Elsevier

Computers in Human Behavior

Volume 72, July 2017, Pages 170-177
Computers in Human Behavior

Full length article
Latent-level relations between DSM-5 PTSD symptom clusters and problematic smartphone use

https://doi.org/10.1016/j.chb.2017.02.051Get rights and content

Highlights

  • We assessed the relations between PTSD clusters and problematic smartphone use.

  • Trauma-exposed participants (N = 347) were recruited through Amazon’s MTurk.

  • Problematic smartphone use was most associated with PTSD’s negative affect.

  • Problematic smartphone use was most associated with PTSD’s arousal.

Abstract

Common mental health consequences following the experience of potentially traumatic events include Posttraumatic Stress Disorder (PTSD) and addictive behaviors. Problematic smartphone use is a newer manifestation of addictive behaviors. People with anxiety severity (such as PTSD) may be at risk for problematic smartphone use as a means of coping with their symptoms. Unique to our knowledge, we assessed relations between PTSD symptom clusters and problematic smartphone use. Participants (N = 347), recruited through Amazon’s Mechanical Turk (MTurk), completed measures of PTSD and smartphone addiction. Results of the Wald tests of parameter constraints indicated that problematic smartphone use was more related to PTSD’s negative alterations in cognitions and mood (NACM) than to PTSD’s avoidance factor, Wald χ2(1, N = 347) = 12.51, p = 0.0004; and more to PTSD’s arousal compared to PTSD’s avoidance factor, Wald χ2(1, N = 347) = 14.89, p = 0.0001. Results indicate that problematic smartphone use is most associated with negative affect and arousal among trauma-exposed individuals. Implications include the need to clinically assess problematic smartphone use among trauma-exposed individuals presenting with higher NACM and arousal severity; and targeting NACM and arousal symptoms to mitigate the effects of problematic smartphone use.

Introduction

The co-occurrence of PTSD with addictive behaviors is normative following the experience of a potentially traumatic events (PTE) (e.g., Breslau, 2009, Khoury et al., 2010). More recently, research on “cyber addictions,” including smartphone addiction, is gaining traction (reviewed in Billieux, 2012). However, no study to our knowledge has examined relations between the PTSD symptom cluster severity and problematic smartphone use; this is the focus of the current study.

Excessive and problematic use of smartphones is characterized as a type of non-chemical behavioral cyber addiction (reviewed in Billieux, 2012, van Deursen et al., 2015). Smart phone addiction is defined as the overuse of smartphones despite impairment in daily functioning (Demirci, Akgönül, & Akpinar, 2015). There are no official diagnostic criteria for problematic smartphone use; however it shares characteristics similar to other addictive behaviors such as habitual overuse, functional impairment, and withdrawal following cessation of use (e.g., Ezoe et al., 2009).

First, increasingly, people are using smartphones as more than a communicative device. They use smartphones habitually for daily everyday functional uses (e.g., social media applications, games, productivity enhancement, and navigation). Such habitual overuse of a smartphone may render it addictive (van Deursen et al., 2015, Kwon et al., 2013, Oulasvirta et al., 2012). Second, excessive smartphone use could result in functional impairment (Demirci et al., 2015, Kwon et al., 2013) including impaired driving (Cazzulino, Burke, Muller, Arbogast, & Upperman, 2014), and difficulties in real-life social engagement (Kuss & Griffiths, 2011). Additionally, excessive smartphone use could relate to sleep difficulties (Demirci et al., 2015), especially for people who experience higher anxiety when separated from technological devices, and have a greater dependence on technological devices (including smartphones), which in turn influences nighttime awakenings related to smartphone use (Rosen, Carrier, Miller, Rokkum, & Ruiz, 2016). In fact, the relatively new concept of “iDisorder” highlights the relation between greater technology use and poorer mental health (Rosen, Cheever, & Carrier, 2012). Unsurprisingly, problematic smartphone use relates to depression, anxiety (Demirci et al., 2015, Elhai et al., 2017), and “technostress” (stress related to technology use; Brod, 1984, Lee et al., 2014). The reasons and nature of technology use (including use of smartphones) can differentially relate to psychopathology. As an example, Rosen, Whaling, Rab, Carrier, and Cheever (2013) found that greater general Facebook use, greater Facebook use for impression management, and having more Facebook friends related to narcissism; whereas using technology to listen to music, and greater general Facebook use related to antisocial personality traits (Rosenm Whaling, et al., 2013).

