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The Association Between Premenstrual Dysphoric Disorder and Internet Use Disorder abc
Chih-Hung Ko MD, PhD d
ab
, Cheng-Fang Yen MD, PhD , Cheng-Yu Long ab
a
MD, PhD , Cheng-Sheng Chen MD, PhD , Tzu-Hui Huang MSc & JuYu Yen MD, PhD
ecb
a
Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan b
Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan c
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan d
Department of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan e
Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan Accepted author version posted online: 10 Feb 2014.Published online: 08 Apr 2014.
To cite this article: Chih-Hung Ko MD, PhD, Cheng-Fang Yen MD, PhD, Cheng-Yu Long MD, PhD, ChengSheng Chen MD, PhD, Tzu-Hui Huang MSc & Ju-Yu Yen MD, PhD (2014) The Association Between Premenstrual Dysphoric Disorder and Internet Use Disorder, Women & Health, 54:3, 245-261, DOI: 10.1080/03630242.2014.883661 To link to this article: http://dx.doi.org/10.1080/03630242.2014.883661
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Women & Health, 54:245–261, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.883661
The Association Between Premenstrual Dysphoric Disorder and Internet Use Disorder
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CHIH-HUNG KO, MD, PhD Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
CHENG-FANG YEN, MD, PhD Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
CHENG-YU LONG, MD, PhD Department of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
CHENG-SHENG CHEN, MD, PhD Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
TZU-HUI HUANG, MSc Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
JU-YU YEN, MD, PhD Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; and Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Premenstrual dysphoric disorder (PMDD) is an important women’s mental health issue. This study aimed to investigate the association between Internet use disorder (IUD), PMDD, and their associated Received April 11, 2013; revised November 30, 2013; accepted January 3, 2014. Address correspondence to Ju-Yu Yen, MD, PhD, Department of Psychiatry, Kaohsiung Medical University Hospital, 100, Tzyou 1st Road, Kaohsiung, 80708, Taiwan. E-mail: [email protected] 245
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factors, such as stress and impulsivity. Women with PMDD ( n = 79) and controls ( n = 76) were recruited from the community. The diagnoses of PMDD and IUD were confirmed by psychiatric interviews. Participants were evaluated with the Chen Internet Addiction Scale, Perceived Stress Scale, and Barratt Impulsiveness Scale in both the premenstrual and follicular phases. Women with PMDD were more likely to have IUD. Women with PMDD had greater severity of IUD, perceived stress, and impulsivity than the control group in the premenstrual phase. Impulsivity mediated the association between PMDD and IUD, while both impulsivity and perceived stress mediated the association between PMDD and IUD severity. Thus, IUD should be evaluated and treated among women with PMDD, particularly for those with higher impulsivity or higher perceived stress. Strategies for stress management and counseling for impulsivity should be provided to women with PMDD, particular to those comorbid with IUD. KEYWORDS impulsivity
PMDD, internet use disorder, perceived stress,
INTRODUCTION About 70%–90 % of menstruating women have one or more signs of physical discomfort or emotional symptoms in the premenstrual phase of the menstrual cycle. About 20%–40 % of the affected women have experienced premenstrual symptoms that are bothersome (Mishell, 2005). A small number, 3%–8%, of menstruating women experience more severe symptoms, which can lead to substantial distress or functional impairment and meet strict criteria for premenstrual dysphoric disorder (PMDD). The affected women have been estimated to experience almost 3,000 days of severe symptoms during their menstruating years, resulting in a heavy life burden and functional impairment (Mishell, 2005). PMDD is included in the official diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2012). Its typical symptoms, including irritability, anger, depression, loss of interest, fatigue, tension/anxiety, abdominal bloating, breast pain, and fatigue, recur monthly and last for an average of six days per month during the majority of menstruating years. These dysphoric symptoms may make affected women unwilling to go out, resulting in social isolation. The Internet is a tool to interact with others without leaving home in modern society. However, whether women with PMDD were more likely to have Internet use disorder (IUD) had not been evaluated. The Internet is now a major communication medium in modern life. However, loss of control over Internet use has resulted in negative
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psychosocial consequences (Yen et al., 2008). IUD is defined in section III of “substance use and addictive disorders” in the proposed DSM-5, and it has been suggested that it deserves further study (APA, 2012). The proposed DSM-5 has suggested nine criteria for IUD, including preoccupation, withdrawal symptoms, tolerance, unsuccessful control, impaired decision-making, rewarding deficit, escape, self-deception about Internet gaming, and impaired function. Depression and irritability are important and the most frequent symptoms of PMDD (Hartlage & Arduino, 2002; Klatzkin et al., 2010). The DSM-5 criteria for IUD (APA, 2012) suggest that individuals with IUD use Internet gaming to escape or relieve dysphoric mood. Previous reports have found that adults with depression or higher hostility are more likely to have IUD (Ko et al., 2008; Yen, Yen et al., 2011). Further, depression and hostility have been reported to be two important risk factors related to IUD in prospective studies (Ko, Yen, Chen, Yeh, et al., 2009). Thus, we hypothesized that women with PMDD who have higher hostility and depression might be a higher risk group for IUD. Perceived stress is an important mental health issue that contributes to cardiovascular disease risk and sleep problems (Iso et al., 2002; Kashani, Eliasson, & Vernalis, 2012). Increased interpersonal conflicts, fatigue, and dysphoric moods—symptoms of PMDD—might bring stress into work, home, and social interactions. Women with PMDD display higher levels of neuroticism-related personality traits that demonstrate a vulnerability to stress (Gingnell et al., 2010). PMDD has also been associated with psychological distress, assessed by a mental health inventory in an epidemiological study (Tschudin et al., 2010). Further, individuals with IUD have been reported to escape to the Internet from their job stress (Whang et al., 2003). Academic stress and recent stress events have also been associated with IUD in crosssectional epidemiological studies (Lam et al., 2009; Wang et al., 2011). These studies indicated that the stress was associated with both PMDD and IUD. Thus, we hypothesized that stress would be involved in the association between PMDD and IUD. What is more, impulsivity is one of the most important factors contributing to the loss of control or addictive behavior (Winstanley et al., 2006). Studies in adults have reported higher impulsivity in those with IUD (Lee et al., 2012; Lin, Ko, & Wu, 2011). Furthermore, impulsivity was also associated with IUD in a longitudinal study (Billieux et al., 2011; Gentile et al., 2011). On the other hand, previous reports have suggested that women with PMDD have higher impulsivity in the premenstrual phase (Yen, Chen et al., 2011). These results suggest that impulsivity is associated with both PMDD and IUD. If the PMDD is comorbid with IUD, we hypothesized that impulsivity would be involved in the association between PMDD and IUD. Thus, the aim of the study was to evaluate IUD, perceived stress and impulsivity of women with PMDD. Furthermore, we also investigated the
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association between PMDD and IUD. Lastly, the possible role of perceived stress and impulsivity in the association between PMDD and IUD was also explored.
METHOD
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Participants Participants were recruited using an advertisement posted specifically for women with PMDD who had not been treated and a control group on a university campus from August 2011 to September 2012. Volunteers in the PMDD group had to have a positive response to five or more symptoms of the 11 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria of PMDD (APA, 2000), and most reported that symptoms were relieved after menstruation. The control group had a positive response to less than three of the 11 symptoms of DSM-IV-TR criteria of PMDD or had no functional impairment under mild symptoms. Women using current psychotropic medication or gonadotropic medication were excluded from the study. A total of 169 women (90 in the PMDD group and 79 in the control group) with at least a college level education responded to the advertisement and were recruited into this study. Written and signed informed consent was obtained from all participants. The study protocol was approved by the Institutional Review Board (IRB) of Kaohsiung Medical University Hospital, Kaohsiung, Taiwain.
