
Work .466† .285† .329† .208† 1 .211† .435† .350† .410† .233† .170* .401† .126* .184* .250† .228†
Exercise .275† .170* .272† 1 .208† .165* .220† .530† .279† .277† .091* .134 .046 .092 .095 .530†
Shopping .514† .440† 1 .272† .329† .302† .474† .347† .524† .372† .313* .436† .200* .228† .161* .250†
Food .514 †
1 .440 †
.170 *
.285 †
.203 *
.343 †
.432 †
.286 †
.122 *
.226 †
.334 †
.118 .203 *
.002 .167*
bingeing
IAS .203* .167* .250† .530† .228† .394† .213† .133* .121* .252† .394† .193* .298† .134* .524† 1
*P<.05
† P<.001

SPQ=Shorter PROMIS Questionnniare; FS=food starving; FB=food bingeing; Sho=shopping; E=exercise; W=work; CHS=compulsive helping submissive;
CHD=compulsive helping dominant; RS=relationship submissive; RD=relationship dominant; S=sex; G=gambling; C=caffeine; T=tobacco; PD=prescribed drug;
D=street drugs; IAS=Internet Addiction Scale.

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 Original Research

This is an epidemiological, non-clinical study, of the behavior and the presence of familiar comor-
but our findings may have some clinical implica- bidity should be investigated. Furthermore, these
tions. We have pointed out the prevalence of some habits may represent a marker for the develop-
behaviors, apparently normal as well as Internet ment of more dangerous dependence. Researchers
abuse, but that are experiment as source of subjec- should conduct perspective examinations of these
tive disability. These habits, these apparently nor- emerging behaviors or check their presence as risk
mal behaviors, may not represent a real disease, factors retrospectively in a clinical sample.
although it is interesting that most of them are The importance of appetitive behavior, when con-
related to dangerous substance dependence as well nected, as in the present findings, to subjective and
as prescribed drugs abuse, caffeine, and alcohol interpersonal negative disability, cannot be argued.
abuse. Whether these behaviors represent a devel- The disability impact reported here and by pre-
opment phase of real diseases should be studied. vious data implies the need of a social effort to
In order to investigate these possibility, the stability contain the potential misuse of the Internet and
the diffusion of concerning behaviors. The emer-
gence of an appetitive behavior that is legal, and
TABLE 4. apparently not dangerous, such as excessive
Pearson rho Correlation Coefficients Internet use, cannot be considered only an incor-
Between Social Disability Scale rect lifestyle, because it may be a hidden threat,
and Addiction-Related Scores (SPQ especially for younger populations. CNS
Subscales and the IAS in Students)

