Assessment of the Correlation between Problematic Internet Usage and Somatic Symptom Disorder in Adolescents

Assessment of the Correlation between Problematic Internet Usage and Somatic Symptom Disorder in Adolescents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of the Correlation between Problematic Internet Usage and Somatic Symptom Disorder in Adolescents Duygu Iskender Mazman, Mustafa Uğurlu, Fadime Yüksel This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8296510/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective Somatic symptom disorder is characterized as recurrent and multiple physical complaints and these symptoms cannot be medically explained despite of all examinations and therefore many adolescents admit to pediatrics clinics. In this study we aimed to investigate whether any association between problematic internet usage and somatic symptom disorder in adolescent who admitted to pediatrics clinic. Methods 287 adolescents diagnosed with somatic symptom disorder participated in the study. The patients were asked to fill in the sociodemographic information form, the International Physical Activity Questionnaire, the Internet Addiction Scale, and the Somatic Symptoms Scale. Data were collected by questionnaire and statistically analyzed. Results The mean age was 16.6 ± 1.3 and 32.4%male, 67.6% female. When internet addiction scores were compared for both genders, no statistically significant difference was found in social networking, chat, education/homework, and movie/music scores (respectively p = 0.485, p = 0.078, p = 0.695, p = 0.208). However, we found that either surfing news score ( p < 0.001) or gaming score (p < 0.001) was higher in male than females at subscales. The model we have established reveals that gender does not have a direct effect on internet addiction, but being female causes an indirect increase in internet addiction scores by increasing somatic symptoms. Conclusions There is a statistically significant correlation between the scores on the internet addiction scale and the presence of somatic symptoms in adolescents. Therefore, it may be possible to obtain good results from methods targeting somatic symptoms in intervention programs for adolescents with internet addiction. Somatic symptom disorder internet addiction adolescent Figures Figure 1 INTRODUCTION The adolescent population constitutes an important part of all admissions among pediatric outpatient clinics in Turkey and other parts of the world. Adolescent patients are mostly referred to pediatricians because of their own somatic symptoms that may concern both them and their family. Generally, physicians do not find any tangible explanation for these symptoms despite all examinations. According to research conducted in Italy, 8.6% of all admissions to pediatric emergency rooms are the result of somatic symptom disorders ( 1 ). Somatic symptoms disorders have been defined as expressions of psychological distress resulting from an experience of physical symptoms for which medical explanation or support is sought, and for most patients, diagnosis is only possible by physicians ruling out all other somatic disorders ( 2 ). Therefore, most patients who have somatic symptom disorders are left seeking psychiatric management too late for these conditions because of diagnostic problems. Therefore, a screening tool is needed for physicians to consult as soon as possible with patients who may need psychiatric management. Physicians should examine detailed anamnesis, family patterns, comprehensive medical stories, and personality features to diagnose somatic symptom disorder. Pediatricians should also examine the behavioral patterns and regular practices of adolescent patients. There may be a reciprocal relationship between somatic symptom disorders and excess screen time and problematic usage of the internet, both of which have become growing issues among adolescents ( 3 , 4 ). The internet is a very beneficial tool for getting news or information, shopping, social networking, engaging in educational activities, and participating in events; however, it can also offer a convenient space for some individuals with a tendency for certain addictions (e.g., gaming, gambling, or pornography). The internet has become very accessible for individuals throughout the world. In developed countries like Iceland, Norway, Denmark, the United Kingdom, and Japan, usage of the internet is common among over 90% of the population ( 5 ). In developing countries such as Africa, the internet is also becoming much more accessible. A new definition of internet addiction or problematic usage of internet (PUI) has emerged, and such a condition depends on accessible internet levels that have been seen only in the last two decades ( 6 ). Young shared a definition of the term in 1998 that was first associated with gambling, and at this time ( 6 ). Problematic usage of internet is an umbrella term that includes a variety of specific addictions, such as gaming, gambling, shopping, pornography viewing, social networking or surfing, cyberbullying, and cyberchondria ( 7 ). There has been a lot of research conducted on PUI over the last decade. Specifically, both national and worldwide research has examined the relationship between PUI and personality, behavioral patterns, hyperactivity and deficiency of attention, depression, anxiety disorders, social phobia, obesity, body mass index, and immunity ( 8 – 12 ). However, there are few studies thus far on the relationship between PUI and somatic symptom disorders in childhood. According to a study conducted in Italy, there was a mild relationship between tension type headaches and problematic usage of internet or mobile phone ( 13 ). In recent years, adolescents have become more addicted to the internet, mobile phones, and personal computers ( 14 ). The risk of internet addiction has also increased, as face-to-face communication is also limited due to the ongoing covid 19 pandemic and time spent online has increased. As they are surfing online, they miss out on physical activity, healthy lifestyles, or real food, such as regulary table meal. Adolescence is also a very challenging period in the human lifetime. For these reasons, adolescents are vulnerable to some addictions, and somatization may therefore be more common among them, serving as a mirror of their physiological struggles. Hence, research needs to be conducted on whether there is any relationship between PUI and somatic symptom disorders. In this study, we aim to investigate whether there is an association between PUI and somatic symptom disorder, which is a subgroup of somatic symptoms disorders, among adolescent patients admitted to pediatric outpatient clinics in Research and Training Hospital. METHODS We obtained research ethics committee approval from the [redacted] University Ethical Committee (Date/ number: 9.5.2019/61). Between January 2019 and December 2019, we enrolled 14 to 19-year-olds who had applied to the general pediatrics outpatient clinics at the Research and Training Hospital with somatic symptom disorder. The questionnaires were given to the participants after they were informed about the study and informed consent. Adolescents reporting to be under pharmacological and/or psychological therapy, those having an already diagnosed chronic disease (e.g., asthma, diabetes, arthritis, cardiovascular disease, kidney disease, or psychiatric disorders), and those who left at least 10% of the questionnaires incomplete were excluded from the study. All patients involved in the study were enrolled on a volunteer basis and only after the informed consent was signed by them and their parents or legal guardians. Based on these exclusion and inclusion criteria, 287 adolescents were recruited for this study. Participants were not evaluated in terms of anxiety and depression symptoms using a separate measurement method. However, the participants were chosen among those who had no previous history of psychiatric disorders. Participants with suspected psychiatric disorder were referred to adolescent psychiatry for evaluation, cases who have been diagnosed as psychiatric ill or got treatment were excluded. Nevertheless, it is a fact that more detailed results about the participants and psychopathology will be obtained with the addition of measures that can evaluate the symptoms of anxiety and depression. On the other hand, anxiety and depression already contain somatic symptoms and these symptoms are common with many somatic complaints in the scale used in our study. Therefore, it can be said that there will probably be a high correlation between anxiety and depression symptom levels and the somatic symptom scale, that is, participants with high somatic symptom scale scores may also get higher scores on anxiety and depression measures. In addition, the correlation between anxiety, depression and internet addiction is well defined in the literature. Therefore, more somatic symptoms have been emphasized in order to maintain the focus of the study. Data Collection Tools Sociodemographic Information Form We collected information from each patient on their date of birth, gender, educational status, economic status, smoking status, alcohol, drug, or chemical abuse, hereditary psychiatric disorders, whether their mother stayed at home or worked, why they used the internet, and how much time they spend on the internet each day? International Physical Activity Questionnaire We administered a self-report scale known as the International Physical Activity Questionnaire developed by Craig et al. and validated in Turkish by Öztürk to all patients ( 15 – 16 ). Participants were asked