Measures The Premenstrual Symptoms Screening Tool (PSST) was developed by Steiner, Macdougall, and Brown (2003) and translates categorical DSM-IV criteria into a rating scale with degrees of severity. The PSST contains 14 items to assess the severity of PMDD symptoms, scored from not at all (1) to severe (4), as well as 5 items using the same scoring to assess the impairments of function for work, relationships with coworkers and family, social life activity, and home responsibility. We used the scale to screen women with moderate-to-severe premenstrual symptoms. They had to have: (1) at least 1 of the first 4 items of the 14 symptoms, (2) 4 or more items of the 14 items assessing PMDD symptoms, and (3) at least 1 of the 5 items assessing functional impairments that were classified as moderate-to-severe levels, with a score of 3 or 4 (Steiner et al., 2003). The 14 items for symptom severity had a Cronbach’s alpha of 0.96, and the 5 items for functional impairment had a Cronbach’s alpha of 0.93 for this study. The total scores of the 14 items assessing PMDD symptoms and the 5 items assessing functional impairment were summed to represent the severity and functional impairment of PMDD, respectively. Lastly, the score of each item of functional impairment of PMDD
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was represented by the severity of the individual impaired function in PMDD in a correlation analysis. In the Chinese version of the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998), the modules of psychotic disorder, bipolar disorder, and major depressive disorder were used to exclude the existence of histories of these disorders. Ko,Yen, Chen, Yang et al. (2009) developed the Diagnostic Criteria of Internet Addiction for College Students (DC-IA-C) based on an empirical diagnostic interview study. Criterion A is met with six of nine characteristic symptoms of Internet addiction: preoccupation, uncontrolled impulse, use more than intended, tolerance, withdrawal, impairment of control, excessive time, and effort devoted to the Internet, and impaired decision-making. Criterion B describes functional impairment secondary to Internet usage. Psychotic disorder, bipolar I disorder, paraphilia, and other impulse control disorders were listed in Criterion C as exclusion criteria. Criteria A, B, and C should be fulfilled to diagnose IUD. Good diagnostic accuracy (95.9%) and specificity (92.4%) have been demonstrated for the diagnostic criteria (Ko, Yen, Chen, Yang, et al., 2009). Because this study was conducted before the diagnostic criteria of IUD was proposed in the DSM-5, we confirmed the diagnosis of IUD based on the DC-IA-C in this study. However, preoccupation, withdrawal, tolerance, unsuccessful control, and continued excessive use despite negative consequences of DC-IA-C are the same as criteria 1–4 and 6 of the DSM-5. Criterion 9 is the same as criteria B of the DC-IA-C. Five or more of criteria 1–9 should be fulfilled to diagnose IUD, and six or more criteria should be fulfilled in DC-IA-C. Thus, the DC-IA-C is similar to the DSM-5 criteria of IUD (APA, 2012) and provided good diagnostic accuracy based on empirical study (Ko et al., 2005; Ko, Yen, Chen, Yang, et al., 2009). The Chen Internet Addiction Scale (CIAS) is a 26-item, self-reported, 4-point scale assessing 5 dimensions of Internet-related symptoms and problems, including symptoms of compulsive use, withdrawal, tolerance, and problems of interpersonal relationships and health/time management. The total scores of the CIAS ranged from 26 to 104 in general. Higher CIAS scores indicate higher severity of IUD. The internal reliability of the scale and the subscales in the original study ranged from 0.79 to 0.93 (Chen et al., 2003). According to the diagnostic criteria for Internet Addiction for College student (IAC), the 67/68 cut-off point of CIAS has the highest diagnostic accuracy (81.5%), accepted sensitivity (74.7%) and specificity (86.0%; Ko, Yen, Chen, Yang, et al., 2009). In this study, the CIAS was used to evaluate the severity of IUD. The Perceived Stress Scale (PSS; Cohen, Kamarack, & Mermelstein, 1983) is a widely used psychological instrument for measuring the perception of stress. It is a measure of the degree to which situations in one’s life are appraised as stressful. Items were designed to determine how unpredictable,
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uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about the current levels of experienced stress. The total score of PSS was used to evaluate the stress level in both premenstrual and follicular phases in this study. The Barratt Impulsiveness Scale (BIS-11; Patton, Standford, & Barratt, 1995) is a questionnaire designed to assess the personality/behavioral construct of impulsiveness. All items are measured on a 4-point scale (1 = rarely/never; 2 = occasionally; 3 = often; 4 = almost always/always). It is a widely cited instrument for the assessment of impulsiveness and has been used to advance our understanding of this construct and its relationship to other clinical phenomena (Stanford et al., 2009). The current version of the BIS-11 (Patton et al., 1995) is composed of 30 items describing frequent impulsive or non-impulsive (for reverse scored items) behaviors and preferences. The total score thus ranges from 30 to 120, with a higher score indicating higher impulsivity (Li & Chen, 2007; Patton et al., 1995).
Procedures A total of 169 (90 in the PMDD group and 79 in the control group) women who responded to the advertisement were screened by the self-reported PSST for moderate or severe premenstrual symptoms. Eighty-six participants in the PMDD group and 76 in the control group were screened as positive and negative with PSST, respectively. After excluding psychotic disorder, bipolar I disorder, and major depressive disorder based on the results of the diagnostic interviews using the MINI, participants were interviewed by one of two psychiatrists to arrive at the diagnosis of PMDD and IUD based on DSMIV-TR and DC-IA-C, respectively. Eighty-two women in the PMDD group and 76 women in the control group were diagnosed to have PMDD and no PMDD, respectively. Symptoms were assessed both in the premenstrual (within one week before menstruation predicted by the last menstruation cycle) and follicular phases (after the end of menstruation) of their menstrual cycles. Half (38 in the PMDD group and 39 in the control group) were assessed first in the premenstrual phase and then again in the follicular phase. Other participants were assessed in the reverse direction.
Statistics The association between PMDD and IUD was evaluated by chi-square analysis. The scores of CIAS, PSS, and BIS-11, both in the premenstrual and follicular phases were compared between the PMDD and control groups with independent t-test. A p-value lower than 0.017 was considered statistically significant for the t-test for CIAS, PSS, and BIS-11 based on a Bonferroni correction for multiple comparison. The levels between the premenstrual and follicular phases were compared by paired t-tests in each group.
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According to the concept of Baron and Kenny (1986), a mediator between the association of PMDD and IUD should meet the following condition: (a) PMDD should significantly account for variations in the mediators, (b) the mediators should significantly account for IUD, and (c) when the effect of mediators are controlled, a previously significant relation between the PMDD and IUD should no longer be significant. We evaluated the mediating effect of impulsivity or perceived stress in the association between PMDD and IUD in premenstrual phase. The association between PMDD diagnosis, impulsivity, and perceived stress could be evaluated by t-test to confirm criterion (a). Then, we evaluated the associations among IUD, impulsivity, and perceived stress in the premenstrual phase by using logistic regression, controlling for age and educational level to confirm criterion (b). All hypothesized variables, impulsivity and perceived stress, were entered into the model to determine their associations with IUD in the regression model. Then, hierarchical logistic regression analysis was used to evaluate the effect of PMDD to diagnosis of IUD first. Then, the candidate mediators were entered into the forward regression model to see whether the association between PMDD and IUD would be insignificant to confirm the significant mediating effect. Only mediators with significant (p < 0.05) relations to IUD were entered into the final model. The mediating effect of impulsivity or perceived stress in the association between PMDD and the severity of IUD in the premenstrual phase was evaluated in the same way. The same evaluations were also conducted for the associations among impulsivity, stress, PMDD, IUD, and severity of IUD in the follicular phase. The model fit for the logistic and linear regression models were determined by Hosmer and Lemeshow test (p > 0.05) and R square (>5%), respectively. Lastly, the correlations among the scores of CIAS, PSS, BIS 11, symptom severity, and functional impairment in PSST scale in the premenstrual phase were evaluated by Pearson’s correlation. A p-value lower than 0.05 was considered statistically significant for all analyses.
