General Hospital Psychiatry 36 (2014) 203–207

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General Hospital Psychiatry

journal homepage: http://www.ghpjournal.com

Attachment and family functioning in patients with Internet addiction

Ömer Şenormancı a,⁎, Güliz Şenormancı b, Oya Güçlü c, Ramazan Konkan c
a
Bülent Ecevit University School of Medicine psychiatry department, Zonguldak, Turkey
b
Zonguldak Atatürk State Hospital, Zonguldak, Turkey
c
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.
Keywords:
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

People throughout the world have found the Internet to be a fast
and easy was to gather information and to interact. However, some
people lose control over their Internet-related behaviour, leading to
difficulties in their daily lives and family relationships [1,2]. Such
uncontrolled behaviour has been described as “Internet addiction” or
“problematic Internet use”, and this problem has been suggested to
constitute a behavioural addiction [3,4]. Internet addiction has been
defined as excessive preoccupation with the Internet, recurring
thoughts about limiting and controlling use of the Internet, inability
to eliminate cravings for Internet access, continued use of the Internet
despite impaired functioning in various domains, spending increas-
ingly more time on the Internet, and experiencing longings and
cravings for the Internet even when it is unavailable [5].
⁎ 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.
E-mail address: senorman_7@hotmail.com (Ö. Şenormancı).
problems in users’ daily lives and relationships with family members
[2,6,7]. Disturbed family functioning also renders individuals vul-
nerable to Internet addiction [8,9]. Yen et al. found that unhealthy
family functioning and family conflict were related to Internet addic-
tion in a large young sample [8]. Park et al. warned that domestic
violence and unhealthy communication may enhance Internet
addiction in young individuals and suggested that programs to pre-
vent addiction should include patients’ families [9].
Like other non-chemical addictions such as those involving
gambling, sex, and shopping, the primary features of Internet ad-
diction include preoccupation, emotional lability, tolerance, with-
drawal, interpersonal conflict, and engagement in repetitive
behaviours [10]. Several studies have found a relationship between
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-
tigate the family functioning and attachment styles of patients with
Internet addiction.