Third, individuals may experience withdrawal-like symptoms when separated from their smartphones (Kwon, Lee, et al., 2013). The concept of “nomophobia” describes one’s dependency on technological devices to the extent of causing anxiety when separated from the technological device (King et al., 2013). Evidence indicates that people experience physiological symptoms (e.g., increasing heart rate and blood pressure), increased anxiety, and a decline in cognitive performance when they are unable to answer their ringing phones (Clayton, Leshner, & Almond, 2015). Additionally, evidence indicates an increase in anxiety levels among smartphone users when separated from their technological devices, especially for students who used the technological devices more frequently (Cheever, Rosen, Carrier, & Chavez, 2014). Lastly, there may be a reinforcement element embedded in smartphone use such as obtaining pleasurable experiences (Kwon et al., 2013, Song et al., 2004), and engagement in virtual social relationships (Kwon, Lee, et al., 2013). This conceptualization of smartphone addiction is similar to the defining features of addictive behaviors such as substance use (Fisher et al., 1998, Marlatt et al., 1988, Shaffer, 1996).

In our paper, we were interested in problematic smartphone use in relation to PTSD symptoms. PTSD, a trauma-related disorder in DSM 5, is conceptualized as comprising of four symptom clusters: intrusions, avoidance of internal and external triggers serving as reminders of the traumatic event, alterations in affect and belief structures as a result of the traumatic event experiences (negative alterations in cognitions and mood; NACM), and physiological arousal symptoms (alterations in arousal and reactivity; AAR) (American Psychiatric Association, 2013). NACM symptoms are conceptualized as being distress-based and hypothesized to underlie co-occurring PTSD and distress-based disorders such as depression (Contractor et al., 2014).

PTSD shares common risk factors with problematic smartphone use, and other addictive behaviors. Low self-esteem, neuroticism, and impulsivity relate to problematic smartphone use (Bianchi & Phillips, 2005; reviewed in; Billieux, 2012), as well as to increased PTSD severity (Contractor et al., 2016, Contractor et al., 2016, Jakšić et al., 2012), and other addictive behaviors such as alcohol misuse (Fisher et al., 1998, Marlatt et al., 1988). Extrapolating from the literature linking PTSD and addictive behaviors (e.g., Keane and Wolfe, 1990, Stewart, 1996), the relation between problematic smartphone use and PTSD severity can be characterized from two perspectives: the reinforcement perspective and the socialization perspective.

There is potentially a bi-directional relationship between PTSD severity and smartphone addiction due to the reinforcing properties of smartphone use (positive and/or negative reinforcement). From a positive reinforcement model perspective, smartphone use may elicit, maintain, or increase positive affect and pleasure (reviewed in Billieux, 2012). An example is the increase in positive affect when receiving notifications on one’s smartphone (Oulasvirta et al., 2012). Consequent positive effects in turn may lead to “wanting” behaviors characterized by a desire of even greater smartphone use (Robinson and Berridge, 2000, Song et al., 2004). This framework has been termed as the incentive-sensitization theory in substance addiction research (Robinson & Berridge, 2000), and as the process-related gratification perspective in smartphone addiction research (Song et al., 2004). Thus, excessive smartphone use may be positively reinforcing for people who experience PTSD severity, particularly among those who report social isolation and low positive affect.

From a negative reinforcement model perspective, excessive smartphone use driven by poor self-control, anxiety, impulsivity, and difficulties regulating emotions could function to reduce or distract from negative affect (e.g., NACM symptoms) and withdrawal symptoms (reviewed in Billieux, 2012, Elhai et al., 2017, Jeong et al., 2016). This explanation has been conceptualized as the self-medicating theory in substance addiction research (Khantzian, 1985, Stewart, 1996), and as the impulsive pathway perspective in smartphone addiction research (reviewed in Billieux, 2012). In fact, the impulsive pathway perspective comprehensively details the role of several impulsivity facets (negative urgency, lack of perseverance, lack of premeditation, and sensation seeking) underlying problematic smartphone use (reviewed in Billieux, 2012). The tendency to act impulsively when experiencing intense emotional states, termed as negative urgency (Whiteside & Lynam, 2001) is highly related to PTSD subscale severity, and to NACM symptom severity in particular (Contractor et al., 2016, Roley et al., 2017); and to problematic phone use (Billieux et al., 2007, Billieux et al., 2008). In summary, similar to other addictive impulsive behaviors (Marshall-Berenz et al., 2011, O’Hare et al., 2009, Sacks et al., 2008), excessive smartphone use may be a negatively reinforcing coping strategy for people experiencing negative affect related to PTSD severity (i.e., primarily NACM symptom severity).

Finally, positive and negative reinforcement may interact to contribute to a compulsive pattern of smartphone use. To elaborate, one’s smartphone use could be positively reinforced by the pleasure and gratification one experiences when initially using the smartphone. On discontinuation of smartphone use, one could experience negative affect (similar to a withdrawal effect) that would reduce when smartphone use is resumed. This pattern could be negatively reinforcing, and thus could contribute to increased smartphone use (Wise & Koob, 2014).

