Comprehensive Psychiatry 122 (2023) 152376
Available online 1 February 2023
0010-440X/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Gaming disorder: A summary of its characteristics and aetiology
Orsolya Kir´aly a,*
, Patrik Koncz a,b
, Mark D. Griffiths c
, Zsolt Demetrovics a,d
a
Institute of Psychology, ELTE E¨otv¨os Lor´and University, Budapest, Hungary
b
Doctoral School of Psychology, ELTE E¨otv¨os Lor´and University, Budapest, Hungary
c
International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, United Kingdom
d
Centre of Excellence in Responsible Gaming at the University of Gibraltar, Gibraltar
A R T I C L E I N F O
Keywords:
Gaming disorder
Aetiology
Gaming-related factors
Individual factors
Environmental factors
A B S T R A C T
The emergence, development, and maintenance of gaming disorder (GD) is the result of an interplay between
gaming-related factors, individual factors, and environmental factors. None of these alone are sufficient to cause
a disordered state, but it is the interactive co-occurrence of all these factors, which in some cases leads to GD. The
goal of the present paper is to discuss in detail these three factors based on relevant and recent findings of the
literature. Among gaming-related factors, we discuss online vs. offline videogames, the role of game genres,
structural characteristics, game design elements, as well as some important monetization techniques. Among
individual factors demographic risk factors, personality traits, motivational factors, comorbid psychopathology,
genetic predisposition, and neurobiological processes are considered. Finally, among environmental factors we
discuss family factors, early life experiences, the role of peers and school-related factors, as well as the broader
context of culture including the popularity of esports.
1. Introduction
In the past 60 years, videogame playing has gone from a leisure activity
pursued by a narrow group of young males to one of the most
popular hobbies across gender and age groups [1]. Although for most
individuals gaming is a recreational activity or even a passion, a small
group of gamers experiences negative symptoms which impact their
mental and physical health and cause functional impairment [2]. To
stimulate research in the field and help develop efficient prevention and
treatment measures, the World Health Organization formally recognized
gaming disorder (GD) by including it in the International Classification
of Diseases 11th Revision [ICD-11]. According to the ICD-11 [3] GD is a
“persistent or recurrent gaming behaviour, which results in marked distress or
significant impairment in personal, family, social, educational, occupational,
or other important areas of functioning”.
It is also worth to be noted that videogame playing is not the only
activity which may cause severe harm for the individuals. Other common
activities such as gambling, exercise, work, and internet use can
also become unhealthy activities that take over individuals’ lives [e.g.,
[4–6]] resulting in ‘behavioural addictions’ [7]. While there is an
ongoing debate whether other problematic behaviours such as the
problematic engagement in pornography, social media use, and buying/
shopping should be defined as mental health disorders or not [8–10], the
inclusion of GD in the ICD-11 is the result of a fairly broad expert
consensus [11].
One of the most important research topics in the field of GD is its
aetiology. To prevent and treat the problem effectively, it is of key
importance to have robust empirical knowledge concerning the course
of its development. Similar to other addictions, it is the interactive cooccurrence
of three factors, which in some cases leads to GD. These
three factors are (i) the gaming-related factors (i.e., structural characteristics),
(ii) the individual factors (i.e., person-based characteristics),
and (iii) the environmental factors (i.e., situational characteristics) [12].
None of these alone are sufficient to cause a disordered state, only
specific patterns of their co-occurrence. For instance, individuals with
low self-esteem may chase in-game success and high status to feel better
about themselves which may lead to disordered gaming [13], while
players with impulse control problems may be especially susceptible to
gambling-like mechanisms built in videogames and may end up
spending large amounts of money through microtransactions [14].
In the case of substance use disorders, Khantzian [15] argued that
drug addicts select their main substance in a way that its psychopharmacological
effect matches the type of pain that dominates their lives
(e.g., heroin and other opiates have their appeal because of their strong
* Corresponding author at: Institute of Psychology, ELTE E¨otv¨os Lor´and University, Izabella utca 46, Budapest 1064, Hungary.
E-mail address: kiraly.orsolya@ppk.elte.hu (O. Kir´aly).
