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General Hospital Psychiatry 36 (2014) 203–207

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General Hospital Psychiatry

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Attachment and family functioning in patients with Internet addiction

Ömer Şenormancı a,⁎, Güliz Şenormancı b, Oya Güçlü c, Ramazan Konkan c
Bülent Ecevit University School of Medicine psychiatry department, Zonguldak, Turkey
Zonguldak Atatürk State Hospital, Zonguldak, Turkey
Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, İstanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Although the Internet is used effectively in many areas of life, some users experience problems
Received 9 July 2013 because of over-use due to a lack of control. The diagnostic criteria for Internet addiction include disruptions
Revised 10 October 2013 in family relationships, but adequate data on the attachment styles and family functioning associated with
Accepted 14 October 2013 this condition are limited. This study aimed to investigate the attachment styles and family functioning of
patients with Internet addiction.
Method: The sample included 30 male patients consecutively admitted to the Bakırköy Mental Health and
Internet addiction
Family functioning
Research Hospital Internet Addiction Outpatient Clinic, who were diagnosed in clinical interviews as having
Anxious attachment Internet addiction according to Young’s (1998) criteria. Thirty healthy males who were matched with the
Avoidant attachment experimental group in terms of sociodemographic characteristics were included as control subjects. Both
Depression groups provided sociodemographic data and completed the Beck Depression Inventory (BDI), the Experiences
in Close Relationships Questionnaire-r (ECR-r) and the Family Assessment Device (FAD).
Results: Patients with Internet addiction had higher BDI scores (Pb.001) and higher attachment anxiety
subscores on ECR-r (Pb .001) compared with those in the control group. Patients with Internet addiction
evaluated their family functioning as more negative and reported problems in every aspect addressed by the
FAD. Scores on the FAD behaviour control, affective responsiveness, and problem-solving subscales (Pb .05)
and on the FAD communication, roles, and general functioning subscales (Pb.001) were significantly higher in
the patient compared with the control group.
Conclusion: Patients with Internet addiction have more anxious attachment styles as well as prominent
disruptions in family functioning. Thus, it may be important to evaluate the attachment styles and family
functioning of patients with Internet addiction. Indeed, comprehensive treatment approaches including other
family members may make important contributions to treatment success.
© 2014 Elsevier Inc. All rights reserved.

1. Introduction Internet addiction disrupts family functioning by leading to

problems in users’ daily lives and relationships with family members
People throughout the world have found the Internet to be a fast [2,6,7]. Disturbed family functioning also renders individuals vul-
and easy was to gather information and to interact. However, some nerable to Internet addiction [8,9]. Yen et al. found that unhealthy
people lose control over their Internet-related behaviour, leading to family functioning and family conflict were related to Internet addic-
difficulties in their daily lives and family relationships [1,2]. Such tion in a large young sample [8]. Park et al. warned that domestic
uncontrolled behaviour has been described as “Internet addiction” or violence and unhealthy communication may enhance Internet
“problematic Internet use”, and this problem has been suggested to addiction in young individuals and suggested that programs to pre-
constitute a behavioural addiction [3,4]. Internet addiction has been vent addiction should include patients’ families [9].
defined as excessive preoccupation with the Internet, recurring Like other non-chemical addictions such as those involving
thoughts about limiting and controlling use of the Internet, inability gambling, sex, and shopping, the primary features of Internet ad-
to eliminate cravings for Internet access, continued use of the Internet diction include preoccupation, emotional lability, tolerance, with-
despite impaired functioning in various domains, spending increas- drawal, interpersonal conflict, and engagement in repetitive
ingly more time on the Internet, and experiencing longings and behaviours [10]. Several studies have found a relationship between
cravings for the Internet even when it is unavailable [5]. insecure attachment styles and alcohol/drug addiction [11–13]. A
recent study about the relationship between Internet addiction and
attachment styles [14] found an association between anxious and
avoidant styles and Internet addiction. This study aimed to inves-
⁎ Corresponding author. Bulent Ecevit University Medicine Faculty psychiatry depart-
ment, Esenköy-Kozlu 67600 Zonguldak. Tel.: +90 505 794 20 52; fax: +90 212 572 95 95. tigate the family functioning and attachment styles of patients with
E-mail address: (Ö. Şenormancı). Internet addiction.

