Psychology
2012. Vol.3, No.8, 626-631
Published Online August 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.38096
626
Problematic Internet Users and Psychiatric Morbidity in a Sample
of Egyptian Adolescents*
Mona Reda1, Menan Rabie2, Nesrin Mohsen2, Aisha Hassan3
1Institute of Childhood Postgraduate Studies, Ain Shams University, Cairo, Egpyt
2Institute of Psychiatry, Ain Shams University, Cairo, Egpyt
3Ministry of Health, Ahmed Maher Hospital, Alexandria, Egpyt
Received May 8th, 2012; revised June 7th, 2012; accepted July 10th, 2012
Background: A growing body of research suggests that Problematic Internet use is becoming more com-
mon in society as on-line usage increases everyday. Is psychiatric morbidity common among problematic
internet users? What are the characteristics of these patients? Methods: 501 adolescents (295 males), 11 -
18 years old, recruited from 2 private (group 1) and 2 governmental schools (group 2). All were subjected
to A Psychiatric sheet, An Informative designed questionnaire, Fahmy and El Sherbiny’s Social
Classification Scale, Young internet addiction test (IAT), and Mini International Neuropsychiatric Inter-
view for children and adolescents (MINI KID). Results: Comparison between the two groups in regard
places of use of internet, number of computers available, money spent on internet activities, parental
knowledge of use, duration of use and purpose of use, revealed significant differences. Problematic
internet use was more frequent in group 1, while internet addiction was more frequent in group 2. A
significant relation was found between IAT score and social phobia, specific phobia and oppositional
defiant disorder, and a highly significant relation with generalized anxiety disorder and ADHD. Female
sex, horror movies and internet problematic use are independent predictors of psychiatric morbidity. Male
sex, private schools, high social class are independent predictors for internet use problems in our sample.
Conclusion: This study revealed that Egyptian adolescents are at high risk for problematic internet use
and to a lesser extent Internet Addiction. Adolescents with Problematic Internet use were more prone to
psychiatric disorders (social phobia, specific phobia, oppositional defiant disorders, generalized anxiety
disorder and ADHD).
Keywords: Problematic Internet Use; Psychiatric Morbidity; Adolescents
Introduction
Within the context of the development of new information
and communication technologies, the Internet has become a means
of accessing information, interpersonal communication and
entertainment. Its widespread use has important repercussions
at the individual, social, technological and economic levels
(Munoz et al., 2010). In Egypt, more than 80% of Internet Café
clients were young people, 60% of the youth surveyed spent
their time chatting, 20% browsing pornography sites, 12%
conducting business or scientific work and 8% visiting political
sites (UNDP & INP, 2010).
This study was initiated in light of the relatively high
prevalence of Egyptian Internet users coinciding with the new
era of Problematic internet use allover the world. Dysfunctional
use of such technology probably leads to changes in the
psychological profiles of the young population and may inter-
fere with the person’s social life, school work, or job-related
tasks at work, enhancing withdrawal from the real world, and at
certain occasions constituting a predisposing factor for the
appearance of psychiatric disorders.
Problematic Internet Use (PIU) has received increasing
research attention; a consistent definition of this construct has
not been currently applied. PIU has been proposed as a novel
entity of dysfunctional behavioral patterns similar to those
identified within the spectrum of impulse control disorders.
Worldwide, the prevalence of PIU among adolescents and
young adults has been observed to range between 2% and 11%
(Aboujaoude, 2010).
Researchers have established that the disorder develops into
a dependency for the person; they experience tolerance and
withdrawal affects (Ferris, 2003). Similar to what an addict of
any other substance goes through, and becomes just as isolated
as them. Rejecting the real world and adopting the Internet as a
route of escape to a mood altering experience (DeAngelis, 2000).
Given the recent expansion and the expected increase in
internet availability and usage in the coming years, it is important
that healthcare professionals be informed about this behavior
and its associated problems; internet addiction is a newly
emergent disorder. It has been found to be associated with a
variety of psychiatric disorders (Ko et al., 2012) as well as,
subjective distress, functional impairment and Axis I psychiatric
disorders (Shapira et al., 2000).