RESULTS Age and educational level of the PMDD and the control groups did not differ significantly (Table 1). Ten participants in the PMDD group and two in the control group were diagnosed to have IUD. Women with PMDD (12.2%) were more likely to have IUD than the controls (2.6%). The mean scores of the CIAS, PSS, and BIS-11 questions, both in the premenstrual and follicular phases, were compared between the PMDD and control groups with independent t-tests. The PMDD group had higher mean scores in CIAS, PSS, and BIS-11 in both the premenstrual and follicular phases. This indicated women with PMDD had greater severity of IUD, perceived stress, and impulsivity than controls in both of these phases of the menstrual cycle. The levels
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TABLE 1 Comparison of Characteristics of Women with Premenstrual Dysphoric Disorder (PMDD; N = 82) and Controls (N = 76) Variables Internet use disorder (IUD) Yes No
PMDD group, N (%)
Control group, N (%)
Chi-squared test
10 (12.2%) 72 (87.8%)
2 (2.6%) 74 (97.4%)
5.140∗
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PMDD group (Mean ± SD) Age (years) Education level (years) Severity of IUD Premenstrual Follicular Perceived stress Premenstrual Follicular Impulsivity Premenstrual Follicular
Paired t-test
23.37 ± 3.26 16.12 ± 1.52
Control group (Mean ± SD)
Paired t-test
23.59 ± 3.47 16.26 ± 1.72
Independent t-test −0.423 −0.547
59.38 ± 15.10 56.98 ± 13.45
2.123∗
51.04 ± 12.28 49.92 ± 10.98
1.368
3.791∗∗∗ 3.595∗∗∗
24.37 ± 5.62 18.48 ± 7.62
6.114∗∗∗
14.16 ± 5.34 14.11 ± 5.09
0.093
11.681∗∗∗ 4.268∗∗∗
62.44 ± 10.29 61.77 ± 8.70
0.829
58.61 ± 7.35 58.46 ± 7.66
0.324
2.710∗∗ 2.528∗
Note. Severity of IUD = score of Chen Internet Addiction Scale (range: 26–104); Perceived stress = score of Perceived Stress Scale (range: 0–40); Impulsivity = score of Barratt Impulsivity Scale (range: 30–120). ∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.
between the premenstrual and follicular phases were compared by paired t-tests in each group and demonstrated that the scores for the CIAS and PSS were higher in the premenstrual phase than those in the follicular phase among the PMDD group, but not in the control group. The correlation analysis revealed that the score of CIAS was positively correlated with the scores of the PSS and BIS-11, severity of symptoms and the functional impairment from PMDD in the premenstrual phase among the women with PMDD (Table 2). The scores of the CIAS also correlated with difficulties in coworkers and social activity subscale of functional impairment of the PSST. Further, the premenstrual exacerbation of IUD symptoms (premenstrual phase—follicular phase) correlated with premenstrual exacerbations (premenstrual phase—follicular phase) of functional impairment. Women with PMDD had higher stress and impulsivity (Table 1). In the logistic regression, impulsivity, but not perceived stress was significantly associated with the diagnosis of IUD among all participants in the premenstrual, but not in the follicular phase (Table 3). Both impulsivity and perceived stress were associated with severity of IUD among all participants both in premenstrual and follicular phase. Because only impulsivity was associated with IUD in the premenstrual phase, we evaluated the mediating effect of impulsivity in the association
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TABLE 2 Correlation between Severity of Internet Use Disorder (IUD) with Symptom Severity and Functional Impairment of Premenstrual Dysphoric Disorder (PMDD), Perceived Stress, and Impulsivity in the Premenstrual Phase Among Women with PMDD
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Variable PMDD group Premenstrual phase Stress Impulsivity PMDD total score PMDD function score Coworker relationship Social activity Premenstrual phase-follicular phase Stress Impulsivity PMDD total score PMDD function score
Severity of IUD in premenstrual phase
Premenstrual exacerbation of IUD
0.22∗ 0.40∗∗∗ 0.24∗ 0.28∗ 0.31∗∗ 0.30∗∗ 0.08 0.07 0.18 0.32∗∗
Note. Severity of IUD = score of Chen Internet Addiction Scale; Perceived stress = score of Perceived Stress Scale; Impulsivity = score of Barratt Impulsivity Scale. ∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.
between PMDD and IUD according to the concept of Baron and Kenny (1986). First, PMDD was significantly associated with IUD when age and educational level were controlled in the logistic regression model (Table 4, model 1, odds ratio [OR] = 5.13 95%, Confidence Interval [CI] = 1.08–24.34). The association between PMDD and IUD was insignificant when impulsivity was entered into the logistic regression model (model 2), indicating that impulsivity mediated the association between PMDD and IUD in the premenstrual phase. Then, we evaluated the mediating effects of impulsivity and perceived stress in the association between PMDD and severity of IUD in the premenstrual phase in the same way. PMDD was significantly associated with the severity of IUD (CIAS score) in the linear regression model (model 1, Table 4) in both the premenstrual and follicular phases. The association became insignificant when impulsivity and perceived stress were entered into the regression model, suggesting that impulsivity and perceived stress mediated the association between PMDD and the severity of IUD in the premenstrual phase (model 1, Table 4). However, the association between PMDD and severity of IUD in the follicular phase as still significant when impulsivity and perceived stress were entered into the regression model, suggesting that the association between IUD severity and PMDD was not completely mediated by impulsivity and perceived stress in the follicular phase. Further, we evaluated the associations between IUD, impulsivity, and perceived stress among women with PMDD. The logistic regression demonstrated that impulsivity, but not perceived stress, was associated with IUD
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TABLE 3 Relation of Impulsivity and Perceived Stress to the Diagnosis or Severity of Internet Use Disorder (IUD) in the Premenstrual and Follicular Phases Logistic regression for Diagnosis of IUD
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Premenstrual phase In all participants
Wald
OR
95% CI
Age (years) Education level (years) Impulsivity Stress
0.65 0.15 12.09∗∗ 0.07
0.88 0.89 1.14 1.01
In PMDD group Age (years) Education level (years) Impulsivity Stress
0.84 0.03 7.57∗∗ 0.24
0.85 0.94 1.12 0.97
Follicular phase Wald
OR
95% CI
0.64–1.21 0.48–1.63 1.06–1.23 0.93–1.10
1.04 0.11 3.60 1.15
0.86 1.09 1.07 1.05
0.64–1.15 0.67–1.78 0.99–1.15 0.96–1.14
0.60–1.21 0.47–1.87 1.03–1.21 0.85–1.10
1.43 0.35 1.30 0.58
0.81 1.19 1.05 1.04
0.7–1.15 0.66–2.15 0.97–1.14 0.94–1.14
Linear regression for severity of IUD In all participants
β
β
t
R 2 = 22.6%
−0.38 0.37 0.32 0.44
−1.12 0.52 2.69∗∗ 3.02∗∗
R 2 = 13.8%
R 2 = 19.9%
−0.33 0.25 0.34 0.26
−0.63 0.22 1.90 1.30
R 2 = 9.5%
t
Age (years) −0.22 Education level (years) 1.14 Impulsivity 0.46 Perceived stress 0.52
−0.58 1.48 3.94∗∗∗ 4.64∗∗∗
In PMDD group Age (years) −0.24 Education level (years) 1.79 Impulsivity 0.48 Perceived stress 0.38
−0.17 1.44 3.03∗∗ 1.35
OR = Odds Ratio; CI = Confidence Interval; Severity of IUD = score of Chen Internet Addiction Scale; Perceived stress = score of Perceived Stress Scale; Impulsivity: score of Barratt Impulsivity Scale. P value of Hosmer and Lemeshow test is >0.05 in all the logistic regression models in this table. ∗∗ p < 0.01; ∗∗∗ p < 0.001.
among women with PMDD in the premenstrual phase, but not in the follicular phase.