Contents lists available at ScienceDirect
Comprehensive Psychiatry
journal homepage: www.elsevier.com/locate/comppsych
https://doi.org/10.1016/j.comppsych.2023.152376
Received 29 September 2022; Received in revised form 30 January 2023; Accepted 31 January 2023
Comprehensive Psychiatry 122 (2023) 152376
2
muting action on emotions such as rage and aggression). It was also
suggested that this may be similar for behavioural addictions, namely
that activities (e.g., pornography use, gambling, social media use,
shopping) are purposely chosen and adjusted to personal vulnerabilities
[16]. This may even be the case for gaming. Specific videogames or
game genres may be preferred to cope with specific pathologies. However,
this assumption needs to be investigated in future studies.
While there are reviews discussing specific topics of GD aetiology
such as the role of structural game characteristics [17], personality traits
[18], depression and depressive symptoms [19], gaming motivations
[20], and gender [21], comprehensive reviews are lacking. Therefore,
the goal of the present paper is to provide a broad overview by discussing
in detail the three factors that can influence GD, namely the
gaming-related factors, the individual factors, and the environmental
factors. By doing so, this will provide a general picture of the current
state of aetiological research regarding GD, its most important findings,
and main directions for future research.
2. Gaming-related factors
Videogames are the products of a profit-oriented and continuously
growing industry. To maximize their revenue, companies aim to create
games that are engaging and keep as many players as possible for long
periods. To secure continuous play, developers use game design elements
based on psychological mechanisms such as operant conditioning
that foster player engagement on a long-term basis [22]. Consequently,
videogames are highly rewarding experiences and as such they have a
significant addictive potential [23]. This does not mean that videogames
alone can make specific individuals addicted, as the media-induced
moral panic suggests [24], but it means that videogames have several
structural characteristics that make them “addictive” in a way that
vulnerable individuals may develop GD [25]. In the following sections,
we discuss some of the most important game-related factors (e.g.,
structural characteristics, game design elements, monetization techniques),
which increase player involvement.
2.1. Online vs. offline games
The aim of differentiating online and offline games is to divide games
based on their social aspects, since online games often (although not
always) permit playing together with others, while offline games (in
general) do not. Research has consistently found that GD is more prevalent
among online game players than players of offline games [26–29].
However, offline games have also been linked to GD [30,31]. Given that
loneliness, social anxiety, lower social competence, and low self-esteem
are associated with the risk of GD [32–34], the most plausible explanation
is that online multiplayer games provide safe environments, in
which players can fulfil their social needs [35], while remaining invisible
and anonymous, decreasing their anxiety from face-to-face interactions
in this way [34,36]. Therefore, players with psychosocial
vulnerabilities tend to have a preference for online social interactions
compared with traditional face-to-face social activities because they feel
more socially competent and efficacious in these virtual environments
[37] and therefore, seem particularly susceptible to problematic
engagement with multiplayer online games involving social interaction
[27].
2.2. Game genres, structural characteristics, and game design elements
Videogames can be classified into different genres such as shooter,
strategy, role-playing, multiplayer online battle arena (MOBA) games,
etc. although there are many different game genre classifications. There
are many genres and there is much overlap between them. Moreover, a
great number of games belong to simultaneous genres and due to the
increasingly advanced technological development in the videogame
industry, new game genres are continuously appearing, often from the
fusion of existing ones. Development and change are fast. Moreover,
new and popular genres sometimes emerge so suddenly that research
struggles to keep pace with them. Consequently, some research findings
regarding game genres may even be outdated by the time of their publication.
Nevertheless, there are several genres and standalone games
that have maintained their popularity and some of these genres have
higher addictive potential than others, according to the literature.
Massively multiplayer online role-playing games (MMORPGs) are by
far the most researched game type genre and the one that was consistently
found as being associated with problematic gaming alongside
first-person/third person shooter (FPS/TPS) games, real-time strategy
(RTS) games, and multiplayer online battle arena (MOBA) games
[17,38]. MMORPGs are immersive 3D virtual environments (often fantasy
or science-fiction-themed worlds) that enable a considerable
number of users to interact with each another via the internet, and
which are permanent. This means that the world continues to exist and
evolve while users are away from the game. The player takes the role of a
character and competes and cooperates with other players in real-time
to advance in the game by completing quests and achieving different
goals. FPS games are centred on gun-based and other weapon-based
combat in a first-person perspective and are usually match-based
games, where players cooperate with members of their team and
compete with other teams in real time in virtual environments. RTS
games require commanding large medieval, fantasy or sci-fi-themed
armies and often include military base or settlement creation and
resource management. Lastly, MOBAs, similar to shooter games, are
match-based, where two teams compete with each other, demand high
cooperativeness. The players usually use spells and skills to combat each
other and during the course of the game, they can purchase special
equipment to enhance and personalize their fighting style.