0163-8343/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
204 Ö. Şenormancı et al. / General Hospital Psychiatry 36 (2014) 203–207

2. Methods 2.3. Statistical analyses

2.1. Subjects SPSS 16 for Windows was used for all statistical analyses. Normal
distribution of the data was evaluated with the Kolmogorov–
This study included 30 males consecutively admitted to the Smirnov distribution test. chi-Square analyses were used in tests of
Bakirkoy Mental and Neurological Diseases Hospital Internet Addic- categorical differences. Independent-sample t tests and analysis of
tion Outpatient Clinic. Patients were diagnosed with Internet addic- variance were used to compare quantitative variables that were
tion by experienced clinicians according to Young’s (1998) criteria. normally distributed. Mann–Whitney U tests and Kruskal–Wallis
Patients under the age of 18 and those with severe mental or physical tests were used to compare quantitative variables that were not
illnesses, comorbid schizophrenia, schizophrenia-like psychotic dis- normally distributed. Relationships among scales were analysed
orders, or bipolar affective disorder were excluded from the study. using Person correlation analysis when data were distributed nor-
All patients included in the sample were capable of completing the mally and Spearman correlation analysis when data were not dis-
self-report scales, and they all provided written informed consent. tributed normally. In all tables, numeric variables are presented as
Control group was constituted with the people who had applied to our medians (25–75%), and categorical variables are presented in terms
study announcement. We gave them the information of the study. of both numbers of observations and percentages (%). Significance
After a psychiatric interview; 30 healthy males without any levels were set at Pb .05 and Pb.001.
psychiatric disorder who have similar sociodemographic characteris-
tics and who met the inclusion criteria of our study were included as
the control group. They used internet for academic purposes and for 3. Results
work. They didn’t have problematic Internet use for such internet
facilities (e.g., gaming, sex). We obtained approval to conduct the The mean age of the patient group was 21.6 (18–20) years. The
study from the Hospital’s ethics committee prior to the initiation of daily duration of Internet use was 7.5 (7–9) hours in the patient
the research. group and 2.7 ± 1.5 hours in the control group. The patient group
contained 3 (10%) individuals who had completed 8 years of
2.2. Instruments education, 25 (83.3%) with 12 years of education, and 2 (6.7%) with
more than 12 years of education. The patient group included 27 (90%)
2.2.1. Sociodemographic data single people, 2 (6.7%) married individuals and 1 (3.3%) who was
The investigators developed a form to obtain sociodemographic divorced. In terms of employment status, 6 (20%) people in the
data from the subjects in keeping with the objectives of the study. patient group were unemployed, 20 (66.7%) were students, and 4
(13.3%) were employed. In the patient group, 10 (33.3%) entered
treatment on their own initiative, whereas 20 (66.7%) were
2.2.2. Internet Addiction Test (IAT)
encouraged to get treatment by their relatives. One (3.3%) patient
This instrument uses a 20-item Likert-type scale scored from 1 to 5
lived alone, and 29 (96.7%) lived with their families. Six patients’
[5]. One item was removed from the scale because it reduced the
parents (20%) had divorced, and the parents of 24 (80%) had not. Two
reliability in a Turkish validation study. The internal consistency reli-
patients (6.7%) had a family history of Internet addiction, and 28
ability Chronbach’s alpha was 0.89 [15].
(93.3%) did not. The patient and control groups did not differ
significantly in terms of age, level of education, or occupational
2.2.3. Beck Depression Inventory (BDI)
status (PN .05).
This is a 21-item scale measuring the emotional, cognitive,
A one-way analysis of variance on occupational status and the FAD
somatic, and motivational symptoms of depression. Each item is
behaviour control subscale revealed that those who were unem-
scored on a scale from 1 to 3, and total scores are calculated by
ployed showed less behavioural control than did the students [F(1–
summing the scores on all items [16]. The cut-off score was set at 17 in
27)=5.35, P= .011].
a Turkish validity and reliability study. The internal consistency
The results of Student’s t-tests revealed significantly higher scores
reliability Chronbach’s alpha was 0.80 [17].
on the FAD affective involvement subscale among patients who
sought treatment voluntarily than among those who were convinced
2.2.4. Experiences in Close Relationships-Revised (ECR-r) by relatives to seek treatment (P= .031, t=−2.284, df=26.685).
This measure uses a 36-item Likert-type scale scored from 1 to 7, Additionally, patients with divorced parents scored significantly
and it was adapted for Turkish samples by Selcuk et al. (2005). It higher on the FAD affective responsiveness subscale than did other
was designed to assess individual differences in attachment-related patients (Pb .001, t=4.651, df= 24.758). Moreover, patients with a
anxiety (i.e., the extent to which people are insecure vs. secure about history of self-injurious behaviour scored significantly higher on the
the availability and responsiveness of romantic partners) and FAD communication subscale (P= .03, t=−3.197, df= 28) and the BDI
attachment-related avoidance (i.e., the extent to which people are (P= .01, t=−2.746, df= 28) than did other patients.
uncomfortable being close to others vs. securely depending on Comparison of the scores of measurements between groups was
others). The ECR-r includes items that are coded in reverse (4, 8, 16, shown in table 1. Relationship between BDI and FAD scores in the
17, 18, 20, 21, 22, 24, 26, 30, 32, 34 and 36). The mean of odd- patient group was shown in Table 2.
numbered items reflects the anxiety score, and that of even- No significant correlation was found between FAD subscales and
numbered items reflects the avoidance score [18,19]. the ECR-r anxious dimension in the patient group (PN.05).
We found a moderate (r= 0.560) positive correlation (P= .001)
2.2.5. Family Assessment Device (FAD) between the FAD behaviour control subscale and the ECR-r avoidant
The FAD, developed by Epstein, identifies the areas in which dimension and a weak to moderate (r= .467) positive correlation
families can and cannot function. It consists of 60 questions organised (P= .009) between the FAD communication subscale and the ECR-r
into seven subscales: problem solving, communication, roles, affec- avoidant dimension in the patient group. No significant correlation
tive responsiveness, affective involvement, behavioural control, and was found between other FAD subscales and the ECR-r avoidant
general functioning. Mean scale scores of 2 and above indicate im- dimension in the patient group (PN.05) (Table 3).
paired functioning. The Turkish adaptation study was conducted by The duration of Internet use was not significantly correlated with
Bulut (1990) [20,21]. the IAT, FAD, and ECR-r scores in the patient group (PN .05).
Ö. Şenormancı et al. / General Hospital Psychiatry 36 (2014) 203–207 205