DISCUSSION This study revealed the association between PMDD and IUD and supported that women with PMDD were about five times as likely to have IUD compared to women without PMDD. The prospective evaluation for severity of IUD demonstrated that its severity was increased in the premenstrual phase among women with PMDD, but not in the control group. Further, women with PMDD had higher severity of IUD not only in the premenstrual phase but also in the follicular phase. IUD is a chronic brain disorder with a mechanism similar to substance use disorder (Ko, Liu, et al., 2009; Ko et al., 2013;
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TABLE 4 Relations of Premenstrual Dysphoric Disorder (PMDD), Impulsivity, and Perceived Stress to the Diagnosis or Severity of Internet Use Disorder (IUD) in the Premenstrual Phase and Follicular Phases Logistic regression for Diagnosis of IUD
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Premenstrual phase Model 1
Wald
OR
95% CI
Age (years) Education level (years) PMDD
1.18 0.35 4.23∗
0.85 1.17 5.13
0.63–1.14 0.70–1.94 1.08–24.34
Model 2 Age (years) Education level (years) PMDD Impulsivity
0.59 0.20 1.69 10.40∗∗
0.89 0.87 2.97 1.13
0.66–1.20 0.48–1.59 0.58–15.25 1.05–1.22
Follicular phase Wald
OR
95% CI
Linear regression for severity of IUD Model 1
β
t
β
t
R 2 = 19.9%
−0.47 0.63 7.04
−1.34 0.87 3.58∗∗∗
R 2 = 23.0%
−0.39 0.45 4.57 0.29 0.35
−1.16 0.64 2.27∗ 2.43∗ 2.30∗
Age (years) Education level (years) PMDD
−0.34 1.63 8.49
−0.87 2.01∗ 3.88∗∗∗
Model 2 Age (years) Education level (years) PMDD Impulsivity Perceived stress
−0.21 1.16 2.56 0.46 0.40
−0.58 1.51 0.92 3.92∗∗∗ 2.11∗
R2 = 8.7%
R2 = 16.7%
OR = Odds Ratio; CI = Confidence Interval; Severity of IUD = score of Chen Internet Addiction Scale; Perceived stress = score of Perceived Stress Scale; Impulsivity = score of Barratt Impulsivity Scale. P value of Hosmer and Lemeshow test is >0.05 in all the logistic regression models in this table. ∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.
Volkow et al., 2012). Thus, more attention should be paid to IUD among women with PMDD, and intervention for IUD should be provided not only in the premenstrual phase, but also in the follicular phase. Further, comorbidity may have one of three models of association: (1) sharing common factors, (2) one disorder causes another disorder, or (3) a bidirectional association. Because a causal relationship could not be proven in this cross-sectional study, we evaluated the possible common factors playing a role in the association between PMDD and IUD. In this study, our mediational model hypothesized that the PMDD was associated with the mediating factor, which, in turn, was associated with IUD. The mediating factors served to explore the mechanism of the association between PMDD and IUD. Impulsivity in the premenstrual phase was a mediator involved in the association between PMDD and IUD or its severity. In line with a
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previous result (Yen, Chen, et al., 2011), women with PMDD had higher impulsivity, not only in the premenstrual phase but also in the follicular phase. Impulsivity is also an important factor contributing to addictive behavior (Crews & Boettiger, 2009). It contributes to the transitional phases of addictive behavior as a mediating factor in the process of addiction (Hosking & Winstanley, 2011; Perry & Carroll, 2008). In line with previous results among those with IUD (Cao et al., 2007), we found impulsivity was associated with IUD and its severity in the premenstrual phase. Impulsivity indicated weak inhibitory control, lack of attention, bad decisions, or rapid responses without reflection (Crews & Boettiger, 2009). It played an important role in retaining addictive behavior despite knowing the negative consequences (Crews & Boettiger, 2009). Thus, although the negative consequence of heavy Internet use was perceived, women with higher impulsivity might have persisted in their heavy Internet use. Further, impulsivity in the premenstrual phase completely mediated the association between PMDD and the diagnosis of IUD, thus indicating that premenstrual impulsivity plays a role in the comorbidity of PMDD and IUD. Our evaluation found that women with PMDD with higher impulsivity were more likely to have IUD in the premenstrual phase, but not in the follicular phase. The symptoms and social difficulties of women with PMDD were exacerbated in the premenstrual phase and limited their social interaction. This might make them use the Internet as an alternative way to interact with others or relieve their emotional difficulty. However, impulsivity might have made them unable to control their Internet use and thus increased the likelihood of IUD. In the follicular phase, the emotional and social difficulties were attenuated. Women with PMDD could freely participate in real-world social interaction. Even if they had higher impulsivity, they did not necessarily maintain excessive Internet use in the follicular phase. This result suggests that counseling for impulsivity should be provided to women with PMDD, particularly in the premenstrual phase, to attenuate the risk of IUD. Further, we need to assess and treat IUD among women with PMDD, particular for those with higher premenstrual impulsivity. Additionally, women with PMDD had a higher severity of IUD, not only in the premenstrual phase, but also in the follicular phase, indicating that IUD symptoms are a persistent problem for women with PMDD. On the other hand, the severity of IUD was greater in the premenstrual phase as for the severity of PMDD (Kornstein et al., 2005) among women with PMDD, but not among controls. Further, the severity of IUD in the premenstrual phase correlated with symptom severity and functional impairment, in particular, social coworker relationships, among women with PMDD. These results suggest that PMDD women experiencing higher symptoms or functional impairment had higher severity of IUD in the premenstrual phase. Further, the greater premenstrual functional impairment among women with
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PMDD positively correlated with greater premenstrual IUD, indicating that among women with PMDD, those with increased difficulty in daily life in the premenstrual phase had increased severity of IUD. The daily life difficulty might limit the social or recreational activity among women with PMDD. This might make it difficult for them to find another activity to replace their online activities. On the other hand, IUD is associated with social anxiety disorder (Ko et al., 2008). If women with IUD were comorbid with PMDD, the PMDD symptoms might deteriorate their social difficulty in the premenstrual phase. Although the causal relationship could not be confirmed in this study, this result suggested that more attention should be paid to functional impairment, particularly social difficulty, for the women with PMDD. Effective counseling for daily life difficulty, such as social interaction problems of women with PMDD, might improve both PMDD and IUD. This study showed that women with PMDD had higher perceived stress, which has been reported to contribute to addiction processes (Crews & Boettiger, 2009; Schwabe, Dickinson, & Wolf, 2011). Because escape from the self while in a negative mood may be one of the mechanisms of IUD (Kwon, Chung, & Lee, 2011), women with higher perceived stress had higher severity of IUD in this present study. Further, the perceived stress mediated the association between PMDD and IUD severity in the premenstrual phase, suggesting higher perceived stress involved in the association between PMDD and severity of IUD in the premenstrual phase. The PMDD women usually experienced prolonged and repeated stress in the premenstrual phase. Further, prolonged or repeated stress may accelerate the transition from voluntary to involuntary addictive behavior and thus promote the development of addiction (Schwabe et al., 2011). Thus, persistent and fluctuating stress around the menstrual cycle could accelerate the transition from repeated use of the Internet to IUD among women with PMDD. Our result revealing the association between severity of IUD and perceived stress among women with PMDD might support this claim. We would suggest that counseling for effective coping strategies (Rizzolo & Sedrak, 2010) for stress should be provided to women with PMDD, particularly for those with greater severity of IUD. However, the association between perceived stress and severity of IUD was insignificant when impulsivity was included in the regression model, suggesting that impulsivity was a more proximally associated factor to severity of IUD among women with PMDD in the premenstrual phase. This study had several limitations that should be considered when interpreting its findings. First, the cross-sectional design of the study did not permit assessment of the temporal and thus potentially causal relationships of IUD, perceived stress, impulsivity, and PMDD. Secondly, the diagnosis of IUD was based only on diagnostic interview without any information provided from the family, which could have resulted in misclassification of this diagnosis. Third, the sample was small and non-representative, so that some
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meaningful associations may not have been detected as statistically significant, and the findings may not be generalizable. Finally, lack of control for other confounding variables may have affected the results.
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CONCLUSION We found that women with PMDD were more likely to have IUD. They experienced greater IUD symptoms not only in the premenstrual phase, but also in the follicular phase. Impulsivity was associated with IUD among women with PMDD in the premenstrual phase and mediated the association between PMDD and IUD. IUD should be assessed, and appropriate interventions designed for women with PMDD, particularly among those with higher premenstrual impulsivity. Both impulsivity and perceived stress were associated with severity of IUD and mediated the association between PMDD and IUD severity. Effective management of stress and counseling of impulsivity are, therefore, suggested when treating women with PMDD to attenuate the severity of comorbid IUD.
FUNDING This study was supported by grants from the National Science Council in Taiwan (NSC100-2629-B-037-001-MY2), Kaohsiung Municipal HsiaoKang Hospital (KMHK-99-001), and Kaohsiung Medical University Hospital (KMUH101-1R61).