These genres include a combination of structural characteristics that
makes them particularly appealing to players. Structural characteristics
refer to those features of videogames that may facilitate initiation,
development, and maintenance of playing over time and include specificities
such as the permanent nature of the game world, the advancement
and complex reinforcement systems and/or the social interactions
aspects [17,39,40]. MMORPGs are particularly successful at inducing
operant conditioning via intermittent reinforcement, meaning that rewards
are not administered every time the desired response is performed
[22], or players keep getting worthless virtual items before a big reward
is provided at an unpredictable moment. These virtual rewards release
dopamine in the brain [41] facilitating a euphoric state among players,
and the variable-ratio reinforcement schedules keep players coming
back in the hope of repeating such states and feelings. The social interactions
aspect in these game genres is also very effective. In
MMORPGs, players join big groups called guilds to achieve in-game
goals, and form meaningful and deep relationships with fellow players
while playing [42]. In FPS games, players often play in permanent teams
in tight cooperation with others improving their skills both individually
and as a team. Moreover, character customizations in videogames provide
a way to create unique virtual avatars that can be experienced as
extensions of the self, which through identification can be used to reduce
self-discrepancy between the real and ideal self. This compensatory
mechanic is a tool for videogame users with higher body dissatisfaction
to boost their self-esteem and fulfil their social needs without the
emergence of social anxiety [43]. Such structural characteristics increase
involvement and may contribute to the development of GD in the
case of psychologically vulnerable players [22].
Finally, it should also be noted that several game genres (especially
MOBA games and the ‘Battle Royale’ genre) have recently become
extremely popular and although these have not yet been extensively
studied, there is a high probability that these also have high addictive
potential due to a good combination of structural features they include
[44,45].
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2.3. Monetization techniques
The videogame industry has undergone a marked growth since its
foundation becoming a multi-billion-dollar global industry. Several innovations
have fuelled this growth. Perhaps the biggest one was the
integration of internet technology in videogames resulting in the
appearance of multiplayer online games, which permit large numbers of
individuals from all over the world playing together in the same virtual
space. Two other important innovations from an economic point were (i)
increasing smartphone use and their use as the most accessible gaming
platform, and (ii) the introduction of digital purchase options in games.
Free-to-play gaming has quickly become one of the most widespread
business models [46] in which revenues are secured from microtransactions
(i.e., the purchase of additional game content in the form of
virtual items such as textures/skins, weapons, currency, or levels). King
and Delfabbro [47] argue that some of the monetization practices often
used in the free-to-play business model can be considered “predatory”
because “they involve in-game purchasing systems that disguise or withhold
the true long-term cost of the activity until players are already financially and
psychologically committed.”
Perhaps the most relevant and highly debated monetization scheme
to date is the “loot box”. This refers to an in-game reward system, a
consumable virtual item usually in the form of a box or crate that can be
purchased for real-world money (through microtransactions), which
provides players with randomized rewards of unclear value. The psychological
mechanism underlying microtransactions is linked to the socalled
“sunk-cost effect”. The sunk-cost refers to the tendency to
continue a behaviour because investments in money, effort or time have
been made previously [48]. Thereby, if players have already spent
money on loot boxes and did not get what they wished for, they are more
likely to make further purchases to get the desired item(s). Occasionally
receiving the rare, high-quality rewards they wished for acts as an
intermittent reinforcement, meaning that the players get strongly reinforced
to continue buying loot boxes for other valuable rewards.
Furthermore, free loot boxes are usually provided at the beginning of
games to get players familiar with the experience. Moreover, research
shows that dopamine is released when anticipating a reward, not only
when actually getting it [49]. More specifically, in the case of loot boxes,
it is assumed that the brain is already flushed with “joy hormones” at the
moment of opening the loot box irrespective of its content [50].