Hypothesis of the Study
*The submitted manuscript contains original unpublished work and is
not being submitted for publication elsewhere at the same time. There
is no conflict of interest.
The hypothesis of the study was that adolescents experienc-
ing problematic internet use have psychiatric morbidity.

M. REDA ET AL.
Aim of the Study
Primarily explore current psychiatric morbidity in problematic
adolescent internet users and its potential risk factors.
Design and Methods
Participants
Cross sectional design was applied for purpose of the study;
all data were collected during the first semester of academic
year 2010-2011. The study was approved by the ethical committee
of the Institute of Postgraduate Studies, Ain-Shams University,
as well as, school administrations and parents of participants,
after careful explanation of the study and its objectives, a
written consent of approval to participate was obtained from
parents as well as students after ensuring confidentiality of data.
Source of the sample was randomly selected students from
16 classes in four high schools, two private international schools
(moderate to high annual fees) and two governmental schools
(no annual fees) all students were encouraged to participate in
the study (N = 539). No exclusion criteria, including demographic
and/or socioeconomic characteristics, for the study participants
were applied.
Assessments
Ain Shams University Psychiatric sheet: that includes items
related to demographic information (age, sex, school grade),
family history, past history, psychiatric symptoms and examination.
Informative designed questionnaire: to assess patterns of
internet use, including questions to identify the following: the
location of internet access: 1) one’s own home portal; 2) a
friend’s home portal; and 3) internet café portal. The scope of
internet sites accessed included: 1) educational (a. study, b.
information, c. research); 2) entertainment (a. email, b. chatting,
c. online games); 3) other specific uses to be named. Also
duration and frequency of internet use, as well as parents’
awareness of internet use.
Fahmy and El Sherbiny’s Social Classification Scale (Fahmy
& El Sherbini, 1988): the classification is based on 5 parameters:
education of the father, education of the mother, income,
crowding index and sanitation. The parameter yields a total
score. Score of 25 - 30 is considered high social class 1, score
of 20 - 25 is considered middle & high middle social class 2,
score of 15 - 20 is considered low social class 3, score of 14 or
lower is considered very low social class 4.
The Young Internet Addiction Test (IAT): was used to detect
problematic internet use and internet addiction (Young, 1999).
The IAT is a 20 items questionnaire on which the person is
asked to rate the items on a 5 point scale. It can be used in
clinical settings to screen for internet abuse among adults and
adolescents. It classifies internet users into three groups: Aver age
Users who have complete control over their internet activities,
problematic users who experience frequent problems due to
their internet activities and Internet Addicts who experience
significant problems due to their dependence on internet activities.
The IAT is a valid and reliable instrument that can be used in
research (Widyanto & Mcmurran, 2004). It was translated to
Arabic in the current study. The reliability of the translated
version was tested in a pilot study of 50 subjects (age and sex
matching control); Cronbach’s Alpha based on standardized
items was .814.
The Mini International Neuropsychiatric Interview for
children and adolescents (MINI KID) (Sheehan et al., 1998)
was used to identify psychiatric morbidity. The MINI KID is a
structured clinical interview for the major Axis I disorders. It
was developed jointly by psychiatrists and clinicians in the
United States and Europe, for DSM-IV and ICD-10 psychiatric
disorders. It is divided into 22 modules designated by letters,
each corresponding to psychiatric diagnostic category. With an
administration time of approximately 15 minutes, it was designed
to meet the need for a short but accurate structured psychiatric
interview for multicenter clinical trials and epidemiology studies
and to be used as a first step in outcome tracking in non research
clinical settings. The reliability of the translated version was
tested in a pilot study of 100 subjects; Cronbach’s Alpha based
on standardized items was .795.