Given theoretical evidence to suggest that smartphone use may elicit, maintain, or increase positive affect and/or reduce or distract from negative affect, it is not surprising that preliminary evidence indicates a positive relationship between stress and problematic smartphone use. Specifically, one study found that university students developed an addiction to mobile phones to possibly alleviate the negative emotions of pain and tension in relation to family and emotional stress (Chiu, 2014). Thus, excessive smartphone use serve as a coping mechanism for stressor-related distress including PTSD symptoms.

The socialization-related purposes of smartphones use could make it addictive for people with PTSD symptoms because smartphone use may compensate for lack of real-life socialization or may facilitate social avoidance. People with greater PTSD severity have social difficulties (e.g., lack of social relationships; discomfort in social situations) due to avoidance symptoms (Solomon, 1989) or possibly attributable to neuroticism, low self-esteem (Jakšić et al., 2012), and social anxiety (Hofmann, Litz, & Weathers, 2003). As such, according to the social usage perspective (Yang & Tung, 2007) and the relationship maintenance pathway perspective (reviewed in Billieux, 2012), they may use their smartphones to make up for perceived deficiencies in their social life and to obtain reassurances in their relationships. Alternatively, we can hypothesize that people with PTSD severity may use smartphones as a distraction/social avoidance strategy especially when in uncomfortable social situations.

Prior theoretical and empirical literature provides preliminary support for a link between PTSD severity and problematic smartphone use. Thus, the current study aims to assess latent-level structural relations between PTSD symptom clusters (intrusions, avoidance, NACM, and AAR) and problematic smartphone use. We consider the study as primarily exploratory given the lack of prior similar empirical studies, and the existence of alternative models linking PTSD severity to problematic smartphone use. We hypothesized that problematic smartphone use would have the strongest association with the distress-laden latent factor of PTSD - NACM cluster (Hypothesis 1). NACM symptoms represent changes in cognitive and emotional states following the experience of a PTE (Friedman, 2013), and symptoms comprising this cluster are significantly associated with distress-related conditions such as depression (Contractor et al., 2014, Elhai et al., 2015) and addictive behaviors such as alcohol use (Biehn et al., 2016). Extrapolating from addiction research (Biehn et al., 2016, Contractor et al., 2016, Jakupcak et al., 2010), we speculated that problematic smartphone use may aid to cope with PTSD-related distress represented by the NACM symptoms. Further, feelings of detachment (Criteria D6 of NACM cluster) could be associated with excessive smartphone use (Billieux, 2012, van Deursen et al., 2015, Yang and Tung, 2007); smartphone use may either enhance social detachment or serve to compensate for the lack in social relationships. The remainder of the analyses were exploratory. Results of the current study could highlight mechanisms linking PTSD severity and problematic smartphone use, and inform treatment-related targets for co-occurring PTSD and problematic smartphone use.

Section snippets

Procedure/participants

Participants were recruited from Amazon’s Mechanical Turk (MTurk) platform (Buhrmester, Kwang, & Gosling, 2011). The study was described as a 30-min survey of an examination of the nature and extent of smartphone use among people who have experienced stressful life events. We screened participants 18 years and older for four inclusionary criteria: (1) living in North America; (2) working knowledge of the English language; (3) using a smartphone; and (4) experiencing a PTE. Participants who met

Results

In the current sample, total PCL-5 scores averaged 32.51 (SD = 20.47), and 47% of trauma-exposed participants (n = 163) met or exceeded the cut-off score for a possible diagnosis of PTSD (Blevins et al., 2015, Bovin et al., 2016). CFA indicated an adequately-fitting DSM-5 PTSD model per the majority of the fit indices, χ2(164, N = 347) = 566.38, p < 0.001, CFI = 0.92, TLI = 0.91, RMSEA = 0.08, SRMR = 0.04. Further, CFA indicated an adequately-fitting combined PTSD and SAS-SV model according to

Discussion

Theoretical and empirical literature supports a link between PTSD symptoms and problematic smartphone use. The current study is the first study to quantify and compare the strength of latent-level associations between PTSD symptom clusters and problematic smartphone use. While the study is primarily exploratory, we did hypothesize that problematic smartphone use would have the strongest association with PTSD’s NAMC symptom cluster compared to other PTSD symptom clusters. We found partial

Conflicts of interest

No author has a conflict of interest.

Disclaimer

The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Sheila Frankfurt is currently at the VISN 17 Center of Excellence for Research on Returning War Veterans. This research is supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Central Texas Veterans Health Care System, and the VISN 17 Center of Excellence for Research on

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