Similarities between loot boxes and slot machines have raised severe
concerns, especially because unlike most slot machines, loot boxes are
available to children and adolescents and they may provide a gateway to
gambling [51,52]. While some studies indicate that microtransaction
spending in general is related to problematic gambling severity [53], the
findings concerning the relationship between loot box expenditure and
problematic gambling [51,54–56] and excessive gaming [57] are much
more consistent [58]. Based upon these findings it can be concluded that
individuals who spend a lot of money on loot boxes, often called
“whales” [46] are not wealthy gamers but more likely to be problematic
users [59]. Consequently, it seems that gaming companies (unintendedly
or not) are disproportionately profiting from vulnerable individuals
(i.e., problem gamblers), rather than high-income customers,
which has implications for harm reduction and policy debates regarding
loot boxes and other monetization techniques in videogames [59]. In
addition to the problems caused by loot box consumption, many sites
allow the use of virtual skins (i.e., a graphic download which changes
the appearance of in-game items or characters) in gambling activity,
further raising the risk of problematic gambling [60]. Various countries
are considering regulating loot boxes after Belgium banned them in
2018 [61]. Nevertheless, besides regulation, screening and public education
concerning the risks should be implemented to mitigate harm
[62].
Another predatory monetization technique worth mentioning is the
personalization of offers and pricing. Companies use in-game behaviour
tracking to collect data about players, their playing, and spending habits
[63]. Based on these data, they carry out behavioural and psychological
profiling and use these profiles to tailor offers and even pricing to individual
players [see patents no. US9138639B1 and US9623335B1 in
63]. More specifically, this means that the same virtual item with production
costs close to zero may be offered and bought for different prices
by different players. Furthermore, games may use pressuring tactics to
encourage spending. One such technique is the use of “limited time offers”,
which influences players to purchase items by creating artificial
scarcity and making them believe that the opportunity will never be
available again. Another pressuring tactic was patented by Activision
Publishing Inc. in 2015 (Patent no. US20160005270A1). According to the
patent, the system identifies an in-game item (e.g., weapon, armour)
that may be relevant for a novice player, then it identifies an experienced
player owning such an item, and matches the two players (i.e.,
places them in the same match), so that the novice player sees how
good/efficient that particular item is and therefore, they are encouraged
to buy it to increase their chances of winning in the subsequent matches
[63].
Based on the aforementioned literature, it can be claimed that videogames
have a high addictive potential and together with other factors
(i.e., environmental, and individual) can contribute to the emergence,
development, and maintenance of GD. Consequently, it is crucial for
research to be constantly updated to understand newer genres, game
design elements, and monetization techniques. Only this way it can
provide policymakers the necessary information to make effective policies
for prevention and harm-reduction.
3. Individual factors
In addition to gaming-related factors and environmental factors,
individual factors play a key role in the aetiology of GD. These include
demographic risk factors, personality traits, motivational factors, comorbid
psychopathology, genetic predisposition, and neurobiological
processes. Ultimately, it is always the players and their individual vulnerabilities,
which determine whether videogame playing remains a
healthy passion or develops into a pathology.
3.1. Demographic risk factors
According to two recent meta-analyses involving tens of thousands of
individuals from a large number of geographic regions, males are more
likely to exhibit GD symptoms than females across all age groups with a
2.5:1 rate or with a moderate effect size, respectively [21,64]. Similarly,
Pontes and colleagues [65] found higher rates of problematic users
among males in a large-scale worldwide study of gamers interested in
esports. A plausible explanation for more GD symptoms among male
players is their greater interest in videogames, which may be explained
from an evolutionary perspective. More specifically, aggressiveness and
inclination to fight is a masculine trait in most cultures and even though
videogames are becoming more diverse, competition is still their major
design element and therefore, they are more attractive to males than
females. Accordingly, the gaming industry identifies males as their main
target group, and keeps designing games for them, which further reinforces
male dominance among videogame users [66-]. In addition,
differences have been found in neural activation to gaming cues between
the two genders, with males demonstrating higher cue-elicited cravingrelated
neural responses [67,68], which indicates that different
processes may be responsible for the emergence of GD among males and
females.
Younger participants (especially adolescents) have reported higher
prevalence rates of GD [64]. On the one hand, a higher proportion of
younger individuals play videogames [1] and are also more motivated to
play videogames than older individuals [69]. On the other hand, transitional
traits such as impaired impulse control and novelty seeking,
which are key risk factors for addictions including GD [70,71], characterize
adolescents due to maturational changes in specific brain
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Comprehensive Psychiatry 122 (2023) 152376
4
regions characteristic to this age group [72].