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Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
The Association Between Premenstrual Dysphoric Disorder and Internet Use Disorder abc
Chih-Hung Ko MD, PhD d
ab
, Cheng-Fang Yen MD, PhD , Cheng-Yu Long ab
a
MD, PhD , Cheng-Sheng Chen MD, PhD , Tzu-Hui Huang MSc & JuYu Yen MD, PhD
ecb
a
Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan b
Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan c
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan d
Department of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan e
Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan Accepted author version posted online: 10 Feb 2014.Published online: 08 Apr 2014.
To cite this article: Chih-Hung Ko MD, PhD, Cheng-Fang Yen MD, PhD, Cheng-Yu Long MD, PhD, ChengSheng Chen MD, PhD, Tzu-Hui Huang MSc & Ju-Yu Yen MD, PhD (2014) The Association Between Premenstrual Dysphoric Disorder and Internet Use Disorder, Women & Health, 54:3, 245-261, DOI: 10.1080/03630242.2014.883661 To link to this article: http://dx.doi.org/10.1080/03630242.2014.883661
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Women & Health, 54:245–261, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.883661
The Association Between Premenstrual Dysphoric Disorder and Internet Use Disorder
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CHIH-HUNG KO, MD, PhD Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
CHENG-FANG YEN, MD, PhD Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
CHENG-YU LONG, MD, PhD Department of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
CHENG-SHENG CHEN, MD, PhD Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
TZU-HUI HUANG, MSc Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
JU-YU YEN, MD, PhD Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; and Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Premenstrual dysphoric disorder (PMDD) is an important women’s mental health issue. This study aimed to investigate the association between Internet use disorder (IUD), PMDD, and their associated Received April 11, 2013; revised November 30, 2013; accepted January 3, 2014. Address correspondence to Ju-Yu Yen, MD, PhD, Department of Psychiatry, Kaohsiung Medical University Hospital, 100, Tzyou 1st Road, Kaohsiung, 80708, Taiwan. E-mail: [email protected] 245
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factors, such as stress and impulsivity. Women with PMDD ( n = 79) and controls ( n = 76) were recruited from the community. The diagnoses of PMDD and IUD were confirmed by psychiatric interviews. Participants were evaluated with the Chen Internet Addiction Scale, Perceived Stress Scale, and Barratt Impulsiveness Scale in both the premenstrual and follicular phases. Women with PMDD were more likely to have IUD. Women with PMDD had greater severity of IUD, perceived stress, and impulsivity than the control group in the premenstrual phase. Impulsivity mediated the association between PMDD and IUD, while both impulsivity and perceived stress mediated the association between PMDD and IUD severity. Thus, IUD should be evaluated and treated among women with PMDD, particularly for those with higher impulsivity or higher perceived stress. Strategies for stress management and counseling for impulsivity should be provided to women with PMDD, particular to those comorbid with IUD. KEYWORDS impulsivity
PMDD, internet use disorder, perceived stress,
INTRODUCTION About 70%–90 % of menstruating women have one or more signs of physical discomfort or emotional symptoms in the premenstrual phase of the menstrual cycle. About 20%–40 % of the affected women have experienced premenstrual symptoms that are bothersome (Mishell, 2005). A small number, 3%–8%, of menstruating women experience more severe symptoms, which can lead to substantial distress or functional impairment and meet strict criteria for premenstrual dysphoric disorder (PMDD). The affected women have been estimated to experience almost 3,000 days of severe symptoms during their menstruating years, resulting in a heavy life burden and functional impairment (Mishell, 2005). PMDD is included in the official diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2012). Its typical symptoms, including irritability, anger, depression, loss of interest, fatigue, tension/anxiety, abdominal bloating, breast pain, and fatigue, recur monthly and last for an average of six days per month during the majority of menstruating years. These dysphoric symptoms may make affected women unwilling to go out, resulting in social isolation. The Internet is a tool to interact with others without leaving home in modern society. However, whether women with PMDD were more likely to have Internet use disorder (IUD) had not been evaluated. The Internet is now a major communication medium in modern life. However, loss of control over Internet use has resulted in negative
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psychosocial consequences (Yen et al., 2008). IUD is defined in section III of “substance use and addictive disorders” in the proposed DSM-5, and it has been suggested that it deserves further study (APA, 2012). The proposed DSM-5 has suggested nine criteria for IUD, including preoccupation, withdrawal symptoms, tolerance, unsuccessful control, impaired decision-making, rewarding deficit, escape, self-deception about Internet gaming, and impaired function. Depression and irritability are important and the most frequent symptoms of PMDD (Hartlage & Arduino, 2002; Klatzkin et al., 2010). The DSM-5 criteria for IUD (APA, 2012) suggest that individuals with IUD use Internet gaming to escape or relieve dysphoric mood. Previous reports have found that adults with depression or higher hostility are more likely to have IUD (Ko et al., 2008; Yen, Yen et al., 2011). Further, depression and hostility have been reported to be two important risk factors related to IUD in prospective studies (Ko, Yen, Chen, Yeh, et al., 2009). Thus, we hypothesized that women with PMDD who have higher hostility and depression might be a higher risk group for IUD. Perceived stress is an important mental health issue that contributes to cardiovascular disease risk and sleep problems (Iso et al., 2002; Kashani, Eliasson, & Vernalis, 2012). Increased interpersonal conflicts, fatigue, and dysphoric moods—symptoms of PMDD—might bring stress into work, home, and social interactions. Women with PMDD display higher levels of neuroticism-related personality traits that demonstrate a vulnerability to stress (Gingnell et al., 2010). PMDD has also been associated with psychological distress, assessed by a mental health inventory in an epidemiological study (Tschudin et al., 2010). Further, individuals with IUD have been reported to escape to the Internet from their job stress (Whang et al., 2003). Academic stress and recent stress events have also been associated with IUD in crosssectional epidemiological studies (Lam et al., 2009; Wang et al., 2011). These studies indicated that the stress was associated with both PMDD and IUD. Thus, we hypothesized that stress would be involved in the association between PMDD and IUD. What is more, impulsivity is one of the most important factors contributing to the loss of control or addictive behavior (Winstanley et al., 2006). Studies in adults have reported higher impulsivity in those with IUD (Lee et al., 2012; Lin, Ko, & Wu, 2011). Furthermore, impulsivity was also associated with IUD in a longitudinal study (Billieux et al., 2011; Gentile et al., 2011). On the other hand, previous reports have suggested that women with PMDD have higher impulsivity in the premenstrual phase (Yen, Chen et al., 2011). These results suggest that impulsivity is associated with both PMDD and IUD. If the PMDD is comorbid with IUD, we hypothesized that impulsivity would be involved in the association between PMDD and IUD. Thus, the aim of the study was to evaluate IUD, perceived stress and impulsivity of women with PMDD. Furthermore, we also investigated the
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association between PMDD and IUD. Lastly, the possible role of perceived stress and impulsivity in the association between PMDD and IUD was also explored.
METHOD
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Participants Participants were recruited using an advertisement posted specifically for women with PMDD who had not been treated and a control group on a university campus from August 2011 to September 2012. Volunteers in the PMDD group had to have a positive response to five or more symptoms of the 11 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria of PMDD (APA, 2000), and most reported that symptoms were relieved after menstruation. The control group had a positive response to less than three of the 11 symptoms of DSM-IV-TR criteria of PMDD or had no functional impairment under mild symptoms. Women using current psychotropic medication or gonadotropic medication were excluded from the study. A total of 169 women (90 in the PMDD group and 79 in the control group) with at least a college level education responded to the advertisement and were recruited into this study. Written and signed informed consent was obtained from all participants. The study protocol was approved by the Institutional Review Board (IRB) of Kaohsiung Medical University Hospital, Kaohsiung, Taiwain.