Procedure
The study proper was performed at the Institute of Childhood
Postgraduate Studies, Ain Shams University Hospitals in the
period from the beginning of January 2009 to the end of June
2010. The students were subjected to the following:
Informed consent was obtained from all students before they
participated in the study.
Each student was interviewed by one of the researchers by
the use of Ain Shams University Psychiatric sheet. This took
about 15 - 30 minutes. An Informative designed questionnaire
and Fahmy and El Sherbiny’s Social Classification Scale were
given to each student so that he fills them in, which took about
5 - 10 minutes. Then the student was submitted to The MINI
KID for Psychiatric diagnosis. This step took about 15 - 25
minutes.
Data Analysis
The collected data were analyzed by the Statistical Package
for Social Sciences (SPSS), version 15 and expressed as following:
Chi-square test was used to compare qualitative variables between
groups, Fisher exact test was used instead of chi-square when
one or more expected cell < 5. Unpaired t-test was used for
comparison of quantities variables, binary logistic regression
analysis was used to find out the most significant independent
predictors affecting outcome by using backward Likelihood
ratio technique. Statistical analyses were conducted with the
application of the SAS version 9.0 (SAS Institute Inc., USA)
software package, P-value (P) of P value > .05 insignificant,
≤ .05 was the criterion for significance and P < .01 highly
significant.
Results
The sample of the study constituted of 501 adolescent
students recruited from 2 private schools (group 1) and 2
governmental schools (group 2). The interview and all assessments
were conducted in presence of a research team member, with
response rate (100%). 295 male students (59%), 206 female
students (41%) with no significant difference (X2 = 0, P ≥ .05),
aged between 11 - 18 years old, with highly significant difference
in money spent on internet activities between two groups, as
well as social class according to Fahmy and El-Sherbiny Social
Classification Scale (X2 = 127, P ≥ .001), (X2 = 14, P ≥ .001)
respectively as shown in Table 1.
Comparison between two groups in regard places of use of
internet (Table 2), number of computers available, parental

M. REDA ET AL.
628
Table 1.
Comparison between both groups as regard general data.
Variables Private (N = 251) Governmental (N = 250) Chi square P-value Significance
Age Mean + SD
15 + 1.5
Mean + SD
14.1 + 1.4 .7 >.05 NS
Gender N (%) N (%) 0 >.05 NS
Female 104 (41.4%) 103 (41.2%)
Male 147 (58.6%) 147 (58.8%)
Spend 127 <.001 HS
<5 41 (16.3%) 144 (61.3%)
6 - 10 82 (32.7%) 72 (30.6%)
>11 117 (46.6%) 19 (8.1%)
NA 11 (4.4%) 15 (6.0%)
Social class 14 <.001 HS
Very low 31 (12.3%) 37 (14.8%)
Low 8 (3.2%) 14 (5.6%)
Middle 5 (2.0%) 20 (8.0%)
High 207 (82.5%) 179 (71.6%)
Table 2.
(a) Comparison between both groups in regard to internet use; (b) Comparison between both groups in regard to purpose of internet use.
(a)
Sig P X2 Governmental N = 250Private N = 251 Variables
HS <.001 22
220 (88%)
30 (12%)
247 (98.4%)
4 (1.6%)
Home Yes
No
S <.05 Fisher
81 (32.4%)
169 (67.6%)
108 (43.0%)
143 (57.0%)
School Yes
No
NS >.05 .11
56 (22.4%)
193 (77.2%)
1 (.4%)
69 (27.5%)
182 (72.5%)
Café Yes
No
NA
HS <.001 48
38 (15.2%)
212 (84.8%)
110 (43.8%)
141 (56.2%)
Friend house Yes
No
S <.05 8
20 (8%)
230 (92%)
42 (16.7%)
209 (83.3%)
Other places Yes
No
HS <.001 7 2 + .4 3 + .6 Number of computers
HS <.001 20
177 (70.8%)
64 (25.6%)
9 (3.6%)
217 (86.4%)
33 (13.2%)
1 (.4%)
Parents knowledge Always
Sometimes
Never
S <.05 7.5
64 (25.6%)
160 (64.0%)
19 (7.6%)
6 (2.4%)
1 (.4%)
45 (17.9%)
169 (67.3%)
22 (8.8%)
15 (6.0%)
How long using < 1 hour
1 - 4 hours
5 - 10 hours
>10 hours
NA
(b)
HS <.001 19 107 (42.8%) 157 (62.5%) Study
S <.05 Fisher 156 (62.4%) 176 (70.1%) Information
S <.05 Fisher 168 (67.2%) 186 (74.1%) Research
Educational
S <.05 Fisher 121 (48.4%) 192 (76.5%) E-mail
HS <.001 Fisher 135 (54.0%) 207 (82.5%) Chat
S <.05 Fisher 163 (65.2%) 143 (56.9%) On line games
Entertainment
knowledge of use, duration of use and purpose of use, revealed
significant differences all in favor of group 1.