The role of ethnicity is an understudied topic [73] and the few
studies reporting such results are contradictory. For instance, Desai [74]
reported that white boys in Connecticut had lower rates of GD symptoms
than non-whites and Asian boys. Wittek et al. [75] reported that respondents
living in Norway but born in Asia, Africa, Central America or
South America were more likely to exhibit GD symptoms compared to
those born in Norway. On the contrary, Gentile [76] found no significant
differences according to the ethnicity of adolescents. Although race and
ethnicity might have some importance regarding the aetiology of GD, it
is very difficult to study it due to its different meaning in each culture
and its strong relationship with several other relevant factors such as the
socio-economic and migration status. Furthermore, findings regarding
socio-economic variables are also inconsistent. A number of studies did
not find any significant associations between education level, employment,
marital status, income and GD symptoms [75,77,78], while others
have reported lower prevalence rates for those who are better educated,
employed, and married (e.g., [79,80] and a negative association with
income [81]. One longitudinal study examined the association with
parental education and family income with 6- and 12-month follow-up
periods [82], only found significant predictive effect of higher family
income at 6-month follow-up. Inconsistent findings indicate that further
studies are required, and possible cultural differences may also be
present.
3.2. Personality traits
A fairly large number of research studies have examined the association
between GD symptoms and the so-called “Big Five personality
traits” based on the Five-Factor Model [83]. To synthetize all available
findings of the relationship between GD and Big Five personality traits,
two meta-analyses have been carried out [18,84], demonstrating
negative association with extraversion, conscientiousness and agreeableness
and positive association with neuroticism. A plausible explanation
for the association between GD symptoms and neuroticism is that
neurotic individuals are prone to anxiety, depression, and stress and may
use virtual game worlds as an escape because they perceive these digital
environments as more controllable and safer than their everyday lives.
However, if they keep escaping in games to avoid negative affective
states, gaming might become problematic [75,85]. Individuals scoring
low on conscientiousness have difficulties with being dutiful and selfdisciplined,
tend to be unstructured and less persistent in pursuing
their goals and may therefore find games attractive due to the clear rules
and constant positive reinforcement [75,85]. Turning to games to satisfy
their need for structure and being easily rewarded may also lead to a
greater risk of developing GD. Extraversion may be negatively associated
with GD symptoms because videogames provide various non-social
opportunities for entertainment, while the negative association with
agreeableness may be due to the conflict-avoidance of highly agreeable
individuals because playing videogames online can involve stressful
social situations and problematic videogame use can also cause interpersonal
conflicts during everyday life [84].
Among personality factors, impulsivity stands out due to its relation
with addictive behaviours in general [86]. Survey studies examining
large-scale adolescent and gamer samples, as well as treatment seeking
clinical samples reported a significant association between trait impulsivity
and GD symptoms [32,87–89]. Furthermore, studies with experimental
design have also found significant associations between
experimental impulsivity-related measures (e.g., go/no-go task,
impaired ability to postpone rewards) and GD symptoms [90,91]. A
study combining survey and experimental assessment in a longitudinal
setting found that more GD symptoms at T1 predicted more impulsive
decision-making at T2 with a moderate effect size. Moreover, a lower
inhibitory control at T2 predicted more time spent on gaming at T3 with
a weak effect size [92]. Other associations were not reported. These
results suggest that impulsivity may not only be a predisposing risk
factor for GD, but the disorder once developed may also further decrease
the decision-making abilities of individuals due to a general overvaluation
of immediate rewards and/or a reduced valuation of longterm
rewards. Finally and relatedly, attention-deficit hyperactivity disorder
(ADHD) has also been reported as an important comorbid disorder
with GD [e.g., [93]] and impulsivity is assumed to be a common
explanatory factor for both disorders [94,95].
The association between GD and other personality traits has also
examined in numerous studies. For example, sensation seeking has been
positively associated with GD symptoms in some studies, while other
studies reported no significant association [96]. It is plausible to think
that seeking novel stimuli through videogame adventures and challenges
can drive individuals to be addicted to such games. Additionally,
narcissism was also found to be positively related to GD symptoms in
several studies [96], which may be due to the reinforcing nature of
several online games, where social status can be achieved through
videogame-related achievements.
3.3. Individual vulnerabilities
Research suggests that similar to other addictions, comorbidity is the
norm rather than the exception in the case of gaming disorder [97].
Among psychopathological conditions, depression and depression
symptoms, as well as generalized anxiety disorder and anxiety symptoms
have been consistently related to GD [19,98,99]. Effect sizes reported
vary between weak and moderate. Players experiencing
depression and anxiety symptoms may be prone to escape into videogames
to avoid facing everyday difficulties and negative affective states
[98,100]. Gaming in such cases serves as a form of distraction (instead of
a real solution to problems) and may lead to disordered gaming, which
in turn may further increase psychopathological symptoms due to
impaired functioning, decreased performance, and social isolation [32].