to fill out a form with questions on all exercises that had been performed for at least ten minutes per week that involved accelerating breath and heartbeat as well as muscle strength. Internet Addiction Scale We administered a self-report form that consisted of 35 questions that had been validated in Turkish by Günüç and Kayri. Responses were scored on a five-point Likert scale ( 17 ). The scale covered four subgroups including deprivation, difficulty of self-control, functional deterioration, and social isolation. Level 2 Somatic Symptom Scale (for parent or legal guardian with an adolescent aged 6–17 years) The participants’ parents or legal guardians completed a form provided in the The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition—DSM-V. The form, known as the Level 2 Somatic Symptom Scale, consists of 13 questions, it is a 3-point Likert type scale and the total score can be between 0–26 ( 18 ). According to whether the adolescents had the related concerns during the last seven days, the adults tick off the boxes assigned to stomach pain, back pain, arthralgia, headache, dizziness, presyncope, palpitation, difficulty in breathing, constipation or diarrhea, dyspeptic complaints, fatigue, weakness, and sleep disturbances ( 18 ). In the results section of the study, the frequency and percentage values of the adolescents who got 2 points from each item are given. Level 2 Somatic Symptom Scale (for children aged 11–17 years) This scale is to be completed by participants aged 11–17 years, and can be found in the DSM-V. The scale consists of 13 questions and is the same structure as the above scale; adolescents tick off boxes assigned to stomach pain, back pain, arthralgia, headache, dizziness, presyncope, palpitation, difficulty in breathing, constipation or diarrhea, dyspeptic complaints, fatigue, weakness, and sleep disturbances ( 18 ). All patients who were admitted to the hospital with somatic symptoms were comprehensively medically examined, and the laboratory tests were gathered by pediatricians who conducted the study. The anamnesis of the patients was obtained from both the patients and the parents or legal guardians. According to the anamnesis, examination, and laboratory results, a symptom that was not attributed to a medical disorder by pediatricians was defined as a somatic symptom disorder. The patients and their legal guardians were asked by the researchers to fill out the scales and questionnaires. Each self-report scale was filled out by either the patients or their parents or guardians in 15-minute sessions in separate rooms. Demographic data were provided to the researchers by the patients and their parents or legal guardians in a face-to-face setting. Since it is thought that the study sample may differ developmentally in perception and expression of somatic symptoms, we used both the self-filled form of the somatic symptom scale and the parent form in order to make a more accurate measurement. Assessment of Data In this study, descriptive statistics were given as mean ± standard deviation (SD) for continuous variables and frequency and percentiles (%) for discrete variables. Patterns of the continuous variables were assessed with the Kolmogorov–Smirnov and Shapiro–Wilks tests. In comparing the independent variables of each sample, we used a Student’s t-test or the Mann–Whitney U test. Correlation was studied with structural equation modeling, and goodness of fit was checked by Goodness-Of-Fit Index (GFI), Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Minimum Discrepancy per Degree of Freedom (CMIN/DF) parameters. A p value < 0.05 was accepted as statistically significant for the differences in the entire analyses. RESULTS We enrolled 287 adolescents in this study. The mean age was 16.6 ± 1.3 years, and the clinical data are shown in Tables 1 and 2 . Table 1 Research sample’s demographic and clinical data N % Age 19 27 9.4 18 60 60 17 80 27,9 16 49 17,1 15 55 19,2 14 16 5,6 Gender Male 93 32,4 Female 194 67,6 Educational status Elementary school 46 16 High school 230 80,1 Absenteeism 11 3,8 Drug or substance None 269 93.7 Smoke 16 5,6 Substance 1 ,3 Smoke and alcohol 1 ,3 Psychiatric disorders in family member None 268 93,4 Exist 19 6,6 Purpose of internet usage Social networking 232 80,8 News/information 66 23,0 Gaming 146 50,9 Chatting 196 68,3 Educational activities/homework 211 73,5 Movie/music 214 74,6 Duration of internet usage 1–2 times per week 17 5,9 Less then1 hour per day 32 11,1 1–3 hours per day 122 42,5 3–6 hours per day 84 29,3 6 hours per day 32 11,1 Table 2 Research sample’s usage of internet (internet addiction scale: IAS) and somatic symptoms (SS) scales N Min. Max. Mean S.D. IAS 287 35 147 74,40 23,69 IAS-deprivation 287 11 68 27,60 9,31 IAS-difficulty of self-control 287 10 50 21,09 7,73 IAS-functional deterioration 287 7 34 14,48 6,01 IAS-social isolation 287 7 33 11,22 4,87 SS by patient’s own (SS-P) 287 0 23 8,52 5,08 SS by legal guardians (SS-LG) 287 0 23 7,85 5,06 IAS: Internet Addiction Score SS: Somatic Syptoms SS-P: Somatic Symptoms by patient SS-LG: Somatic Symptoms by legal guardians Table 3 Correlation between internet addiction and somatic symptoms SS-by P SS-by LG IAS IAS-deprivation IAS-difficulty of self-control IAS-func. deteriorate. SS- by LG r ,761 p ,000 IAS r ,247 ,176 p ,000 ,003 IAS-deprivation r ,267 ,165 ,860 p ,000 ,005 ,000 IAS-difficulty of self-control r ,197 ,132 ,903 ,673 p ,001 ,025 ,000 ,000 IAS-functional deterioration r ,229 ,182 ,851 ,603 ,730 p ,000 ,002 ,000 ,000 ,000 IAS-social isolation r ,094 ,104 ,735 ,456 ,615 ,590 p ,112 ,077 ,000 ,000 ,000 ,000 IAS: Internet Addiction Score SS: Somatic Syptoms SS-P: Somatic Symptoms by patient SS-LG: Somatic Symptoms by legal guardians Table 4 Internet addiction in children and adolescents with or without a family history of psychiatric disease Internet Addiction Score p Non-addiction Threshold value Risky group Family History None 207 51 10 0,898 Exist 15 3 1 Table 5 The differences between medically unexplained symptoms and internet addiction scoring in both genders. Gender N Mean S.D. t/p IAS Male 93 73,97 24,44 -0.212/0.832 Female 194 74,61 23,38 IAS-deprivation Male 93 26,78 9,34 0.985/0.302 Female 194 28 9,30 IAS-difficulty of self-control Male 93 21,11 8,01 0.586/0.975 Female 194 21,08 7,61 IAS-functional deterioration Male 93 14,47 5,97 0.723/0.988 Female 194 14,48 6,04 IAS-social isolation Male 93 11,60 5,36 0.249/0.362 Female 194 11,04 4,62 SS-by P Male 93 6,96 4,90 -3.662/<0.001 Female 194 9,26 5,01 IAS: Internet Addiction Score SS-P: Somatic Symptoms by patient Table 6 Model 1 Goodness of fit CMIN/DF P GFI CFI RMSEA 0.504 0.478 0.999 1 Frequency of those who answer "high level" to each question in the somatic symptom scale; stomach 48 (16.7%), back pain 41 (14.3%), arm, leg, joint pain 60 (20.9%), headache 108 (37.6%), chest pain 28 (9.8%), dizziness 63 (22%), syncope, presyncope 5 (1.7%), palpitations 33 (11.5%), shortness of breath 26 (9.1%), constipation, diarrhea 31 (10.8%), nausea, gas, indigestion 57 (19.9%), fatigue or loss of energy 130 (45.3%), sleep difficulties 63 (22%) respectively. According to cut-off scores of the Internet Addiction Scale, no cases of addiction were found among the included patients. However, we determined that 54 cases (18.8%) were found to be within the cut-off value, and 11 cases (3.8%) were found in the high-risk group among the 287 adolescents. A high correlation was found between the scores of the somatic symptoms between both the adolescents and their parents. Similarly, apart from the social isolation subscale of the internet addiction scale, there is a weak and significant positive relationship between both total scores and subscale scores and Somatic Symptom Scale scores (Table III). The number of participants with positive family history in terms of psychiatry is 19 (% 6.6). Accordingly, no statistically significant difference was found in terms of internet addiction between the participants who had positive family history and no family history of problematic internet addiction (χ2 ( 2 ) = 0.214, p = 0.898) (Table IV). In comparison with the internet addiction scoring, there was no difference between the genders. However, we found that females scored highly on the total somatic symptom scales, and this was a statistically significant difference (Table V). In comparing the internet addiction scores for both genders, there was no statistically significant difference found in terms of social networking (χ 2 ( 1 ) = 0.487 and p = 0.485), chatting (χ 2 ( 1 ) = 3.115 and p = 0.078), educational activities/homework (χ 2 ( 1 ) = 0.154 and p = 0.695), and movie/music (χ 2 ( 1 ) = 1.583 and p = 0.208). However, we found that surfing for news/information (χ 2 ( 1 ) = 14.292 and p < 0.001) and gaming (χ 2 ( 1 ) = 22.233 and p < 0.001) were more common among males than females. In this study; based on the model showing the correlations between gender, internet addiction and somatic symptoms, we can say that gender does not directly affect internet addiction, but indirectly affects somatic symptoms. According to this model, being female leads to a scoring of somatic symptoms that is 2.3 times higher than that of males. The model also shows that a one-unit increase in somatic symptoms scores caused a 1.15-unit increase in internet addiction scoring (Table VI, Fig. 1). DISCUSSION Problematic usage of internet has not yet been well established in medicine, although somatic symptom disorder have been known for some time in psychiatric contexts. Problematic usage of internet and associated disorders have only begun to receive attention in the last decade. Adolescence is