Measures The Premenstrual Symptoms Screening Tool (PSST) was developed by Steiner, Macdougall, and Brown (2003) and translates categorical DSM-IV criteria into a rating scale with degrees of severity. The PSST contains 14 items to assess the severity of PMDD symptoms, scored from not at all (1) to severe (4), as well as 5 items using the same scoring to assess the impairments of function for work, relationships with coworkers and family, social life activity, and home responsibility. We used the scale to screen women with moderate-to-severe premenstrual symptoms. They had to have: (1) at least 1 of the first 4 items of the 14 symptoms, (2) 4 or more items of the 14 items assessing PMDD symptoms, and (3) at least 1 of the 5 items assessing functional impairments that were classified as moderate-to-severe levels, with a score of 3 or 4 (Steiner et al., 2003). The 14 items for symptom severity had a Cronbach’s alpha of 0.96, and the 5 items for functional impairment had a Cronbach’s alpha of 0.93 for this study. The total scores of the 14 items assessing PMDD symptoms and the 5 items assessing functional impairment were summed to represent the severity and functional impairment of PMDD, respectively. Lastly, the score of each item of functional impairment of PMDD
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was represented by the severity of the individual impaired function in PMDD in a correlation analysis. In the Chinese version of the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998), the modules of psychotic disorder, bipolar disorder, and major depressive disorder were used to exclude the existence of histories of these disorders. Ko,Yen, Chen, Yang et al. (2009) developed the Diagnostic Criteria of Internet Addiction for College Students (DC-IA-C) based on an empirical diagnostic interview study. Criterion A is met with six of nine characteristic symptoms of Internet addiction: preoccupation, uncontrolled impulse, use more than intended, tolerance, withdrawal, impairment of control, excessive time, and effort devoted to the Internet, and impaired decision-making. Criterion B describes functional impairment secondary to Internet usage. Psychotic disorder, bipolar I disorder, paraphilia, and other impulse control disorders were listed in Criterion C as exclusion criteria. Criteria A, B, and C should be fulfilled to diagnose IUD. Good diagnostic accuracy (95.9%) and specificity (92.4%) have been demonstrated for the diagnostic criteria (Ko, Yen, Chen, Yang, et al., 2009). Because this study was conducted before the diagnostic criteria of IUD was proposed in the DSM-5, we confirmed the diagnosis of IUD based on the DC-IA-C in this study. However, preoccupation, withdrawal, tolerance, unsuccessful control, and continued excessive use despite negative consequences of DC-IA-C are the same as criteria 1–4 and 6 of the DSM-5. Criterion 9 is the same as criteria B of the DC-IA-C. Five or more of criteria 1–9 should be fulfilled to diagnose IUD, and six or more criteria should be fulfilled in DC-IA-C. Thus, the DC-IA-C is similar to the DSM-5 criteria of IUD (APA, 2012) and provided good diagnostic accuracy based on empirical study (Ko et al., 2005; Ko, Yen, Chen, Yang, et al., 2009). The Chen Internet Addiction Scale (CIAS) is a 26-item, self-reported, 4-point scale assessing 5 dimensions of Internet-related symptoms and problems, including symptoms of compulsive use, withdrawal, tolerance, and problems of interpersonal relationships and health/time management. The total scores of the CIAS ranged from 26 to 104 in general. Higher CIAS scores indicate higher severity of IUD. The internal reliability of the scale and the subscales in the original study ranged from 0.79 to 0.93 (Chen et al., 2003). According to the diagnostic criteria for Internet Addiction for College student (IAC), the 67/68 cut-off point of CIAS has the highest diagnostic accuracy (81.5%), accepted sensitivity (74.7%) and specificity (86.0%; Ko, Yen, Chen, Yang, et al., 2009). In this study, the CIAS was used to evaluate the severity of IUD. The Perceived Stress Scale (PSS; Cohen, Kamarack, & Mermelstein, 1983) is a widely used psychological instrument for measuring the perception of stress. It is a measure of the degree to which situations in one’s life are appraised as stressful. Items were designed to determine how unpredictable,
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uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about the current levels of experienced stress. The total score of PSS was used to evaluate the stress level in both premenstrual and follicular phases in this study. The Barratt Impulsiveness Scale (BIS-11; Patton, Standford, & Barratt, 1995) is a questionnaire designed to assess the personality/behavioral construct of impulsiveness. All items are measured on a 4-point scale (1 = rarely/never; 2 = occasionally; 3 = often; 4 = almost always/always). It is a widely cited instrument for the assessment of impulsiveness and has been used to advance our understanding of this construct and its relationship to other clinical phenomena (Stanford et al., 2009). The current version of the BIS-11 (Patton et al., 1995) is composed of 30 items describing frequent impulsive or non-impulsive (for reverse scored items) behaviors and preferences. The total score thus ranges from 30 to 120, with a higher score indicating higher impulsivity (Li & Chen, 2007; Patton et al., 1995).
Procedures A total of 169 (90 in the PMDD group and 79 in the control group) women who responded to the advertisement were screened by the self-reported PSST for moderate or severe premenstrual symptoms. Eighty-six participants in the PMDD group and 76 in the control group were screened as positive and negative with PSST, respectively. After excluding psychotic disorder, bipolar I disorder, and major depressive disorder based on the results of the diagnostic interviews using the MINI, participants were interviewed by one of two psychiatrists to arrive at the diagnosis of PMDD and IUD based on DSMIV-TR and DC-IA-C, respectively. Eighty-two women in the PMDD group and 76 women in the control group were diagnosed to have PMDD and no PMDD, respectively. Symptoms were assessed both in the premenstrual (within one week before menstruation predicted by the last menstruation cycle) and follicular phases (after the end of menstruation) of their menstrual cycles. Half (38 in the PMDD group and 39 in the control group) were assessed first in the premenstrual phase and then again in the follicular phase. Other participants were assessed in the reverse direction.
Statistics The association between PMDD and IUD was evaluated by chi-square analysis. The scores of CIAS, PSS, and BIS-11, both in the premenstrual and follicular phases were compared between the PMDD and control groups with independent t-test. A p-value lower than 0.017 was considered statistically significant for the t-test for CIAS, PSS, and BIS-11 based on a Bonferroni correction for multiple comparison. The levels between the premenstrual and follicular phases were compared by paired t-tests in each group.
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According to the concept of Baron and Kenny (1986), a mediator between the association of PMDD and IUD should meet the following condition: (a) PMDD should significantly account for variations in the mediators, (b) the mediators should significantly account for IUD, and (c) when the effect of mediators are controlled, a previously significant relation between the PMDD and IUD should no longer be significant. We evaluated the mediating effect of impulsivity or perceived stress in the association between PMDD and IUD in premenstrual phase. The association between PMDD diagnosis, impulsivity, and perceived stress could be evaluated by t-test to confirm criterion (a). Then, we evaluated the associations among IUD, impulsivity, and perceived stress in the premenstrual phase by using logistic regression, controlling for age and educational level to confirm criterion (b). All hypothesized variables, impulsivity and perceived stress, were entered into the model to determine their associations with IUD in the regression model. Then, hierarchical logistic regression analysis was used to evaluate the effect of PMDD to diagnosis of IUD first. Then, the candidate mediators were entered into the forward regression model to see whether the association between PMDD and IUD would be insignificant to confirm the significant mediating effect. Only mediators with significant (p < 0.05) relations to IUD were entered into the final model. The mediating effect of impulsivity or perceived stress in the association between PMDD and the severity of IUD in the premenstrual phase was evaluated in the same way. The same evaluations were also conducted for the associations among impulsivity, stress, PMDD, IUD, and severity of IUD in the follicular phase. The model fit for the logistic and linear regression models were determined by Hosmer and Lemeshow test (p > 0.05) and R square (>5%), respectively. Lastly, the correlations among the scores of CIAS, PSS, BIS 11, symptom severity, and functional impairment in PSST scale in the premenstrual phase were evaluated by Pearson’s correlation. A p-value lower than 0.05 was considered statistically significant for all analyses.