Applying IAT indicated numerical difference in regard to
problematic internet use. It was more frequent in group 1, while
internet addiction was more frequent in group 2, with sig-
nificant difference in favor of group 1 (private schools) (X2 = 5,
P ≤ .05) as shown in Table 3. For statistical reasons, both
groups were summated and named problematic internet users
(PIU) group.
Testing for Frequency of internet use and duration of internet
use was significant in favor of students with problematic use (x2
= 20.47, p ≥ .05, x2 = 21.35, p ≥ .001) respectively.
Using MINI-KID showed no significant difference between
the two groups in regard to psychiatric disorders, still when
using Fisher extract test a significant relation was found
between IAT score and social phobia, specific phobia and
oppositional defiant disorder (P ≤ .05) in all, and a highly
significant relation with generalized anxiety disorder and
Attention deficit hyperactive disorder (P ≤ .001) in all, as
shown in Table 4.

M. REDA ET AL.
Table 3.
Comparison between both groups as regards IA score.
P-value Chi square Govern, N = 250 Private N = 251
202 (80.8%) 184 (73.3%) No IA
45 (18.0%) 66 (26.3%) Some <.05
S
5
3 (1.2%) 1 (.4%) Signifi
Table 4.
Psychiatric disorders in relation to IA problematic use.
Significance P-value
IA problematic use
No Yes
NS >.05 5 (5.9%) 19 (6.7%) Depression
NS >.05 9 (10.5%) 22 (7.8%) Dysthemia
NS >.05 14 (17.1%) 35 (12.6%) Panic
NS >.05 21 (25.6%) 61 (21.9%) Agrophobia
NS >.05 29 (35.8%) 85 (30.7%) Anxiety
S <.05 8 (10%) 14 (5.1%) Social phobia
S <.05 14 (17.5%) 27 (9.8%) Specific phobia
NS >.05 6 (7.5%) 13 (4.7%) OCD
HS <.001 15 (18.8%) 21 (7.7%) Generalized anxiety
NS >.05 2 (2.5%) 5 (1.8%) ADHD
NS >.05 1 (1.3%) 5 (1.8%) ADHD hyperactivity
HS <.001 4 (5%) 1 (.4%) ADHD combined
S <.00 30 (37.5%) 69 (25.3%) Oppositional defiant
In an attempt to identify a relation between PIU and presence
of a psychiatric morbidity in the whole studied group, watching
movies (especially horror movies) was found to be of sig-
nificant relation to the occurrence of a psychiatric disorder (P
≤ .05).
Using binary logistic regression test indicated that female sex,
horror movies and internet problematic use are independent
predictors of psychiatric morbidity. On the other hand males,
private schools, high social class are considered independent
predictors for internet use problems (problematic/addiction) in
our sample. As shown in Table 5.
Discussion
For adolescents, the Internet serves as an inexpensive, readily
accessible platform for social interaction (Paul & Bryant, 2005)
and leisurely activities (Dannon & Iancu, 2007). With the
growing wealth of literature on PIU among adolescents, re-
searchers attempted to investigate the psychiatric morbidity in
PIU, and its possible risk factors.