a challenging time of life, and these challenges may cause adolescents to seek out a realistic space for self-expression in cyber settings, through which they can reflect on their own internal conflicts. Somatic symptoms may be a way of externalizing their emotions and struggles as well. Few studies in the literature link somatic symptoms and PUI. In a study by Zagorscak et al. 722 students were enrolled with a mean age of 13.4 years, and there was a positive correlation found between cyberbullying and somatic symptoms. Cyberbullying is defined as a subheading term in the spectrum of PUI ( 19 ). In the present study, we investigated 287 adolescents. Each adolescent was assessed via an internet addiction screening scale. In the study group, 3.8% of respondents were found to be at risk of internet addiction, but 18.8% were found to be within the cut-off value. We detected that there was a positive correlation between a high score on the internet addiction screening test and a high score for somatic symptoms in adolescents, and this relationship was statistically significant. In our study, there was no statistically significant difference between genders with respect to the scores on the internet addiction screening scale. According to the literature, different results have been reported on this subject. For instance, in research from South Korea, PUI was found to be more common in male adolescents ( 20 ). In another multi-center study from Spain, it was found that PUI was more common among female adolescents than males ( 21 ). Although there was no statistically significance between genders in the scoring of the Internet Addiction Scale in our study, gender was an important factor in determining what purposes the internet was used for. We observed that male adolescents spent much more time surfing online news or information websites than girls. This result is compatible with data in the literature ( 22 ). Based on our findings, we can also assert that gender is a deterministic factor for the level of seriousness in somatic symptoms. In other studies, the scoring of somatic symptoms has been found to be statistically higher in female adolescents than in their male counterparts. For instance, Rehna et al. conducted a study with 663 adolescents in which females were found to have more common somatic symptoms than males ( 22 ). Another study by Kronke and Spitzer examined 1,000 adolescents and found that females were more likely to have somatoform disorders in comparison with male adolescents ( 23 ). We have also assessed how the parental perspective may have been related to the somatic symptoms of the adolescents who enrolled in our study. We paid proper attention to the fact that both the patient and his/her legal guardian were to answer the questionnaires blindly. There was a high correlation between the scores of both the adolescents and the adults on the Somatic Symptoms Scale. This may be a sign that adolescents have a tendency to share their own somatic distress within the family. This can be expected when considering etiological theories of somatic symptom disorder or somatic symptoms disorders. According to the mainstay theories, the body is not only a medium in which one has been experiencing psychological distress, but it is also a communication tool between an individual and others. In individuals whose linguistic skills, emotion recognition, and verbal expression are not sufficiently developed, the transfer of experience can be through the body, as in the early phases of development. Adolescents may also be physically compensating for mental stress and conflicts with family members and/or peers in which their self-expression is not sufficient. As adolescents’ immature brains are still continuing to develop, there is also a disadvantage due to asymmetrical brain development. For this reason, adolescents often use old (somatic) tools when they would like to express themselves, which is a form of expression that remains from early phases in childhood. These findings account for why mental stress is frequent among adolescents, and why they cannot effectively express themselves or resolve certain problems effectively on their own. Somatic symptom disorder have been found to have a familial pattern similar to other psychiatric disorders ( 24 ). The model constructed in our study suggests that gender does not have a direct effect on the scoring of the Internet Addiction Scale, but being female leads to a high risk of expressing somatic symptoms (Fig. 1). It was also found that as the scoring of the somatic symptoms increased, the score on the Internet Addiction Scale was significantly raised as well. In other words, being female indirectly affected the score on the Internet Addiction Scale more than being male. According to this model, as the seriousness of somatic symptoms increases, the score on the Internet Addiction Scale raises as well. This may be kind of a coping skill for any challenges faced in adolescence. This model should be confirmed with additional research in the larger groups. Further work should also examine whether psychiatric management is beneficial for the groups with high scores on the Internet Addiction Scale. Patients who have somatic symptom disorder have occupied a noticeable place in the healthcare system. Every single admission to a hospital is the result of many unnecessary tests and may be construed as waste of time for healthcare a worker that is already limited. Healthcare costs become a burden to social security systems as the patients are evaluating with over and over. When a diagnosis for patients cannot be established, somatic symptom disorder can continue to persist and may be of concern for the patients and families. In this respect, it is important to provide tools that can guide the pediatrician to recommend a psychiatric consultation as soon as possible before the disorder consumes the child’s life. Accordingly, it is extremely important to develop approaches to understand the significance of PUI, how time is spent on the internet, and how this situation affects adolescent’s health and physical symptom perceptions. In conclusion, we have reported that there is a statistically significant correlation between the scores on the Internet Addiction Scale and the presence of somatic symptoms in adolescents. Therefore, one of the ways to combat internet addiction in adolescents seems to be to focus on adolescents' somatic complaints and, in a sense, their communication skills. Our model should be confirmed with additional research in the larger groups. Further work should also examine whether psychiatric management is beneficial for the groups with high scores on the Internet Addiction Scale. Declarations Author Contribution D.I.M design, collecting data, scaling, recording, writing, M.U. bioıstatıstıc and conclusıonF.M. editing and translating References Cozzi, G., Minute, M., Skabar, A., Pirrone, A., Jaber, M., Neri, E et al. Somatic symptom disorder was common in children and adolescents attending an emergency department complaining of pain. Acta paediatrica (Oslo, Norway: 1992). 2017; 106(4), 586–593. Carson, A. J., Ringbauer, B., Stone, J. McKenzie, L., Warlow, C., Sharpe, M. Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics. Journal of neurology, neurosurgery, and psychiatry. 2000; 68(2), 207–210. Zhao, T. Y., Zou, S. P., & Knapp, P. E. Exposure to cell phone radiation up-regulates apoptosis genes in primary cultures of neurons and astrocytes. Neuroscience letters.2007; 412(1), 34–38. Thomée, S., Härenstam, A., Hagberg, M. Mobile phone use and stress, sleep disturbances, and symptoms of depression among young adults--a prospective cohort study. BMC public health. 2011; 11, 66. Internet World Stats, https://www.internetworldstats.com/stats.htm Accessed: September,9. 2020. Young K. S. The evolution of Internet addiction. Addictive behaviors. 2017; 64, 229–230. Fineberg, N. A., Demetrovics, Z., Stein, D. J., Ioannidis, K., Potenza, M. N., Grünblatt, E et al. Manifesto for a European research network into Problematic Usage of the Internet. European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology. 2018; 28(11), 1232–1246. Hussain, Z., Griffiths, M. D., Sheffield, D. An investigation into problematic smartphone use: The role of narcissism, anxiety, and personality factors. Journal of behavioral addictions. 2017; 6(3), 378–386. Kahraman, Ö., Demirci, E. Ö. Internet addiction and attention-deficit-hyperactivity disorder: Effects of anxiety, depression and self-esteem. Pediatrics international: official journal of the Japan Pediatric Society.2018; 60(6), 529–534. Bozkurt, H., Özer, S., Şahin, S., Sönmezgöz, E. Internet use patterns and Internet addiction in children and adolescents with obesity. Pediatric obesity. 2018; 13(5), 301–306. Do, K. Y., & Lee, K. S. Relationship between Problematic Internet Use, Sleep Problems, and Oral Health in Korean Adolescents: A National Survey. International journal of environmental research and public health. 2018; 15(9), 1870. Reed, P., Vile, R., Osborne, L. A., Romano, M., Truzoli, R. Problematic Internet Usage and Immune Function. PloS one. 2015; 10(8), e0134538. Cerutti, R., Presaghi, F., Spensieri, V., Valastro, C., Guidetti, V. The Potential Impact of Internet and Mobile Use on Headache and Other Somatic Symptoms in Adolescence. A Population-Based Cross-Sectional Study. Headache. 2016; 56(7), 1161–1170. Smorti, M., Milone, A., Gonzalez Gonzalez, J., Vitali Rosati, G. Adolescent selfie: an Italian Society of Paediatrics survey of the lifestyle of teenagers. Italian journal of pediatrics. 