Relatedly, another severe concern regarding GD and comorbid depression
is the heightened risk for suicidal ideation [101,102]. In addition,
comorbid polysubstance use and substance misuse have also been reported
in the case of GD [103–105].
Another comorbid condition thoroughly studied is ADHD. According
to a recent meta-analysis [106], both symptoms of inattention and hyperactivity,
as well as the combined ADHD symptoms were moderately
associated with GD. Several factors may contribute to the development
of GD among individuals experiencing ADHD symptoms such as
impaired social and affective functioning and/or impulsivity [106].
Furthermore, videogame players with autism spectrum disorder are also
more likely to show GD symptoms with varying effect sizes [107,108].
Proposed explanations are similar to those provided in the case of
ADHD. Both disorders involve impulse control and response inhibition
deficits, which may lead to the development of GD [109]. Given the
preponderance of cross-sectional design in the studies examining comorbidity
of GD, the direction of the associations is uncertain. Longitudinal
studies are much needed. However, most likely the association is
reciprocal.
In addition to psychopathology, there are many other individual
vulnerabilities. Among these, self-esteem and social competencies are of
particular importance. Low self-esteem has been reported as a risk factor
in developing GD symptoms in numerous studies [104,110], as are social
anxiety or poor social skills [104,111]. Relatedly, a one-year follow
up study reported the predictive effect of social vulnerability (i.e., a
difficulty in establishing and maintaining close relationships) on GD
symptoms, even in interaction with attention problems [112]. For individuals
with low self-esteem and/or low social competence, gaming
may be an easy and efficient way to compensate for these deficiencies
[113], which in turn heightens the risk to develop GD.
3.4. Motivational factors
A lot of research has examined the role of motives in GD. Several
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5
studies reported moderate to strong associations of escapism (playing
videogames to avoid everyday problems), as well as weak or moderate
associations of achievement-related motives (e.g., advancement,
competition) with GD [114–117]. Furthermore, several studies have
reported a significant and considerable mediation effect of escapism
between different psychiatric symptoms (e.g., depression) and GD
[116–118]. These findings suggest that those who play solely for
entertainment purposes are very unlikely to develop GD. However, those
who have psychiatric difficulties may use gaming as a means to avoid
everyday problems or to compensate for their deficiencies, which appears
to work as a maladaptive coping mechanism and if pursued for
long, it may cause negative (addiction-like) consequences. The same
findings were reported in two recent meta-analyses. In the first, the
strongest positive association was found with escapism, followed by
achievement motivation, while also weak, but positive association was
found with immersion and social motivation [119]. In the other metaanalysis
[120], the association of GD with escapism was also the
strongest, followed by achievement motivation and immersion. Social
motivation was only significantly related to GD when a specific measurement
tool (i.e., the Motives for Online Gaming Questionnaire
[MOGQ; [121]]) was used, but not in case of another popular tool (i.e.,
the Motivations for Play in Online Games Questionnaire [114]). An
additional finding of this meta-analysis was that a positive association
was found in the case of several motivations (introjected regulation,
external regulation, amotivation, autonomy and relatedness) of two selfdetermination
theory based scales [120].
Given that escapism involves diverting attention away from an
emotionally demanding situation, it can be considered a form of
distraction – a strategy of emotion regulation [122]. When facing high
intensity negative emotions, a powerful strategy requiring minimum
effort is to obstruct the information related to the aversive affect, by
distracting attention to neutral stimuli unrelated to the original emotions
[123]. For instance, individuals who have experienced a family
conflict may immerse themselves in videogame playing to divert
attention away from uncomfortable thoughts and feelings. The problem
is that this strategy hinders the elaborated processing of the negative
emotional event [122,123] and therefore, it is expected to be inefficient
in the long run [124]. The gamer may feel relieved while playing.
However, the aversive emotions related to the conflict persist and
reappear as soon as they cease the activity. According to Sheppes and
Gross [122], “distraction can be considered as a ‘bandage’ regulation
strategy that can stop the ‘bleeding’ but not offer actual remedy.” What is
crucial, is how often the individual uses distraction to avoid negative
emotions, and whether this is their only strategy to ease the feelings of
distress. Those individuals who have a rich variety of different emotion
regulation strategies and can use these flexibly according to the circumstances
[125], are unlikely to develop GD. However, this argument
needs further investigation.