RESULTS Age and educational level of the PMDD and the control groups did not differ significantly (Table 1). Ten participants in the PMDD group and two in the control group were diagnosed to have IUD. Women with PMDD (12.2%) were more likely to have IUD than the controls (2.6%). The mean scores of the CIAS, PSS, and BIS-11 questions, both in the premenstrual and follicular phases, were compared between the PMDD and control groups with independent t-tests. The PMDD group had higher mean scores in CIAS, PSS, and BIS-11 in both the premenstrual and follicular phases. This indicated women with PMDD had greater severity of IUD, perceived stress, and impulsivity than controls in both of these phases of the menstrual cycle. The levels
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TABLE 1 Comparison of Characteristics of Women with Premenstrual Dysphoric Disorder (PMDD; N = 82) and Controls (N = 76) Variables Internet use disorder (IUD) Yes No
PMDD group, N (%)
Control group, N (%)
Chi-squared test
10 (12.2%) 72 (87.8%)
2 (2.6%) 74 (97.4%)
5.140∗
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PMDD group (Mean ± SD) Age (years) Education level (years) Severity of IUD Premenstrual Follicular Perceived stress Premenstrual Follicular Impulsivity Premenstrual Follicular
Paired t-test
23.37 ± 3.26 16.12 ± 1.52
Control group (Mean ± SD)
Paired t-test
23.59 ± 3.47 16.26 ± 1.72
Independent t-test −0.423 −0.547
59.38 ± 15.10 56.98 ± 13.45
2.123∗
51.04 ± 12.28 49.92 ± 10.98
1.368
3.791∗∗∗ 3.595∗∗∗
24.37 ± 5.62 18.48 ± 7.62
6.114∗∗∗
14.16 ± 5.34 14.11 ± 5.09
0.093
11.681∗∗∗ 4.268∗∗∗
62.44 ± 10.29 61.77 ± 8.70
0.829
58.61 ± 7.35 58.46 ± 7.66
0.324
2.710∗∗ 2.528∗
Note. Severity of IUD = score of Chen Internet Addiction Scale (range: 26–104); Perceived stress = score of Perceived Stress Scale (range: 0–40); Impulsivity = score of Barratt Impulsivity Scale (range: 30–120). ∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.
between the premenstrual and follicular phases were compared by paired t-tests in each group and demonstrated that the scores for the CIAS and PSS were higher in the premenstrual phase than those in the follicular phase among the PMDD group, but not in the control group. The correlation analysis revealed that the score of CIAS was positively correlated with the scores of the PSS and BIS-11, severity of symptoms and the functional impairment from PMDD in the premenstrual phase among the women with PMDD (Table 2). The scores of the CIAS also correlated with difficulties in coworkers and social activity subscale of functional impairment of the PSST. Further, the premenstrual exacerbation of IUD symptoms (premenstrual phase—follicular phase) correlated with premenstrual exacerbations (premenstrual phase—follicular phase) of functional impairment. Women with PMDD had higher stress and impulsivity (Table 1). In the logistic regression, impulsivity, but not perceived stress was significantly associated with the diagnosis of IUD among all participants in the premenstrual, but not in the follicular phase (Table 3). Both impulsivity and perceived stress were associated with severity of IUD among all participants both in premenstrual and follicular phase. Because only impulsivity was associated with IUD in the premenstrual phase, we evaluated the mediating effect of impulsivity in the association
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TABLE 2 Correlation between Severity of Internet Use Disorder (IUD) with Symptom Severity and Functional Impairment of Premenstrual Dysphoric Disorder (PMDD), Perceived Stress, and Impulsivity in the Premenstrual Phase Among Women with PMDD
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Variable PMDD group Premenstrual phase Stress Impulsivity PMDD total score PMDD function score Coworker relationship Social activity Premenstrual phase-follicular phase Stress Impulsivity PMDD total score PMDD function score
Severity of IUD in premenstrual phase
Premenstrual exacerbation of IUD
0.22∗ 0.40∗∗∗ 0.24∗ 0.28∗ 0.31∗∗ 0.30∗∗ 0.08 0.07 0.18 0.32∗∗
Note. Severity of IUD = score of Chen Internet Addiction Scale; Perceived stress = score of Perceived Stress Scale; Impulsivity = score of Barratt Impulsivity Scale. ∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.
between PMDD and IUD according to the concept of Baron and Kenny (1986). First, PMDD was significantly associated with IUD when age and educational level were controlled in the logistic regression model (Table 4, model 1, odds ratio [OR] = 5.13 95%, Confidence Interval [CI] = 1.08–24.34). The association between PMDD and IUD was insignificant when impulsivity was entered into the logistic regression model (model 2), indicating that impulsivity mediated the association between PMDD and IUD in the premenstrual phase. Then, we evaluated the mediating effects of impulsivity and perceived stress in the association between PMDD and severity of IUD in the premenstrual phase in the same way. PMDD was significantly associated with the severity of IUD (CIAS score) in the linear regression model (model 1, Table 4) in both the premenstrual and follicular phases. The association became insignificant when impulsivity and perceived stress were entered into the regression model, suggesting that impulsivity and perceived stress mediated the association between PMDD and the severity of IUD in the premenstrual phase (model 1, Table 4). However, the association between PMDD and severity of IUD in the follicular phase as still significant when impulsivity and perceived stress were entered into the regression model, suggesting that the association between IUD severity and PMDD was not completely mediated by impulsivity and perceived stress in the follicular phase. Further, we evaluated the associations between IUD, impulsivity, and perceived stress among women with PMDD. The logistic regression demonstrated that impulsivity, but not perceived stress, was associated with IUD
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TABLE 3 Relation of Impulsivity and Perceived Stress to the Diagnosis or Severity of Internet Use Disorder (IUD) in the Premenstrual and Follicular Phases Logistic regression for Diagnosis of IUD
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Premenstrual phase In all participants
Wald
OR
95% CI
Age (years) Education level (years) Impulsivity Stress
0.65 0.15 12.09∗∗ 0.07
0.88 0.89 1.14 1.01
In PMDD group Age (years) Education level (years) Impulsivity Stress
0.84 0.03 7.57∗∗ 0.24
0.85 0.94 1.12 0.97
Follicular phase Wald
OR
95% CI
0.64–1.21 0.48–1.63 1.06–1.23 0.93–1.10
1.04 0.11 3.60 1.15
0.86 1.09 1.07 1.05
0.64–1.15 0.67–1.78 0.99–1.15 0.96–1.14
0.60–1.21 0.47–1.87 1.03–1.21 0.85–1.10
1.43 0.35 1.30 0.58
0.81 1.19 1.05 1.04
0.7–1.15 0.66–2.15 0.97–1.14 0.94–1.14
Linear regression for severity of IUD In all participants
β
β
t
R 2 = 22.6%
−0.38 0.37 0.32 0.44
−1.12 0.52 2.69∗∗ 3.02∗∗
R 2 = 13.8%
R 2 = 19.9%
−0.33 0.25 0.34 0.26
−0.63 0.22 1.90 1.30
R 2 = 9.5%
t
Age (years) −0.22 Education level (years) 1.14 Impulsivity 0.46 Perceived stress 0.52
−0.58 1.48 3.94∗∗∗ 4.64∗∗∗
In PMDD group Age (years) −0.24 Education level (years) 1.79 Impulsivity 0.48 Perceived stress 0.38
−0.17 1.44 3.03∗∗ 1.35
OR = Odds Ratio; CI = Confidence Interval; Severity of IUD = score of Chen Internet Addiction Scale; Perceived stress = score of Perceived Stress Scale; Impulsivity: score of Barratt Impulsivity Scale. P value of Hosmer and Lemeshow test is >0.05 in all the logistic regression models in this table. ∗∗ p < 0.01; ∗∗∗ p < 0.001.
among women with PMDD in the premenstrual phase, but not in the follicular phase.