2019; 45(1), 62. Craig, C. L., Marshall, A. L., Sjöström, M., Bauman, A. E., Booth, M. L., Ainsworth, B. et al. International physical activity questionnaire: 12-country reliability and validity. Medicine and science in sports and exercise. 2003; 35(8), 1381–1395. Ulaş, K., Topuz, S., Horasan, G. The validity and reliability of the Turkish version of the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD). Turkish journal of medical sciences. 2019; 49(6), 1620–1625. Günüç S., Kayri M. The Profıle of Internet Dependency In Turkey And Development Of Internet Addiction Scale: Study Of Validity & Reliability. Hacettepe Üniversitesi Eğitim Fakültesi Dergisi (H. U. Journal of Education). 2010; 39: 220-232. Yalın Sapmaz Ş, Serim Demirgören B, Yörük Ülker G, Aydemir Ö. Validity and reliability of the Turkish Version of DSM-5 Level 2 Somatic Symptom Scale (Child Form for 11-17 years and Parent Form for 6-17 years). Anatolian Journal of Psychiatry. 2017;18(Suppl.2):114-121. Zagorscak, P., Schultze-Krumbholz, A., Heinrich, M., Wölfer, R., Scheithauer, H. Efficacy of Cyberbullying Prevention on Somatic Symptoms-Randomized Controlled Trial Applying a Reasoned Action Approach. Journal of research on adolescence: the official journal of the Society for Research on Adolescence. 2019; 29(4), 908–923. Lee, S. Y., Lee, D., Nam, C. R., Kim, D. Y., Park, S., Kwon, J. G et al. Distinct patterns of Internet and smartphone-related problems among adolescents by gender: Latent class analysis. Journal of behavioral addictions. 2018; 7(2), 454–465. Muñoz-Miralles, R., Ortega-González, R., López-Morón, M. R., Batalla-Martínez, C., Manresa, J. M., Montellà-Jordana, N. et al. The problematic use of Information and Communication Technologies (ICT) in adolescents by the cross sectional JOITIC study. BMC pediatrics. 2016;16(1), 140. Rehna, T., Hanif, R., Um e Laila, Ali, S. Z. Life stress and somatic symptoms among adolescents: gender as moderator. JPMA. The Journal of the Pakistan Medical Association. 2016; 66(11), 1448–1451. Kroenke, K., Spitzer, R. L. Gender differences in the reporting of physical and somatoform symptoms. Psychosomatic medicine. 1998; 60(2), 150–155. Van Tilburg, M. A., Levy, R. L., Walker, L. S., Von Korff, M., Feld, L. D., Garner, M.,et al. Psychosocial mechanisms for the transmission of somatic symptoms from parents to children. World journal of gastroenterology. 2015; 21(18), 5532–5541. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8296510","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":556797195,"identity":"f667066c-a8a7-413e-aebe-7011d9fdf7f9","order_by":0,"name":"Duygu Iskender 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University","correspondingAuthor":false,"prefix":"","firstName":"Mustafa","middleName":"","lastName":"Uğurlu","suffix":""},{"id":556797197,"identity":"d9c9b4be-d968-4115-8684-f76945563ca6","order_by":2,"name":"Fadime Yüksel","email":"","orcid":"","institution":"Ankara City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fadime","middleName":"","lastName":"Yüksel","suffix":""}],"badges":[],"createdAt":"2025-12-06 19:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8296510/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8296510/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97757940,"identity":"dc1ca3cc-5ab8-40bd-b6a7-de62dd9f35ee","added_by":"auto","created_at":"2025-12-09 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04:48:29","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98170,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8296510/v1/b1baf6b7857e3dc00c91d1bc.html"},{"id":97757942,"identity":"7a504af7-2f13-46d4-b15d-02da6accb995","added_by":"auto","created_at":"2025-12-09 04:48:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":225259,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"intadd.figure.png","url":"https://assets-eu.researchsquare.com/files/rs-8296510/v1/26a5d1de3f64b53333358a76.png"},{"id":100593927,"identity":"813c6c11-ec3a-4fac-9970-eeb3ae7d9534","added_by":"auto","created_at":"2026-01-19 13:27:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1123255,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8296510/v1/459f51c7-751b-47b6-806c-788b2931bb77.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of the Correlation between Problematic Internet Usage and Somatic Symptom Disorder in Adolescents","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe adolescent population constitutes an important part of all admissions among pediatric outpatient clinics in Turkey and other parts of the world. Adolescent patients are mostly referred to pediatricians because of their own somatic symptoms that may concern both them and their family. Generally, physicians do not find any tangible explanation for these symptoms despite all examinations.\u003c/p\u003e\u003cp\u003eAccording to research conducted in Italy, 8.6% of all admissions to pediatric emergency rooms are the result of somatic symptom disorders (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Somatic symptoms disorders have been defined as expressions of psychological distress resulting from an experience of physical symptoms for which medical explanation or support is sought, and for most patients, diagnosis is only possible by physicians ruling out all other somatic disorders (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Therefore, most patients who have somatic symptom disorders are left seeking psychiatric management too late for these conditions because of diagnostic problems. Therefore, a screening tool is needed for physicians to consult as soon as possible with patients who may need psychiatric management. Physicians should examine detailed anamnesis, family patterns, comprehensive medical stories, and personality features to diagnose somatic symptom disorder. Pediatricians should also examine the behavioral patterns and regular practices of adolescent patients. There may be a reciprocal relationship between somatic symptom disorders and excess screen time and problematic usage of the internet, both of which have become growing issues among adolescents (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe internet is a very beneficial tool for getting news or information, shopping, social networking, engaging in educational activities, and participating in events; however, it can also offer a convenient space for some individuals with a tendency for certain addictions (e.g., gaming, gambling, or pornography). The internet has become very accessible for individuals throughout the world. In developed countries like Iceland, Norway, Denmark, the United Kingdom, and Japan, usage of the internet is common among over 90% of the population (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In developing countries such as Africa, the internet is also becoming much more accessible. A new definition of internet addiction or problematic usage of internet (PUI) has emerged, and such a condition depends on accessible internet levels that have been seen only in the last two decades (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Young shared a definition of the term in 1998 that was first associated with gambling, and at this time (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Problematic usage of internet is an umbrella term that includes a variety of specific addictions, such as gaming, gambling, shopping, pornography viewing, social networking or surfing, cyberbullying, and cyberchondria (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere has been a lot of research conducted on PUI over the last decade. Specifically, both national and worldwide research has examined the relationship between PUI and personality, behavioral patterns, hyperactivity and deficiency of attention, depression, anxiety disorders, social phobia, obesity, body mass index, and immunity (\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, there are few studies thus far on the relationship between PUI and somatic symptom disorders in childhood. According to a study conducted in Italy, there was a mild relationship between tension type headaches and problematic usage of internet or mobile phone (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In recent years, adolescents have become more addicted to the internet, mobile phones, and personal computers (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The risk of internet addiction has also increased, as face-to-face communication is also limited due to the ongoing covid 19 pandemic and time spent online has increased. As they are surfing online, they miss out on physical activity, healthy lifestyles, or real food, such as regulary table meal. Adolescence is also a very challenging period in the human lifetime. For these reasons, adolescents are vulnerable to some addictions, and somatization may therefore be more common among them, serving as a mirror of their physiological struggles. Hence, research needs to be conducted on whether there is any relationship between PUI and somatic symptom disorders. In this study, we aim to investigate whether there is an association between PUI and somatic symptom disorder, which is a subgroup of somatic symptoms disorders, among adolescent patients admitted to pediatric outpatient clinics in Research and Training Hospital.