Social REFERENCES
1. Holden C. ‘Behavioral’ addictions: do they exist? Science. 2001;294:980-982.
Disability Scale Job Relationship Family
2. Grant JE, Brewer JA, Potenza MN. The neurobiology of substance and behavioral
SPQ addictions. CNS Spectr. 2006;11:924-930.
3. Coventry KR, Norman AC. Arousal, erroneous verbalisations and the illusion of control
Alcohol .089 .161* .078 during a computer-generated gambling task. Br J Clin Psychol. 1998;89:629-645.
4. DeCaria CM, Begaz T, Hollander E. Serotonergic and noradrenergic function in patho-
Drugs –.023 .036 .014
logical gambling. CNS Spectr. 1998;3:38-47.
Prescribed drugs .036 .065 .080 5. Pallanti SP, Bernardi S, Quercioli L, DeCaria C, Hollander E. Serotonin dysfunction in
pathological gamblers: increased prolactin response to oral m-CPP versus placebo.
Tobacco .088 .175 *
.127* CNS Spectr. 2006;11:956-964.
6. Roth K. Sexual addiction in alcohol abuse and dependence. Clinical, nosologic and
Caffeine .094 .062 .048
psychoanalytic aspects [German]. Nervenarzt. 1992;63:157-162.
Gambling .018 .069 .256† 7. Orford J. Excessive Appetites: A Psychological View of Addictions. New York, NY:
Wiley; 1985.
Sex .126 *
.207 *
.082 8. Christensen GA, Farber RJ, DeZwaan M. Compulsive buying descriptive characteris-
tics and psychiatric morbidity. J Clin Psychiatry. 1994;55:5-11.
Relationship .084 .156 *
.098
9. Furst DM, Germone K. Negative addiction in male and female runners and exercisers.
dominant Percept Mot Skills. 1993;77:192-194.
Relationship .158* .103 .079 10. Phillips CA, Rolls S, Rouse A, Griffiths MD. Home video game playing in schoolchil-
submissive dren: a study of incidence and patterns of play. J Adolesc. 1995;18:687-691.
11. Cummings C, Gordon JR, Marlatt GA. Relapse: prevention and prediction. In: Miller
Compulsive help- .172* .067 .085 WR, ed. The Addictive Behaviours: Treatment of Alcoholism, Drug Abuse, Smoking
ing dominant and Obesity. New York, NY: Pergamon; 1980:291-321.
12. Aubin H-J, Laureaux C, Tilikete S, Barrucand D. Changes in cigarette smoking and cof-
Compulsive help- .070 –.043 .051 fee drinking after alcohol detoxification in alcoholics. Addiction. 199;94:411-416.
ing submissive 13. Young KS. Psychology of computer use: XL. Addictive use of the Internet: a case that
breaks the stereotype. Psychol Rep. 1996;79(3 pt 1):899-902.
Work –.007 –.009 –.042
14. Griffiths M. Psychology of computer use: XLIII. Some comments on ‘addictive use of
Exercise .123 *
.109 .067 the Internet’ by Young. Psychol Rep. 1997;80:81-82.
15. Shapira NA, Goldsmith TD, Keck PE Jr, Khosla UM, McElroy SL. Psychiatric features of
Shopping .151 *
.095 .174† individuals with problematic internet use. J Affect Disord. 2000;57:267-272.
16. Young KS. Internet addiction: the emergence of a new clinical disorder. Cyberpsycol
Food bingeing .215† .186* .243†
Behav. 1998;1:237-244.
Food starving .178 *
.178 *
.157* 17. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text rev. Washington,
DC: American Psychiatric Association; 2000.
IAS Total .102* .203† .235† 18. Young KS. Caught in the Net. New York, NY: John Wiley & Sons; 1998.
*
P<.05 19. Anderson KJ. Internet use among college students: an exploratory study. J Am Coll
† Health. 2001;50:21-26.
P<.001
20. Chou C. Internet heavy use and addiction among Taiwanese college students: an
SPQ=Shorter PROMIS Questionnaire; IAS=Internet Addiction Scale. online interview study. Cyberpsycol Behav. 2001;4:573-585.
Pallanti S, Bernardi S, Quercioli L. CNS Spectr. Vol 11, No 12. 2006. 21. Ko CH, Yen JY, Chen CC, Chen SH, Yen CF. Proposed diagnostic criteria of Internet
addiction for adolescents. J Nerv Ment Dis. 2005;193:728-733.