The act of seeking in-game achievements is driven by the rewarding
nature of videogames [23] and the process of operant conditioning [22].
Furthermore, these achievements may additionally result in higher
recognition and status within the gaming community [96], which
cannot be achieved by some individuals during their everyday lives.
Finally, social motivation can lead to excessive use through creating an
obligation to play because virtual team membership can be as important
as belonging to any other groups [119]. In addition, videogames can also
serve as safe environments to fulfil social needs [43]. Overall, research
greatly supports the idea that it is not gaming time in itself, which
predicts GD [126], but the way gamers play, their motives, and the
degree they can integrate this leisure time activity in their lives.
Neurobiological processes and genetic predisposition
Research suggests that neural mechanisms underlying GD resemble
those of other addictions such as substance use disorder, alcohol use
disorder, and gambling disorder [127]. More specifically, GD shares
many of the cognitive-affective alterations typical for other addictions
such as impaired decision-making, emotion processing, impulsivity, and
executive functioning related to different functioning in prefrontal areas
and the temporoparietal, frontolimbic and subcortical regions [128].
Besides these functional brain mechanisms, there are also structural
changes associated with GD, mainly reduction in grey-matter volume in
the ventromedial and dorsolateral prefrontal areas, the anterior cingulate
and premotor cortices which are responsible for decision-making,
emotion regulation, and cognitive/motor control [129]. Additionally,
altered white-matter density has been found in several brain regions
involved in behavioural inhibition, decision-making, and emotional
regulation [130].
According to an early experimental study, dopamine is released in
the ventral striatum during videogame play in a similar magnitude to
amphetamine-induced dopamine release [41]. Studies have also reported
alterations in the volume of the ventral striatum, which could
reflect altered reward processing and indicate adaptive neural plasticity
among highly engaged videogame players. Relatedly, research suggests
that GD is associated with dysfunction in the dopaminergic brain systems
and involves changes in loss of control and reward inhibitory
mechanisms [131]. Additional similarities have been found with other
addictions, such as with stronger activation in the dorsolateral prefrontal
cortex (which was associated with higher level of craving) and
different activation of the orbitofrontal cortex (indicating lower level of
punishment sensitivity), when individuals with GD were compared to
controls using functional near-infrared spectroscopy [132]. Finally, according
to comorbidity studies, altered executive control mechanisms in
ADHD may increase the vulnerability to develop GD. Relatedly, research
suggests that patients with GD, ADHD, and major depressive disorder
may share specific characteristics in terms of neurochemical changes in
frontal and temporal cortices [131].
Genetic factors also play an important role in the aetiology of substance
use disorders [133]. Recent genome-wide linkage and association
studies have identified numerous genes in relation to addictive disorders
such as alcohol and tobacco [134]. Given the similar neurobiological
basis of substance use disorders and GD, it is assumed that some individuals
are genetically more vulnerable to develop GD than others.
However, to date, there are few studies investigating this. For instance, a
recent study found an association between the nicotinic acetylcholine
receptor α4 subunit gene (CHRNA4) rs1044396 and GD among Korean
male adults [135]. Another study investigating Korean male adolescents
reported that the polymorphism of the corticotropin-releasing hormone
receptor 1 (CRHR1) gene may play an important role in GD susceptibility
[136]. Therefore, future research, on one hand, should examine
the association of other genes and variants previously linked to addictive
disorders with GD, while on the other hand, it should replicate previous
findings in independent samples, and also try to determine the functional
mechanisms of these genes and variants.
4. Environmental factors
Finally, environmental factors are influences that do not occur from
within the individual but from elsewhere in the environment. Examples
of environmental factors are the family and peers, work and school, and
also the culture in which the gamer lives in. Besides game-related and
individual factors, situational and environmental factors also play an
important role in the aetiology of GD.
4.1. Family factors and early life experiences
As in the case of substance use and other potentially addictive behaviours,
familial influences and early life experiences affect the likelihood
of an individual developing GD. According to a systematic review
of 14 studies examining family factors in adolescent problematic gaming
[137], the majority of studies have focused on parent-child relationships
(e.g., warmth, conflict, abuse) and they reported a negative association
between the quality of relationships and severity of problematic gaming.