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e We obtained research ethics committee approval from the [redacted] University Ethical Committee (Date/ number: 9.5.2019/61). Between January 2019 and December 2019, we enrolled 14 to 19-year-olds who had applied to the general pediatrics outpatient clinics at the Research and Training Hospital with somatic symptom disorder. The questionnaires were given to the participants after they were informed about the study and informed consent. Adolescents reporting to be under pharmacological and/or psychological therapy, those having an already diagnosed chronic disease (e.g., asthma, diabetes, arthritis, cardiovascular disease, kidney disease, or psychiatric disorders), and those who left at least 10% of the questionnaires incomplete were excluded from the study. All patients involved in the study were enrolled on a volunteer basis and only after the informed consent was signed by them and their parents or legal guardians. Based on these exclusion and inclusion criteria, 287 adolescents were recruited for this study.\u003c/p\u003e\u003cp\u003eParticipants were not evaluated in terms of anxiety and depression symptoms using a separate measurement method. However, the participants were chosen among those who had no previous history of psychiatric disorders. Participants with suspected psychiatric disorder were referred to adolescent psychiatry for evaluation, cases who have been diagnosed as psychiatric ill or got treatment were excluded. Nevertheless, it is a fact that more detailed results about the participants and psychopathology will be obtained with the addition of measures that can evaluate the symptoms of anxiety and depression. On the other hand, anxiety and depression already contain somatic symptoms and these symptoms are common with many somatic complaints in the scale used in our study. Therefore, it can be said that there will probably be a high correlation between anxiety and depression symptom levels and the somatic symptom scale, that is, participants with high somatic symptom scale scores may also get higher scores on anxiety and depression measures.\u003c/p\u003e\u003cp\u003eIn addition, the correlation between anxiety, depression and internet addiction is well defined in the literature. Therefore, more somatic symptoms have been emphasized in order to maintain the focus of the study.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Collection Tools\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eSociodemographic Information Form\u003c/strong\u003e\u003cp\u003eWe collected information from each patient on their date of birth, gender, educational status, economic status, smoking status, alcohol, drug, or chemical abuse, hereditary psychiatric disorders, whether their mother stayed at home or worked, why they used the internet, and how much time they spend on the internet each day?\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInternational Physical Activity Questionnaire\u003c/strong\u003e\u003cp\u003eWe administered a self-report scale known as the International Physical Activity Questionnaire developed by Craig et al. and validated in Turkish by \u0026Ouml;zt\u0026uuml;rk to all patients (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Participants were asked to fill out a form with questions on all exercises that had been performed for at least ten minutes per week that involved accelerating breath and heartbeat as well as muscle strength.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInternet Addiction Scale\u003c/strong\u003e\u003cp\u003eWe administered a self-report form that consisted of 35 questions that had been validated in Turkish by G\u0026uuml;n\u0026uuml;\u0026ccedil; and Kayri. Responses were scored on a five-point Likert scale (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The scale covered four subgroups including deprivation, difficulty of self-control, functional deterioration, and social isolation.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLevel 2 Somatic Symptom Scale (for parent or legal guardian with an adolescent aged 6\u0026ndash;17 years)\u003c/strong\u003e\u003cp\u003eThe participants\u0026rsquo; parents or legal guardians completed a form provided in the The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition\u0026mdash;DSM-V. The form, known as the Level 2 Somatic Symptom Scale, consists of 13 questions, it is a 3-point Likert type scale and the total score can be between 0\u0026ndash;26 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). According to whether the adolescents had the related concerns during the last seven days, the adults tick off the boxes assigned to stomach pain, back pain, arthralgia, headache, dizziness, presyncope, palpitation, difficulty in breathing, constipation or diarrhea, dyspeptic complaints, fatigue, weakness, and sleep disturbances (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In the results section of the study, the frequency and percentage values of the adolescents who got 2 points from each item are given.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLevel 2 Somatic Symptom Scale (for children aged 11\u0026ndash;17 years)\u003c/strong\u003e\u003cp\u003eThis scale is to be completed by participants aged 11\u0026ndash;17 years, and can be found in the DSM-V. The scale consists of 13 questions and is the same structure as the above scale; adolescents tick off boxes assigned to stomach pain, back pain, arthralgia, headache, dizziness, presyncope, palpitation, difficulty in breathing, constipation or diarrhea, dyspeptic complaints, fatigue, weakness, and sleep disturbances (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003eAll patients who were admitted to the hospital with somatic symptoms were comprehensively medically examined, and the laboratory tests were gathered by pediatricians who conducted the study. The anamnesis of the patients was obtained from both the patients and the parents or legal guardians. According to the anamnesis, examination, and laboratory results, a symptom that was not attributed to a medical disorder by pediatricians was defined as a somatic symptom disorder. The patients and their legal guardians were asked by the researchers to fill out the scales and questionnaires. Each self-report scale was filled out by either the patients or their parents or guardians in 15-minute sessions in separate rooms. Demographic data were provided to the researchers by the patients and their parents or legal guardians in a face-to-face setting.\u003c/p\u003e\u003cp\u003eSince it is thought that the study sample may differ developmentally in perception and expression of somatic symptoms, we used both the self-filled form of the somatic symptom scale and the parent form in order to make a more accurate measurement.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAssessment of Data\u003c/h3\u003e\n\u003cp\u003eIn this study, descriptive statistics were given as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for continuous variables and frequency and percentiles (%) for discrete variables. Patterns of the continuous variables were assessed with the Kolmogorov\u0026ndash;Smirnov and Shapiro\u0026ndash;Wilks tests. In comparing the independent variables of each sample, we used a Student\u0026rsquo;s t-test or the Mann\u0026ndash;Whitney U test. Correlation was studied with structural equation modeling, and goodness of fit was checked by Goodness-Of-Fit Index (GFI), Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Minimum Discrepancy per Degree of Freedom (CMIN/DF) parameters. A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was accepted as statistically significant for the differences in the entire analyses.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe enrolled 287 adolescents in this study. The mean age was 16.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 years, and the clinical data are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResearch sample\u0026rsquo;s demographic and clinical data\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" 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colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17,1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32,4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eEducational status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eElementary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e230\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80,1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsenteeism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eDrug or substance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSmoke\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubstance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSmoke and alcohol\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ePsychiatric disorders in family member\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93,4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003ePurpose of internet usage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial networking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e232\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80,8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNews/information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23,0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGaming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChatting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducational activities/homework\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMovie/music\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74,6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eDuration of internet usage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;2 times per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5,9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLess then1 hour per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11,1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;3 hours per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u0026ndash;6 hours per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 hours per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11,1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResearch sample\u0026rsquo;s usage of internet (internet addiction scale: IAS) and somatic symptoms (SS) scales\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMin.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMax.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eS.D.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIAS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e74,40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e23,69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIAS-deprivation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27,60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e9,31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIAS-difficulty of self-control\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21,09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7,73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIAS-functional deterioration\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14,48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6,01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIAS-social isolation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11,22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4,87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSS by patient\u0026rsquo;s own (SS-P)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8,52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5,08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSS by legal guardians (SS-LG)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7,85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5,06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eIAS: Internet Addiction Score\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eSS: Somatic Syptoms\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eSS-P: Somatic Symptoms by patient\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eSS-LG: Somatic Symptoms by legal guardians\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between internet addiction and somatic symptoms\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSS-by P\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSS-by LG\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIAS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIAS-deprivation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eIAS-difficulty of self-control\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIAS-func. deteriorate.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSS- by LG\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003er\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,761\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003er\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-deprivation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003er\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,860\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-difficulty of self-control\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003er\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,197\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,903\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e,673\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-functional deterioration\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003er\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,851\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e,603\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e,730\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-social isolation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003er\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,735\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e,456\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e,615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e,590\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e,112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e,077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e,000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eIAS: Internet Addiction Score\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eSS: Somatic Syptoms\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eSS-P: Somatic Symptoms by patient\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eSS-LG: Somatic Symptoms by legal guardians\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInternet addiction in children and adolescents with or without a family history of psychiatric disease\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eInternet Addiction Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon-addiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThreshold value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRisky group\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFamily History\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0,898\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe differences between medically unexplained symptoms and internet addiction scoring in both genders.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eS.D.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003et/p\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e73,97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e24,44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.212/0.832\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e74,61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e23,38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-deprivation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26,78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9,34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.985/0.302\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9,30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-difficulty of self-control\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21,11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8,01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.586/0.975\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21,08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7,61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-functional deterioration\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14,47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5,97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.723/0.988\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14,48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6,04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eIAS-social isolation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11,60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5,36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.249/0.362\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11,04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSS-by P\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6,96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-3.662/\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9,26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5,01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eIAS: Internet Addiction Score\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eSS-P: Somatic Symptoms by patient\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eModel 1 Goodness of fit\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCMIN/DF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGFI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCFI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRMSEA\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0.504\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.478\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrequency of those who answer \"high level\" to each question in the somatic symptom scale; stomach 48 (16.7%), back pain 41 (14.3%), arm, leg, joint pain 60 (20.9%), headache 108 (37.6%), chest pain 28 (9.8%), dizziness 63 (22%), syncope, presyncope 5 (1.7%), palpitations 33 (11.5%), shortness of breath 26 (9.1%), constipation, diarrhea 31 (10.8%), nausea, gas, indigestion 57 (19.9%), fatigue or loss of energy 130 (45.3%), sleep difficulties 63 (22%) respectively.\u003c/p\u003e\u003cp\u003eAccording to cut-off scores of the Internet Addiction Scale, no cases of addiction were found among the included patients. However, we determined that 54 cases (18.8%) were found to be within the cut-off value, and 11 cases (3.8%) were found in the high-risk group among the 287 adolescents.\u003c/p\u003e\u003cp\u003eA high correlation was found between the scores of the somatic symptoms between both the adolescents and their parents. Similarly, apart from the social isolation subscale of the internet addiction scale, there is a weak and significant positive relationship between both total scores and subscale scores and Somatic Symptom Scale scores (Table III). The number of participants with positive family history in terms of psychiatry is 19 (% 6.6). Accordingly, no statistically significant difference was found in terms of internet addiction between the participants who had positive family history and no family history of problematic internet addiction (χ2 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;0.214, p\u0026thinsp;=\u0026thinsp;0.898) (Table IV).