Full length articleLatent-level relations between DSM-5 PTSD symptom clusters and 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
References (77)
- et al.
The validity and reliability of the turkish version of the smart phone addiction scale-short form for adolescent
Procedia-Social and Behavioral Sciences
(2014) - et al.
Out of sight is not out of mind: The impact of restricting wireless mobile device use on anxiety levels among low, moderate and high users
Computers in Human Behavior
(2014) The relationship between life stress and smartphone addiction on Taiwanese university student: A mediation model of learning self-efficacy and social self-efficacy
Computers in Human Behavior
(2014)- et al.
Latent profiles of DSM-5 PTSD symptoms and the “Big Five” personality traits
Journal of Anxiety Disorders
(2016) - et al.
DSM-5 PTSD’s symptom dimensions and relations with major depression’s symptom dimensions in a primary care sample
Psychiatry Research
(2014) - et al.
The moderating role of dysphoria in the relationship between intrusions and alcohol use
Addictive Behaviors
(2016) - et al.
Modeling habitual and addictive smartphone behavior: The role of smartphone usage types, emotional intelligence, social stress, self-regulation, age, and gender
Computers in Human Behavior
(2015) - et al.
Structural relations between DSM-5 PTSD and major depression symptoms in military soldiers
Journal of Affective Disorders
(2015) - et al.
Problematic smartphone use: A conceptual overview and systematic review of relations with anxiety and depression psychopathology
Journal of Affective Disorders
(2017) - et al.
Fear of missing out, need for touch, anxiety and depression are related to problematic smartphone use
Computers in Human Behavior
(2016)
Non-social features of smartphone use are most related to depression, anxiety and problematic smartphone use
Computers in Human Behavior
Posttraumatic stress disorder in DSM-5: Estimates of prevalence and symptom structure in a nonclinical sample of college students
Journal of Anxiety Disorders
Social anxiety, depression, and PTSD in Vietnam veterans
Journal of Anxiety Disorders
PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking post-deployment VA health care
Addictive Behaviors
What type of content are smartphone users addicted to?: SNS vs. games
Computers in Human Behavior
Nomophobia: Dependency on virtual environments or social phobia?
Computers in Human Behavior
The dark side of smartphone usage: Psychological traits, compulsive behavior and technostress
Computers in Human Behavior
Impulsivity and alcohol use coping motives in a trauma-exposed sample: The mediating role of distress tolerance
Personality and Individual Differences
I need my smartphone: A hierarchical model of personality and cell-phone addiction
Personality and Individual Differences
Sleeping with technology: Cognitive, affective, and technology usage predictors of sleep problems among college students
Sleep Health
Is Facebook creating “iDisorders”? The link between clinical symptoms of psychiatric disorders and technology use, attitudes and anxiety
Computers in Human Behavior
Self-mutilative behaviors in male veterans with posttraumatic stress disorder
Journal of Psychiatric Research
Functional associations among trauma, PTSD, and substance-related disorders
Addictive Behaviors
Impulsive behaviors as an emotion regulation strategy: Examining associations between PTSD, emotion dysregulation, and impulsive behaviors among substance dependent inpatients
Journal of Anxiety Disorders
The five factor model and impulsivity: Using a structural model of personality to understand impulsivity
Personality and Individual Differences
Comparison of Internet addicts and non-addicts in Taiwanese high school
Computers in Human Behavior
Diagnostic and statistical manual of mental disorders
Addiction motivation reformulated: An affective processing model of negative reinforcement
Psychological Review
Psychological predictors of problem mobile phone use
CyberPsychology & Behavior
Latent dimensions of posttraumatic stress disorder and their relations with alcohol use disorder
Social Psychiatry and Psychiatric Epidemiology
Problematic use of the mobile phone: A literature review and a pathways model
Current Psychiatry Reviews
Does impulsivity relate to perceived dependence and actual use of the mobile phone?
Applied Cognitive Psychology
The role of impulsivity in actual and problematic use of the mobile phone
Applied Cognitive Psychology
The posttraumatic stress disorder checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation
Journal of Traumatic Stress
Measuring mobile phone use: Self-report versus log data
Journal of Computer-Mediated Communication
Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders–fifth edition (PCL-5) in veterans
Psychological Assessment
The epidemiology of trauma, PTSD, and other posttraumatic disorders
Trauma Violence Abuse
Technostress: The human cost of the computer revolution
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