0163-8343/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.genhosppsych.2013.10.012
204 Ö. Şenormancı et al. / General Hospital Psychiatry 36 (2014) 203–207
2. Methods
2.1. Subjects
This study included 30 males consecutively admitted to the
Bakirkoy Mental and Neurological Diseases Hospital Internet Addic-
tion Outpatient Clinic. Patients were diagnosed with Internet addic-
tion by experienced clinicians according to Young’s (1998) criteria.
Patients under the age of 18 and those with severe mental or physical
illnesses, comorbid schizophrenia, schizophrenia-like psychotic dis-
orders, or bipolar affective disorder were excluded from the study.
All patients included in the sample were capable of completing the
self-report scales, and they all provided written informed consent.
Control group was constituted with the people who had applied to our
study announcement. We gave them the information of the study.
After a psychiatric interview; 30 healthy males without any
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
work. They didn’t have problematic Internet use for such internet
facilities (e.g., gaming, sex). We obtained approval to conduct the
study from the Hospital’s ethics committee prior to the initiation of
the research.
2.2. Instruments
2.2.1. Sociodemographic data
The investigators developed a form to obtain sociodemographic
data from the subjects in keeping with the objectives of the study.
2.2.2. Internet Addiction Test (IAT)
This instrument uses a 20-item Likert-type scale scored from 1 to 5
[5]. One item was removed from the scale because it reduced the
reliability in a Turkish validation study. The internal consistency reli-
ability Chronbach’s alpha was 0.89 [15].
2.2.3. Beck Depression Inventory (BDI)
This is a 21-item scale measuring the emotional, cognitive,
somatic, and motivational symptoms of depression. Each item is
scored on a scale from 1 to 3, and total scores are calculated by
summing the scores on all items [16]. The cut-off score was set at 17 in
a Turkish validity and reliability study. The internal consistency
reliability Chronbach’s alpha was 0.80 [17].
2.2.4. Experiences in Close Relationships-Revised (ECR-r)
This measure uses a 36-item Likert-type scale scored from 1 to 7,
and it was adapted for Turkish samples by Selcuk et al. (2005). It
was designed to assess individual differences in attachment-related
anxiety (i.e., the extent to which people are insecure vs. secure about
the availability and responsiveness of romantic partners) and
attachment-related avoidance (i.e., the extent to which people are
uncomfortable being close to others vs. securely depending on
others). The ECR-r includes items that are coded in reverse (4, 8, 16,
17, 18, 20, 21, 22, 24, 26, 30, 32, 34 and 36). The mean of odd-
numbered items reflects the anxiety score, and that of even-
numbered items reflects the avoidance score [18,19].
2.2.5. Family Assessment Device (FAD)
The FAD, developed by Epstein, identifies the areas in which
families can and cannot function. It consists of 60 questions organised
into seven subscales: problem solving, communication, roles, affec-
tive responsiveness, affective involvement, behavioural control, and
general functioning. Mean scale scores of 2 and above indicate im-
paired functioning. The Turkish adaptation study was conducted by
Bulut (1990) [20,21].
2.3. Statistical analyses
SPSS 16 for Windows was used for all statistical analyses. Normal
distribution of the data was evaluated with the Kolmogorov–
Smirnov distribution test. chi-Square analyses were used in tests of
categorical differences. Independent-sample t tests and analysis of
variance were used to compare quantitative variables that were
normally distributed. Mann–Whitney U tests and Kruskal–Wallis
tests were used to compare quantitative variables that were not
normally distributed. Relationships among scales were analysed
using Person correlation analysis when data were distributed nor-
mally and Spearman correlation analysis when data were not dis-
tributed normally. In all tables, numeric variables are presented as
medians (25–75%), and categorical variables are presented in terms
of both numbers of observations and percentages (%). Significance
levels were set at Pb .05 and Pb.001.
3. Results
The mean age of the patient group was 21.6 (18–20) years. The
daily duration of Internet use was 7.5 (7–9) hours in the patient
group and 2.7 ± 1.5 hours in the control group. The patient group
contained 3 (10%) individuals who had completed 8 years of
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%)
single people, 2 (6.7%) married individuals and 1 (3.3%) who was
divorced. In terms of employment status, 6 (20%) people in the
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
encouraged to get treatment by their relatives. One (3.3%) patient
lived alone, and 29 (96.7%) lived with their families. Six patients’
parents (20%) had divorced, and the parents of 24 (80%) had not. Two
patients (6.7%) had a family history of Internet addiction, and 28
(93.3%) did not. The patient and control groups did not differ
significantly in terms of age, level of education, or occupational
status (PN .05).
A one-way analysis of variance on occupational status and the FAD
behaviour control subscale revealed that those who were unem-
ployed showed less behavioural control than did the students [F(1–
27)=5.35, P= .011].
The results of Student’s t-tests revealed significantly higher scores
on the FAD affective involvement subscale among patients who
sought treatment voluntarily than among those who were convinced
by relatives to seek treatment (P= .031, t=−2.284, df=26.685).
Additionally, patients with divorced parents scored significantly
higher on the FAD affective responsiveness subscale than did other
patients (Pb .001, t=4.651, df= 24.758). Moreover, patients with a
history of self-injurious behaviour scored significantly higher on the
FAD communication subscale (P= .03, t=−3.197, df= 28) and the BDI
(P= .01, t=−2.746, df= 28) than did other patients.
Comparison of the scores of measurements between groups was
shown in table 1. Relationship between BDI and FAD scores in the
patient group was shown in Table 2.
No significant correlation was found between FAD subscales and
the ECR-r anxious dimension in the patient group (PN.05).
We found a moderate (r= 0.560) positive correlation (P= .001)
between the FAD behaviour control subscale and the ECR-r avoidant
dimension and a weak to moderate (r= .467) positive correlation