Table 5.
Relation between psychiatric disorders, internet problematic use and
different variables by logistic regression.
Odd’s (95% CI)P-value Beta-coefficientIndependent predictors
Psychiatric disorder
1.7 (.4 - 7.8) <.05 .98 Female sex
1.2 (.4 - 6) <.05 .45 Horror movies
1.1 (.1 - 7) <.05 .42 IA (positive problem)
1.01 (.2 - 4.9) >.05 .19 Govern school
Internet problematic use
1.3 (.3 - 10.8) <.05 .56 Male sex
1.1 (.3 - 11.7) <.05 .33 Private school
1 (.4 - 7) <.05 .25 High social class
Although the internet enhances psycho-social development,
still pathological internet use encouraged researchers to monitor
this phenomena, European prevalence reported between 1 and
9% (Pallanti et al., 2006; Siomos et al., 2008; Villella et al., 2010),
Middle Eastern prevalence at between 1 and 12% (Ghassemzadeh
et al., 2008; Canbaz et al., 2009; Canan et al., 2010). And
prevalence in Asia reported between 2 and 18% (Ko et al., 2007;
Park et al.; 2008, Song et al., 2010). Variation in figures can be
explained by the different criteria used to identify internet
problematic use and/or addiction (pathological use), which was
evident in our study as 22.1% (n = 111) showed to have
problematic Internet use, and .8% (n = 4) proved to have
Internet addiction, in the current work both (problematic and
addictive users) were referred to as PIU.
Excessive and pathological Internet users are inevitably
making regular and intense use of the Internet, with regard to
both the frequency and duration of each Internet session,
especially for accessing e-mail, chat rooms, and Internet games
(Cak & Leung, 2004), which consistent with the current work,
as students with problematic internet users tend to login more
frequent and stay online for longer duration, as it is a major
contributor in defining PIU.
Psychiatric morbidity in adolescents with PIU has been
identified in several researches, (Ha et al., 2006; Ko et al.,
2008), in the current study PIU subjects showed higher
tendency in showing anxiety disorders i.e., social phobia,
specific phobia as well as generalized anxiety disorder, which is
in agreement with previous studies (Shapira et al., 2000; Milani
et al., 2009; Akin & Iskender, 2011). These findings could be
explained by the speculation that online social networking gives
adolescents the chance to form virtual friends they can’t face in
real world which positively affect social and moral knowledge
among adolescents.
Attention-deficit/hyperactivity disorder (ADHD), hostility,
depression, were correlated in other study to internet addiction

M. REDA ET AL.
(Ko et al., 2009), in the current study we could identify ADHD
(P ≥ .001) but failed to correlate with depression, this could be
explained by the outnumber of 295 male (59%) to 206 females
(41%). PIU is known for the multiple windows with different
activities, rapid responses and immediate reward which may
resembles symptoms of ADHD.
Using logistic regression to identify independent predictors
to psychiatric disorder; female gender and horror movies were
related, on the other hand, males, high social class, private
school were independent predictors to PIU, gender difference
was proven in previously conducted studies (Ceyhan, 2008;
Frangos & Sotiropoulos, 2011). These factors should be taken
with caution, and larger scale studies should be conducted, as
although in Egypt gender gap regarding internet use is 59%
males and 41% females (MCIT, 2010), still several barriers
exist such as basic computer illiteracy and high price of internet
service.
In conclusion PIU is not an uncommon problem among
Egyptian adolescents, potential risk factors identified in this
work include: high social class, male gender and availability of
access. Anxiety disorders and ADHD are the most prevalent
comorbid psychiatric disorders.
Limitations
The researchers admit having difficulties in obtaining higher
sample size due to refusal of few schools to participate, secondary
to denying approval for psychiatric assessment as well as
reluctance of adolescents to participate. Another limitation is
excluding smart phones as sample included students from low
economic families’.
Acknowledgements
Special thanks go to the subjects of the study, without them
this study wouldn’t be possible.
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