Table 1 Table 3
Comparison of scores in the patient and control groups (n=60) Relationship between FAD and ECR-r avoidant scores in the patient group (n=30)

Patients Controls Z/T p FAD ECR-r avoidant

Mean ± SD Mean ± SD r P
a a
IAT 55.43 ± 15.32 24.53 ± 4.79 10.540 b.001 Behaviour control 0.560 .001
a a
BDI 23.23 ± 15.76 7.03 ± 5.92 5.268 b.001 Communication 0.467 .009
ECR-r Roles 0.264 .159
a a
Anxious 4.33 ± 0.93 3.18 ± 0.84 4.991 b.001 Affective responsiveness 0.254 .175
a a
Avoidant 3.79 ± 0.73 3.53 ± 1.07 1.068 .291 Problem solving 0.231 .220
FAD General functioning 0.250 .183
a b
Behaviour control 2.31 ± 0.44 2.05 ± 0.35 2.509 .015 Affective involvement 0.114 .548
Communication 2.32 ± 0.61 1.75 ± 0.48 3.973 b.001 a
a Pearson.
Roles 2.53 ± 0.48 2.05 ± 0.36 4.291 b.001 b
a Spearman, Pb.05, level of significance.
Affective responsiveness 2.33 ± 0.80 1.82 ± 0.56 2.858 .006
Med (25–75%)
Problem solving 2.43 ± 0.67 1.87 (2.14–2.46) −2.911 .004
General functioning 2.31 ± 073 1.63 (1.16–2.10) −3.635 b.001
Med (25–75%) have reported that an insecure attachment style is related to depres-
Affective involvement 2.56 (2.14–3) 2.33 (2.14–2.46) −1.336 .182 sive symptoms [30,33,34]. Although a secure attachment style has
Student t test.
been consistently associated with better mental health, research on
Mann–Whitney U test, Pb.05, Pb.001 level of significance. the relationship between an insecure attachment style and psychiatric
disorders has been inconsistent. It has been found a relationship
between depressive symptoms and an avoidant attachment style [35].
4. Discussion
In contrast, some studies have found no differences in the relation-
ship between insecure attachment styles and depression [36]. It has
Our study aimed to investigate the attachment styles and family
been suggested that these inconsistent results regarding depression
relationships of patients with Internet addiction and to compare them
and attachment styles are attributable to the use of different scales
with a control group. We did not find any statistically significant
and different classifications of attachment styles [37].
differences between the patient and control groups in terms of
Wei et al. noted that people who have high levels of attachment
sociodemographic variables.
anxiety have a much greater need for assurance from others. The
In our study, the depression scores of the patients were
authors suggested that insecurity renders people vulnerable to
significantly higher than those of the healthy control group. Indeed,
depression [38].
the literature indicates that depression is often associated with
According to problem-behaviour theory, alcohol and substance
Internet addiction [22–31], and our study supports this conclusion in
abuse and smoking are classified as problematic behaviours in ado-
that we found a difference between the patient and control groups in
lescents. Individuals with these conditions share certain psychosocial
terms of depression scores.
features, including factors related to their social environment, their
However, findings of the coexistence of these two disorders do not
perceived environment, their personality, and their behaviour [39].
elucidate its aetiology. In the current context of insufficient research
Internet addiction was also recognised as a problematic behaviour
about the comorbidity of Internet addiction and other psychopathol-
when this condition became widespread. Additionally, those with
ogies, it would seem more useful to treat Internet addiction and
Internet addiction have personality and familial characteristics similar
depression as coexisting conditions rather than to draw conclusions
to those who abuse substances [8].
about causality [32]. Furthermore, our study design does not permit
Because Internet addiction has been described as a behavioural
conclusions about the direction of any causal relationships.
addiction, theories that explain other addictions can be used to
Sang-Eun Shin et al. investigated attachment styles in Internet
elucidate this condition [14]. Several studies have found that alcohol
addiction by evaluating 141 male participants with problematic
dependence is generally associated with anxious attachment [11–14].
Internet or alcohol use and comparing the two groups according to