CNS Spectr 11:12 © MBL Communications Inc. 973 December 2006

 Original Research

22. Nichols LA, Nicki R. Development of a psychometrically sound internet addiction 39. Huang B, Dawson DA, Stinson FS, et al. Prevalence, correlates, and comorbidity of
scale: a preliminary step. Psychol Addict Behav. 2004;18:381-384. nonmedical prescription drug use and drug use disorders in the United States: results
23. Giovino GA. Epidemiology of tobacco use among US adolescents. Nicotine Tobacco of the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin
Res Suppl. 1999;1:S31-S40. Psychiatry. 2006;67:1062-1073.
24. Grant BF. Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in 40. Greenfield DN. The nature of Internet addiction: psychological factors in compulsive
the United States: results of the National Longitudinal Alcohol Epidemiologic Survey. Internet use. Paper presented at: Annual Meeting of the American Psychological
J Stud Alcohol. 1997; 58:464-473. Association; May 1999. Boston, Mass.
25. Warner LA, Kessler RC, Hughes M, Anthony JC, Nelson CB. Prevalence and cor- 41. Yang CK, Choe BM, Baity M, Lee JH, Cho JS. SCL-90-R and 16PF profiles of senior high
relates of drug use and dependence in the United States: results from the National school students with excessive internet use. Can J Psychiatry. 2005;50:407-414.
Comorbidity Survey. Arch Gen Psychiatry. 1995;52:219-229. 42. Kim K, Ryu E, Chon MY, et al. Internet addiction in Korean adolescents and its rela-
26. Lesieur HR, Klein R. Pathological gambling among high school students. Addict Behav. tion to depression and suicidal ideation: a questionnaire survey. Int J Nurs Stud.
1987;12:129-135. 2006;43:185-192.
27. Anthony JC, Petronis KR. Early-onset drug use and risk of later drug problems. Drug 43. Kim HS. Internet addiction treatment: the faster, the better. Publication Ethics.
Alcohol Depend. 1995;40:9-15.
2001;276:12-15.
28. Winter KC, Stinchfield R, Fulkerson J. Adolescent Gambling Behavior in Minnesota:
44. Armstrong L, Philips JG, Saling LL. Potential determinantes of heavier Internet usage.
A Benchmark. Report to the Department of Human Services Mental Health Division.
International Journal of Human-Computer Studies. 2000;53:537-550.
Duluth, Minn: Center for Addiction Studies, University of Minnesota; 1990.
45. Reynolds WM, Mazza JJ. Assessment of suicidal ideation in inner-city children and
29. Burge AN, Pietrzak RH, Petry NM. Pre/Early adolescent onset of gambling and psychosocial
young adolescents: reliability and validity of the Suicidal Ideation Questionnaire-JR.
problems in treatment-seeking pathological gamblers. J Gambl Stud. 2006;22:263-274.
School Psych Rev. 1999;28:17-30.
30. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in ado-
46. Charney DS, ed. Impact of substance abuse on the diagnosis, course and treatment of
lescence: a critical period of addiction vulnerability. Am J Psychiatry. 2003;160:1041-1052.
mood disorders (theme issue). Biol Psychiatry. 2004;56:703-818.
31. Evenden JL. Varieties of impulsivity. Psychopharmacology (Berl). 1999;146:348-361.
32. Christo G, Jones SL, Haylett S, Stephenson GM, Lefever RM, Lefever R. The Shorter 47. Brown KT, Coventry L. Queen of Hearts: The Needs of a Woman with Gambling
PROMIS Questionnaire: further validation of a tool for simultaneous assessment of Problems. Melbourne, Australia: Financial and Consumer Rights Council; 1994.
multiple addictive behaviours. Addict Behav. 2003;28:225-248. 48. Griffiths M, Sutherland I. Adolescent gambling and drug use. J Community Appl Soc
33. Sheehan DV. The Anxiety Disease. New York, NY: Scribner; 1983. Psychol. 1998;8:423-427.
34. Leon AC, Shear MK, Portera L, Klerman GL. Assessing impairment in patients with panic 49. Mitchell P. Internet addiction: genuine diagnosis or not? Lancet. 2000;355:632.
disorder: the Sheehan Disability Scale. Soc Psychiatry Psychiatr Epidemiol. 1992;27:78-82. 50. Berke J, Hyman SE. Addiction, dopamine, and the molecular mechanism of memory.
35. SPSS for Windows. Chicago, Ill: SPSS, Inc.; 1989. Neuron. 2000;25:515-532.
36. Bernstein GA,Carroll ME, Thuras PD, Cosgrove KP, Roth ME. Caffeine dependence in 51. Carnes P. The obsessive shadow. Professional Counselor. 1998;13:15-17.
teenagers. Drug Alcohol Depend. 2002;66:1-6. 52. Desai RA, Maciejewski PK, Pantalon MV, Potenza MN. Gender differences in adoles-
37. Guerrini I, Gentili C, Guazzelli M. Alcohol consumption and heavy drinking: a survey in cent gambling. Ann Clin Psychiatry. 2005;17:249-258.
three Italian villages. Alcohol Alcohol. 2006;41:336-340. 53. Lanzi G, Rossi G, Balottin U, et al. Eating behavior disorders. Epidemiologic study of
38. Crouch BI, Caravati EM, Booth J. Trends in child and teen nonprescription drug abuse 434 adolescents. Minerva Pediatr. 1997;49:249-260.
reported to a regional poison control center. Am J Health Syst Pharm. 2004;61:1252-1257.

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