(P= .009) between the FAD communication subscale and the ECR-r
avoidant dimension in the patient group. No significant correlation
was found between other FAD subscales and the ECR-r avoidant
dimension in the patient group (PN.05) (Table 3).
The duration of Internet use was not significantly correlated with
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
a
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
a
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
a
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%)
b
Problem solving 2.43 ± 0.67 1.87 (2.14–2.46) −2.911 .004
b
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-
b
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
a
Student t test.
been consistently associated with better mental health, research on
b
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
FAD BDI
most important contributor to this process [41]. People can mature
r P into healthy individuals when they grow up in well-functioning
a
Behaviour control 0.488 .006 families. Families that solve their problems together, have emotional
a
Communication 0.652 b.001 bonds, take care of one another without limiting one another’s free-
a
Roles 0.481 .007
a dom, share roles fairly, exert moderate control over one another’s
Affective responsiveness 0.381 .038
a
Problem solving 0.559 .001 behaviours, and have open, comfortable, and direct communication
a
General functioning 0.710 b.001 are described as healthy [42].
b
Affective involvement 0.182 .335 The current study did not evaluate patients as individuals. Instead,
a
Pearson. we evaluated participants in the context of relationship systems that
b
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
their family functioning and their general functioning to be more
problematic. Few studies on the relationship between family func-
tioning and Internet addiction have been conducted thus far, and most
of the extant research has focussed on adolescents.
Ju-Yu et al. compared the family functioning of adolescents with
Internet addiction with that of those with drug addiction and found
similarities between the groups. For this reason, they suggested that
Internet addiction should be treated as a behavioural syndrome to
which disturbed family functioning and parent–adolescent conflicts,
especially those related to perceived parental overcontrol of online
access, can contribute [8].
It has been suggested that the characteristics of family systems
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
family’s inability to change and form emotional bonds (low
cohesion) was related to drug addiction. In other words, drug
addiction was observed in families with weak emotional bonds (low
cohesion) and the inability to change their power structure (i.e., the
rules governing relationships) in response to situational and
developmental stress [43]. As the current study used a different
scale to evaluate family functioning, the subscales were not the same
as those analysed in the study conducted by Tafa et al. However, the
definitions of the relevant terms demonstrate that the emotional
bonds (cohesion) subscale can overlap with the FAD affective re-
sponsiveness subscale and that the adaptability subscale can overlap
with the FAD role subscale.
In the current study, the patient group had significantly higher
scores on all FAD subscales than did the control group. These results may
indicate that Internet addiction can disturb family functioning or that
disturbed family functioning can lead to Internet addiction. Because of
its design, our study cannot draw conclusions about any causal
relationship between Internet addiction and family functioning.
Our data showed that increased BDI scores were associated
with increased scores on all FAD subscales except affective
involvement. This relationship was the strongest among the scales
of general functioning.
Both Internet addiction and depressive symptoms are important
stressors for individuals and their families. The current study found
that depression scores were significantly higher in the patient group,
which suggests that the family functioning of those with Internet
addiction is disturbed. However, it is not possible to determine
whether depression or Internet addiction is the more important
contributor to family dysfunction.
The current study has several limitations. Our study sample was
restricted to male participants because no women met our study
criteria. Therefore, our control group was also confined to male par-
ticipants. This may be seen as a limitation of our study, but research
using community-based, online, and clinical samples has shown that
Internet addiction is more prevalent among males than females [44].
As we used self-report scales, our data may be biased, and it would
be useful to try to replicate our findings using more objective
measures. Another limitation is the small number of participants.
Due to the absence of female referrals to our Internet Addiction Clinic
who met our inclusion criteria, we conducted our study with a small
sample of males. Thus, our clinical sample may not reflect the com-
munity. Moreover, all patients included in the study sought
treatment for a problem with Internet addiction, although some of
them were forced to do so by their families or friends. The current
findings must be re-evaluated by studies with different clinical and
community-based samples. Additionally, because the current study
used a cross-sectional design, causal relationships among the
variables cannot be identified [45–47].
At some future point, we may be able to conclude that higher
anxiety scores in patients than in controls indicate that early
developmental factors, such as those contributing to attachment
style, can also contribute to Internet addiction. Indeed, the findings
related to disturbed family functioning, which is often seen in Internet
addiction, may indicate that including other family members in the
treatment of those with Internet addiction is important. It may be
necessary to use an integrative approach that makes family partici-
pation in treatment mandatory to enhance the success rate of
treatment for Internet addiction. Nowadays, the Internet is pervasive,
and the age at which individuals start using the Internet is declining.
Thus, new approaches to prevention are needed. The current study
is one of the few to examine associations of attachment styles and
family functioning with Internet addiction. Thus, it can be considered
a first step toward future research.
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