DISCUSSION This study revealed the association between PMDD and IUD and supported that women with PMDD were about five times as likely to have IUD compared to women without PMDD. The prospective evaluation for severity of IUD demonstrated that its severity was increased in the premenstrual phase among women with PMDD, but not in the control group. Further, women with PMDD had higher severity of IUD not only in the premenstrual phase but also in the follicular phase. IUD is a chronic brain disorder with a mechanism similar to substance use disorder (Ko, Liu, et al., 2009; Ko et al., 2013;
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TABLE 4 Relations of Premenstrual Dysphoric Disorder (PMDD), Impulsivity, and Perceived Stress to the Diagnosis or Severity of Internet Use Disorder (IUD) in the Premenstrual Phase and Follicular Phases Logistic regression for Diagnosis of IUD
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Premenstrual phase Model 1
Wald
OR
95% CI
Age (years) Education level (years) PMDD
1.18 0.35 4.23∗
0.85 1.17 5.13
0.63–1.14 0.70–1.94 1.08–24.34
Model 2 Age (years) Education level (years) PMDD Impulsivity
0.59 0.20 1.69 10.40∗∗
0.89 0.87 2.97 1.13
0.66–1.20 0.48–1.59 0.58–15.25 1.05–1.22
Follicular phase Wald
OR
95% CI
Linear regression for severity of IUD Model 1
β
t
β
t
R 2 = 19.9%
−0.47 0.63 7.04
−1.34 0.87 3.58∗∗∗
R 2 = 23.0%
−0.39 0.45 4.57 0.29 0.35
−1.16 0.64 2.27∗ 2.43∗ 2.30∗
Age (years) Education level (years) PMDD
−0.34 1.63 8.49
−0.87 2.01∗ 3.88∗∗∗
Model 2 Age (years) Education level (years) PMDD Impulsivity Perceived stress
−0.21 1.16 2.56 0.46 0.40
−0.58 1.51 0.92 3.92∗∗∗ 2.11∗
R2 = 8.7%
R2 = 16.7%
OR = Odds Ratio; CI = Confidence Interval; Severity of IUD = score of Chen Internet Addiction Scale; Perceived stress = score of Perceived Stress Scale; Impulsivity = score of Barratt Impulsivity Scale. P value of Hosmer and Lemeshow test is >0.05 in all the logistic regression models in this table. ∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.
Volkow et al., 2012). Thus, more attention should be paid to IUD among women with PMDD, and intervention for IUD should be provided not only in the premenstrual phase, but also in the follicular phase. Further, comorbidity may have one of three models of association: (1) sharing common factors, (2) one disorder causes another disorder, or (3) a bidirectional association. Because a causal relationship could not be proven in this cross-sectional study, we evaluated the possible common factors playing a role in the association between PMDD and IUD. In this study, our mediational model hypothesized that the PMDD was associated with the mediating factor, which, in turn, was associated with IUD. The mediating factors served to explore the mechanism of the association between PMDD and IUD. Impulsivity in the premenstrual phase was a mediator involved in the association between PMDD and IUD or its severity. In line with a
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previous result (Yen, Chen, et al., 2011), women with PMDD had higher impulsivity, not only in the premenstrual phase but also in the follicular phase. Impulsivity is also an important factor contributing to addictive behavior (Crews & Boettiger, 2009). It contributes to the transitional phases of addictive behavior as a mediating factor in the process of addiction (Hosking & Winstanley, 2011; Perry & Carroll, 2008). In line with previous results among those with IUD (Cao et al., 2007), we found impulsivity was associated with IUD and its severity in the premenstrual phase. Impulsivity indicated weak inhibitory control, lack of attention, bad decisions, or rapid responses without reflection (Crews & Boettiger, 2009). It played an important role in retaining addictive behavior despite knowing the negative consequences (Crews & Boettiger, 2009). Thus, although the negative consequence of heavy Internet use was perceived, women with higher impulsivity might have persisted in their heavy Internet use. Further, impulsivity in the premenstrual phase completely mediated the association between PMDD and the diagnosis of IUD, thus indicating that premenstrual impulsivity plays a role in the comorbidity of PMDD and IUD. Our evaluation found that women with PMDD with higher impulsivity were more likely to have IUD in the premenstrual phase, but not in the follicular phase. The symptoms and social difficulties of women with PMDD were exacerbated in the premenstrual phase and limited their social interaction. This might make them use the Internet as an alternative way to interact with others or relieve their emotional difficulty. However, impulsivity might have made them unable to control their Internet use and thus increased the likelihood of IUD. In the follicular phase, the emotional and social difficulties were attenuated. Women with PMDD could freely participate in real-world social interaction. Even if they had higher impulsivity, they did not necessarily maintain excessive Internet use in the follicular phase. This result suggests that counseling for impulsivity should be provided to women with PMDD, particularly in the premenstrual phase, to attenuate the risk of IUD. Further, we need to assess and treat IUD among women with PMDD, particular for those with higher premenstrual impulsivity. Additionally, women with PMDD had a higher severity of IUD, not only in the premenstrual phase, but also in the follicular phase, indicating that IUD symptoms are a persistent problem for women with PMDD. On the other hand, the severity of IUD was greater in the premenstrual phase as for the severity of PMDD (Kornstein et al., 2005) among women with PMDD, but not among controls. Further, the severity of IUD in the premenstrual phase correlated with symptom severity and functional impairment, in particular, social coworker relationships, among women with PMDD. These results suggest that PMDD women experiencing higher symptoms or functional impairment had higher severity of IUD in the premenstrual phase. Further, the greater premenstrual functional impairment among women with
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PMDD positively correlated with greater premenstrual IUD, indicating that among women with PMDD, those with increased difficulty in daily life in the premenstrual phase had increased severity of IUD. The daily life difficulty might limit the social or recreational activity among women with PMDD. This might make it difficult for them to find another activity to replace their online activities. On the other hand, IUD is associated with social anxiety disorder (Ko et al., 2008). If women with IUD were comorbid with PMDD, the PMDD symptoms might deteriorate their social difficulty in the premenstrual phase. Although the causal relationship could not be confirmed in this study, this result suggested that more attention should be paid to functional impairment, particularly social difficulty, for the women with PMDD. Effective counseling for daily life difficulty, such as social interaction problems of women with PMDD, might improve both PMDD and IUD. This study showed that women with PMDD had higher perceived stress, which has been reported to contribute to addiction processes (Crews & Boettiger, 2009; Schwabe, Dickinson, & Wolf, 2011). Because escape from the self while in a negative mood may be one of the mechanisms of IUD (Kwon, Chung, & Lee, 2011), women with higher perceived stress had higher severity of IUD in this present study. Further, the perceived stress mediated the association between PMDD and IUD severity in the premenstrual phase, suggesting higher perceived stress involved in the association between PMDD and severity of IUD in the premenstrual phase. The PMDD women usually experienced prolonged and repeated stress in the premenstrual phase. Further, prolonged or repeated stress may accelerate the transition from voluntary to involuntary addictive behavior and thus promote the development of addiction (Schwabe et al., 2011). Thus, persistent and fluctuating stress around the menstrual cycle could accelerate the transition from repeated use of the Internet to IUD among women with PMDD. Our result revealing the association between severity of IUD and perceived stress among women with PMDD might support this claim. We would suggest that counseling for effective coping strategies (Rizzolo & Sedrak, 2010) for stress should be provided to women with PMDD, particularly for those with greater severity of IUD. However, the association between perceived stress and severity of IUD was insignificant when impulsivity was included in the regression model, suggesting that impulsivity was a more proximally associated factor to severity of IUD among women with PMDD in the premenstrual phase. This study had several limitations that should be considered when interpreting its findings. First, the cross-sectional design of the study did not permit assessment of the temporal and thus potentially causal relationships of IUD, perceived stress, impulsivity, and PMDD. Secondly, the diagnosis of IUD was based only on diagnostic interview without any information provided from the family, which could have resulted in misclassification of this diagnosis. Third, the sample was small and non-representative, so that some
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meaningful associations may not have been detected as statistically significant, and the findings may not be generalizable. Finally, lack of control for other confounding variables may have affected the results.
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CONCLUSION We found that women with PMDD were more likely to have IUD. They experienced greater IUD symptoms not only in the premenstrual phase, but also in the follicular phase. Impulsivity was associated with IUD among women with PMDD in the premenstrual phase and mediated the association between PMDD and IUD. IUD should be assessed, and appropriate interventions designed for women with PMDD, particularly among those with higher premenstrual impulsivity. Both impulsivity and perceived stress were associated with severity of IUD and mediated the association between PMDD and IUD severity. Effective management of stress and counseling of impulsivity are, therefore, suggested when treating women with PMDD to attenuate the severity of comorbid IUD.
FUNDING This study was supported by grants from the National Science Council in Taiwan (NSC100-2629-B-037-001-MY2), Kaohsiung Municipal HsiaoKang Hospital (KMHK-99-001), and Kaohsiung Medical University Hospital (KMUH101-1R61).
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