\u003c/p\u003e\u003cp\u003eIn comparison with the internet addiction scoring, there was no difference between the genders. However, we found that females scored highly on the total somatic symptom scales, and this was a statistically significant difference (Table V).\u003c/p\u003e\u003cp\u003eIn comparing the internet addiction scores for both genders, there was no statistically significant difference found in terms of social networking (χ\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;0.487 and p\u0026thinsp;=\u0026thinsp;0.485), chatting (χ\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;3.115 and p\u0026thinsp;=\u0026thinsp;0.078), educational activities/homework (χ\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;0.154 and p\u0026thinsp;=\u0026thinsp;0.695), and movie/music (χ\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;1.583 and p\u0026thinsp;=\u0026thinsp;0.208). However, we found that surfing for news/information (χ\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;14.292 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and gaming (χ\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;22.233 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were more common among males than females.\u003c/p\u003e\u003cp\u003eIn this study; based on the model showing the correlations between gender, internet addiction and somatic symptoms, we can say that gender does not directly affect internet addiction, but indirectly affects somatic symptoms. According to this model, being female leads to a scoring of somatic symptoms that is 2.3 times higher than that of males. The model also shows that a one-unit increase in somatic symptoms scores caused a 1.15-unit increase in internet addiction scoring (Table VI, Fig.\u0026nbsp;1).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eProblematic usage of internet has not yet been well established in medicine, although somatic symptom disorder have been known for some time in psychiatric contexts. Problematic usage of internet and associated disorders have only begun to receive attention in the last decade. Adolescence is a challenging time of life, and these challenges may cause adolescents to seek out a realistic space for self-expression in cyber settings, through which they can reflect on their own internal conflicts. Somatic symptoms may be a way of externalizing their emotions and struggles as well. Few studies in the literature link somatic symptoms and PUI. In a study by Zagorscak et al. 722 students were enrolled with a mean age of 13.4 years, and there was a positive correlation found between cyberbullying and somatic symptoms. Cyberbullying is defined as a subheading term in the spectrum of PUI (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the present study, we investigated 287 adolescents. Each adolescent was assessed via an internet addiction screening scale. In the study group, 3.8% of respondents were found to be at risk of internet addiction, but 18.8% were found to be within the cut-off value. We detected that there was a positive correlation between a high score on the internet addiction screening test and a high score for somatic symptoms in adolescents, and this relationship was statistically significant.\u003c/p\u003e\u003cp\u003eIn our study, there was no statistically significant difference between genders with respect to the scores on the internet addiction screening scale. According to the literature, different results have been reported on this subject. For instance, in research from South Korea, PUI was found to be more common in male adolescents (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In another multi-center study from Spain, it was found that PUI was more common among female adolescents than males (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Although there was no statistically significance between genders in the scoring of the Internet Addiction Scale in our study, gender was an important factor in determining what purposes the internet was used for. We observed that male adolescents spent much more time surfing online news or information websites than girls. This result is compatible with data in the literature (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Based on our findings, we can also assert that gender is a deterministic factor for the level of seriousness in somatic symptoms. In other studies, the scoring of somatic symptoms has been found to be statistically higher in female adolescents than in their male counterparts. For instance, Rehna et al. conducted a study with 663 adolescents in which females were found to have more common somatic symptoms than males (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Another study by Kronke and Spitzer examined 1,000 adolescents and found that females were more likely to have somatoform disorders in comparison with male adolescents (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe have also assessed how the parental perspective may have been related to the somatic symptoms of the adolescents who enrolled in our study. We paid proper attention to the fact that both the patient and his/her legal guardian were to answer the questionnaires blindly. There was a high correlation between the scores of both the adolescents and the adults on the Somatic Symptoms Scale. This may be a sign that adolescents have a tendency to share their own somatic distress within the family. This can be expected when considering etiological theories of somatic symptom disorder or somatic symptoms disorders. According to the mainstay theories, the body is not only a medium in which one has been experiencing psychological distress, but it is also a communication tool between an individual and others. In individuals whose linguistic skills, emotion recognition, and verbal expression are not sufficiently developed, the transfer of experience can be through the body, as in the early phases of development. Adolescents may also be physically compensating for mental stress and conflicts with family members and/or peers in which their self-expression is not sufficient. As adolescents\u0026rsquo; immature brains are still continuing to develop, there is also a disadvantage due to asymmetrical brain development. For this reason, adolescents often use old (somatic) tools when they would like to express themselves, which is a form of expression that remains from early phases in childhood. These findings account for why mental stress is frequent among adolescents, and why they cannot effectively express themselves or resolve certain problems effectively on their own. Somatic symptom disorder have been found to have a familial pattern similar to other psychiatric disorders (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe model constructed in our study suggests that gender does not have a direct effect on the scoring of the Internet Addiction Scale, but being female leads to a high risk of expressing somatic symptoms (Fig.\u0026nbsp;1). It was also found that as the scoring of the somatic symptoms increased, the score on the Internet Addiction Scale was significantly raised as well. In other words, being female indirectly affected the score on the Internet Addiction Scale more than being male. According to this model, as the seriousness of somatic symptoms increases, the score on the Internet Addiction Scale raises as well. This may be kind of a coping skill for any challenges faced in adolescence. This model should be confirmed with additional research in the larger groups. Further work should also examine whether psychiatric management is beneficial for the groups with high scores on the Internet Addiction Scale.\u003c/p\u003e\u003cp\u003ePatients who have somatic symptom disorder have occupied a noticeable place in the healthcare system. Every single admission to a hospital is the result of many unnecessary tests and may be construed as waste of time for healthcare a worker that is already limited. Healthcare costs become a burden to social security systems as the patients are evaluating with over and over. When a diagnosis for patients cannot be established, somatic symptom disorder can continue to persist and may be of concern for the patients and families. In this respect, it is important to provide tools that can guide the pediatrician to recommend a psychiatric consultation as soon as possible before the disorder consumes the child\u0026rsquo;s life. Accordingly, it is extremely important to develop approaches to understand the significance of PUI, how time is spent on the internet, and how this situation affects adolescent\u0026rsquo;s health and physical symptom perceptions.\u003c/p\u003e\u003cp\u003eIn conclusion, we have reported that there is a statistically significant correlation between the scores on the Internet Addiction Scale and the presence of somatic symptoms in adolescents. Therefore, one of the ways to combat internet addiction in adolescents seems to be to focus on adolescents' somatic complaints and, in a sense, their communication skills. Our model should be confirmed with additional research in the larger groups. Further work should also examine whether psychiatric management is beneficial for the groups with high scores on the Internet Addiction Scale.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD.I.M design, collecting data, scaling, recording, writing, M.U. bioıstatıstıc and conclusıonF.M. editing and translating\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCozzi, G., Minute, M., Skabar, A., Pirrone, A., Jaber, M., Neri, E et al. \u0026nbsp;Somatic symptom disorder was common in children and adolescents attending an emergency department complaining of pain. Acta paediatrica (Oslo, Norway: 1992). 2017; 106(4), 586\u0026ndash;593.