Studies based on traditional dependency theory have focussed pri-
attachment style. Internet addiction was related to both avoidant and
marily on alcohol dependence. De Rick et al. found that more than half
anxious attachment styles [14]. In our study, Internet addiction was
of their 101 participants with problematic alcohol use had an insecure
related only to anxious attachment. However, our study consisted of
attachment style [40]. They suggested that a disturbance in the
outpatients with Internet addiction, whereas the other study used a
attachment system should be interpreted as a developmental disorder
community-based sample. Thus, differences between the samples
that precedes alcohol use rather than as a cognitive and social dis-
may have contributed to differences in the results of the studies.
turbance caused by chronic alcohol use. Likewise, the greater pre-
In the current study, the anxious attachment and depression
valence of an avoidant attachment style in patients with Internet
scores of patients were higher than those of controls. Many studies
addiction in our study may reflect early pathology. Moreover, dis-
turbed family functioning may also increase the prevalence of Internet
Table 2 addiction [14].
Relationship between BDI and FAD scores in the patient group (n=30) Individuals mature and grow in the context of family interac-
tions and the social environment, and familial relationships are the
most important contributor to this process [41]. People can mature
r P into healthy individuals when they grow up in well-functioning
Behaviour control 0.488 .006 families. Families that solve their problems together, have emotional
Communication 0.652 b.001 bonds, take care of one another without limiting one another’s free-
Roles 0.481 .007
a dom, share roles fairly, exert moderate control over one another’s
Affective responsiveness 0.381 .038
Problem solving 0.559 .001 behaviours, and have open, comfortable, and direct communication
General functioning 0.710 b.001 are described as healthy [42].
Affective involvement 0.182 .335 The current study did not evaluate patients as individuals. Instead,
Pearson. we evaluated participants in the context of relationship systems that
Spearman, Pb.05, P b.001 level of significance. were analysed in terms of functioning and attachment styles.
206 Ö. Şenormancı et al. / General Hospital Psychiatry 36 (2014) 203–207

In the current study, people with Internet addiction perceived developmental factors, such as those contributing to attachment
their family functioning and their general functioning to be more style, can also contribute to Internet addiction. Indeed, the findings
problematic. Few studies on the relationship between family func- related to disturbed family functioning, which is often seen in Internet
tioning and Internet addiction have been conducted thus far, and most addiction, may indicate that including other family members in the
of the extant research has focussed on adolescents. treatment of those with Internet addiction is important. It may be
Ju-Yu et al. compared the family functioning of adolescents with necessary to use an integrative approach that makes family partici-
Internet addiction with that of those with drug addiction and found pation in treatment mandatory to enhance the success rate of
similarities between the groups. For this reason, they suggested that treatment for Internet addiction. Nowadays, the Internet is pervasive,
Internet addiction should be treated as a behavioural syndrome to and the age at which individuals start using the Internet is declining.
which disturbed family functioning and parent–adolescent conflicts, Thus, new approaches to prevention are needed. The current study
especially those related to perceived parental overcontrol of online is one of the few to examine associations of attachment styles and
access, can contribute [8]. family functioning with Internet addiction. Thus, it can be considered
It has been suggested that the characteristics of family systems a first step toward future research.
can predict addictive behaviour [42]. Tafa et al. studied how ado-
lescent and parental perceptions of family system characteristics
predict adolescent addictive behaviour patterns. They found that a
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