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCarson, A. J., Ringbauer, B., Stone, J.\u0026nbsp;McKenzie, L., Warlow, C., Sharpe, M. Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics. Journal of neurology, neurosurgery, and psychiatry. 2000; 68(2), 207\u0026ndash;210.\u003c/li\u003e\n \u003cli\u003eZhao, T. Y., Zou, S. P., \u0026amp; Knapp, P. E. Exposure to cell phone radiation up-regulates apoptosis genes in primary cultures of neurons and astrocytes. Neuroscience letters.2007; 412(1), 34\u0026ndash;38.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThom\u0026eacute;e, S., H\u0026auml;renstam, A., Hagberg, M. \u0026nbsp;Mobile phone use and stress, sleep disturbances, and symptoms of depression among young adults--a prospective cohort study. BMC public health. 2011; 11, 66.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eInternet World Stats, https://www.internetworldstats.com/stats.htm Accessed: September,9. 2020.\u003c/li\u003e\n \u003cli\u003eYoung K. S. The evolution of Internet addiction. Addictive behaviors. 2017; 64, 229\u0026ndash;230.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFineberg, N. A., Demetrovics, Z., Stein,\u0026nbsp;D. J., Ioannidis, K., Potenza, M. N., Gr\u0026uuml;nblatt, E et al. Manifesto for a European research network into Problematic Usage of the Internet. European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology. 2018; 28(11), 1232\u0026ndash;1246.\u003c/li\u003e\n \u003cli\u003eHussain, Z., Griffiths, M. D., Sheffield, D. An investigation into problematic smartphone use: The role of narcissism, anxiety, and personality factors. Journal of behavioral addictions. 2017; 6(3), 378\u0026ndash;386.\u003c/li\u003e\n \u003cli\u003eKahraman, \u0026Ouml;., Demirci, E. \u0026Ouml;. Internet addiction and attention-deficit-hyperactivity disorder: Effects of anxiety, depression and self-esteem. Pediatrics international: official journal of the Japan Pediatric Society.2018; 60(6), 529\u0026ndash;534.\u003c/li\u003e\n \u003cli\u003eBozkurt, H., \u0026Ouml;zer, S., Şahin, S., S\u0026ouml;nmezg\u0026ouml;z, E. \u0026nbsp;Internet use patterns and Internet addiction in children and adolescents with obesity. Pediatric obesity. 2018; 13(5), 301\u0026ndash;306.\u003c/li\u003e\n \u003cli\u003eDo, K. Y., \u0026amp; Lee, K. S. \u0026nbsp; Relationship between Problematic Internet Use, Sleep Problems, and Oral Health in Korean Adolescents: A National Survey. International journal of environmental research and public health. 2018; 15(9), 1870.\u003c/li\u003e\n \u003cli\u003eReed, P., Vile, R., Osborne, L. A., Romano, M., Truzoli, R. Problematic Internet Usage and Immune Function. PloS one. 2015; 10(8), e0134538.\u003c/li\u003e\n \u003cli\u003eCerutti, R., Presaghi, F., Spensieri, V., Valastro, C., Guidetti, V. \u0026nbsp;The Potential Impact of Internet and Mobile Use on Headache and Other Somatic Symptoms in Adolescence. A Population-Based Cross-Sectional Study. Headache. 2016; 56(7), 1161\u0026ndash;1170.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSmorti, M., Milone, A., Gonzalez Gonzalez, J., Vitali Rosati, G. Adolescent selfie: an Italian Society of Paediatrics survey of the lifestyle of teenagers. Italian journal of pediatrics. 2019; 45(1), 62.\u003c/li\u003e\n \u003cli\u003eCraig, C. L., Marshall, A. L., Sj\u0026ouml;str\u0026ouml;m, M.,\u0026nbsp;Bauman, A. E., Booth, M. L., Ainsworth, B. et al. International physical activity questionnaire: 12-country reliability and validity. Medicine and science in sports and exercise. 2003; 35(8), 1381\u0026ndash;1395.\u003c/li\u003e\n \u003cli\u003eUlaş, K., Topuz, S., Horasan, G. \u0026nbsp;The validity and reliability of the Turkish version of the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD). Turkish journal of medical sciences. 2019; 49(6), 1620\u0026ndash;1625.\u003c/li\u003e\n \u003cli\u003eG\u0026uuml;n\u0026uuml;\u0026ccedil; S., Kayri M. The Profıle of Internet Dependency In Turkey And Development Of Internet Addiction Scale: Study Of Validity \u0026amp; Reliability. \u0026nbsp;Hacettepe \u0026Uuml;niversitesi Eğitim Fak\u0026uuml;ltesi Dergisi (H. U. Journal of Education). 2010; 39: 220-232. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYalın Sapmaz Ş, Serim Demirg\u0026ouml;ren B, Y\u0026ouml;r\u0026uuml;k \u0026Uuml;lker G, Aydemir \u0026Ouml;. \u0026nbsp;Validity and reliability of the Turkish Version of DSM-5 Level 2 Somatic Symptom Scale (Child Form for 11-17 years and Parent Form for 6-17 years). Anatolian Journal of Psychiatry. 2017;18(Suppl.2):114-121.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZagorscak, P., Schultze-Krumbholz, A., Heinrich, M., W\u0026ouml;lfer, R., Scheithauer, H. Efficacy of Cyberbullying Prevention on Somatic Symptoms-Randomized Controlled Trial Applying a Reasoned Action Approach. Journal of research on adolescence: the official journal of the Society for Research on Adolescence. 2019; 29(4), 908\u0026ndash;923.\u003c/li\u003e\n \u003cli\u003eLee, S. Y., Lee, D., Nam,\u0026nbsp;C. R., Kim, D. Y., Park, S., Kwon, J. G\u0026nbsp;et al. \u0026nbsp;Distinct patterns of Internet and smartphone-related problems among adolescents by gender: Latent class analysis. Journal of behavioral addictions. 2018; 7(2), 454\u0026ndash;465.\u003c/li\u003e\n \u003cli\u003eMu\u0026ntilde;oz-Miralles, R., Ortega-Gonz\u0026aacute;lez, R., L\u0026oacute;pez-Mor\u0026oacute;n, M. R.,\u0026nbsp;Batalla-Mart\u0026iacute;nez, C., Manresa, J. M., Montell\u0026agrave;-Jordana, N.\u0026nbsp;et al. The problematic use of Information and Communication Technologies (ICT) in adolescents by the cross sectional JOITIC study. BMC pediatrics. 2016;16(1), 140.\u003c/li\u003e\n \u003cli\u003eRehna, T., Hanif, R., Um e Laila, Ali, S. Z. Life stress and somatic symptoms among adolescents: gender as moderator. JPMA. The Journal of the Pakistan Medical Association. 2016; 66(11), 1448\u0026ndash;1451.\u003c/li\u003e\n \u003cli\u003eKroenke, K., Spitzer, R. L. \u0026nbsp;Gender differences in the reporting of physical and somatoform symptoms. Psychosomatic medicine. 1998; 60(2), 150\u0026ndash;155.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eVan Tilburg, M. A., Levy, R. L., Walker, L. S., Von Korff, M., Feld, L. D., Garner, M.,et al. Psychosocial mechanisms for the transmission of somatic symptoms from parents to children. World journal of gastroenterology. 2015; 21(18), 5532\u0026ndash;5541.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Somatic symptom disorder, internet addiction, adolescent","lastPublishedDoi":"10.21203/rs.3.rs-8296510/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8296510/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eSomatic symptom disorder is characterized as recurrent and multiple physical complaints and these symptoms cannot be medically explained despite of all examinations and therefore many adolescents admit to pediatrics clinics. In this study we aimed to investigate whether any association between problematic internet usage and somatic symptom disorder in adolescent who admitted to pediatrics clinic.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e287 adolescents diagnosed with somatic symptom disorder participated in the study. The patients were asked to fill in the sociodemographic information form, the International Physical Activity Questionnaire, the Internet Addiction Scale, and the Somatic Symptoms Scale. Data were collected by questionnaire and statistically analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean age was 16.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 and 32.4%male, 67.6% female. When internet addiction scores were compared for both genders, no statistically significant difference was found in social networking, chat, education/homework, and movie/music scores (respectively p\u0026thinsp;=\u0026thinsp;0.485, p\u0026thinsp;=\u0026thinsp;0.078, p\u0026thinsp;=\u0026thinsp;0.695, p\u0026thinsp;=\u0026thinsp;0.208). However, we found that either surfing news score ( p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) or gaming score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was higher in male than females at subscales. The model we have established reveals that gender does not have a direct effect on internet addiction, but being female causes an indirect increase in internet addiction scores by increasing somatic symptoms.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThere is a statistically significant correlation between the scores on the internet addiction scale and the presence of somatic symptoms in adolescents. Therefore, it may be possible to obtain good results from methods targeting somatic symptoms in intervention programs for adolescents with internet addiction.\u003c/p\u003e","manuscriptTitle":"Assessment of the Correlation between Problematic Internet Usage and Somatic Symptom Disorder in Adolescents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-09 04:48:24","doi":"10.21203/rs.3.rs-8296510/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-15T06:20:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-13T10:41:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-13T10:39:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-06T18:59:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"798277ca-5759-4626-8c9e-fc0051711b6c","owner":[],"postedDate":"December 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-03T07:53:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-09 04:48:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8296510","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8296510","identity":"rs-8296510","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}