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6
Similar findings were reported by studies not included in the review
[28,138]. A more recent systematic review focusing on associated
parental and family factors [139] also reported similar findings. Positive
family functioning, characterized by good parent-child communication,
common social activities, cohesion, connectedness, acceptance, secure
attachment, warmth, and affectivity were protective factors, while poor
family functioning, conflicts, hostility and demanding, authoritarian,
neglectful or permissive parenting style were risk factors for problematic
gaming. More recent findings confirmed that in addition to the low
quality parent-child relationship, lack of monitoring, and violent disciplining
have deleterious effect [140].
Moreover, studies suggest the mediating effect of specific variables.
For instance, it has been found that core-self evaluations mediate the
effect of parental rejection on GD [141]. Another study reported that the
relationships between attachment styles (anxious and avoidant) and GD
were fully mediated by stressful events [142]. Furthermore, the
importance of father-child relationship as a possible protective factor for
problematic gaming has also been noted in several studies
[137,141,143].
A two-wave longitudinal study [144] examining a sample of German
students from Grades 4 to 9 (N = 406) found that 15-year-old adolescents’
problematic gaming have already shown several risk factors at the
age of 10 years. One important risk-factor was growing up in a singleparent
family, in agreement with the results of other studies
[137,145]. The effect stayed stable with time even when controlling for
parental devotion and supervision, which suggests that the risk is not
due to a lack of parental care in single-parent families but the insufficient
time and fewer resources to provide alternative leisure time activities
for the children in a balanced way. A 12-month prospective study
among 9–10-year-old children [146] showed that earlier parental
marital conflict directly predicted GD symptoms at follow-up. Additionally,
an indirect path was also identified. More specifically, parental
marital conflict influenced GD severity of children one year later via
poor father-child attachment and impaired self-esteem. Another longitudinal
study found that parental involvement can attenuate the harmful
effect of bullying on GD severity by preventing the development of
present-oriented consideration of future consequences and promoting
the development of future-orientation [147].
Review findings suggest that parental monitoring and regulation of
the gaming behaviour are effective strategies for GD prevention [148].
Parents who regulate their children’s gaming are also more likely to help
them find and practice alternative leisure time activities [149], which is
crucial in maintaining a healthy balance and is recommended as a
prevention strategy [149,150]. Another risk factor for the onset and
maintenance of GD is childhood maltreatment [e.g., [139,151,152]],
which refers to emotional, sexual, or physical abuse and physical or
emotional neglect. In the case of maltreatment, parents or caregivers
who fail to satisfy the basic physical and psychological needs of their
children (e.g., nurturing, belonging), may produce severe and longlasting
negative consequences like feelings of guilt and shame, poor
self-esteem, psychological functioning and social relationships [148].
These children may use videogame playing to compensate for their
unmet needs (e.g., achievement, relatedness) or cope with psychological
symptoms like depression or anxiety [113].
Another relevant aspect is the ownership of gaming equipment (e.g.,
personal computer, videogame consoles) and its availability in adolescents’
rooms. Both adolescents’ access to their own gaming devices, as
well as gaming in their bedrooms have been linked to increased hours of
gaming [153] and to problematic gaming [144]. However, when other
factors (i.e., media usage and school-related variables) were included in
the model in a longitudinal design, having gaming consoles in the
children’s rooms at age 10 years no longer predicted problematic use
five years later [144]. This suggests that seemingly simple preventive
solutions such as banning gaming devices from children’s rooms are not
enough in themselves. Most probably, reasons underlying the development
of GD are of a fundamental nature, related mostly to the
personality and motives of the players. Nevertheless, keeping gaming
devices in the shared spaces to ease monitoring may be a useful
recommendation [149].
Findings regarding the familial influences emphasize the importance
to involve families in the intervention programs targeting adolescents
with GD. The efficacy of interventions involving families is less
researched than interventions focusing on the individuals but there are
some successful outcomes. A study by Liu et al. [154] assessed the efficacy
of the multi-family group therapy (i.e., a combination of family
and group psychotherapy in which several families meet in the presence
of therapists) to reduce problematic internet use among adolescents.
According to the findings, the therapy was highly successful, mostly due
to the improvement of the adolescents’ satisfaction of their psychological
needs and parent-child communication and closeness. A family
approach to GD prevention and treatment recognizes the importance of
dysfunctional family dynamics, an aspect also emphasized in the case of
substance use disorders [155]. Relatedly, prevention programs which
focus only on adolescents may be perceived as blaming by the target
group and fail to address family-related issues, which may be one of the
main reasons for using games excessively and problematically [137].
Consequently, prevention programs should also target parents and
caregivers to reduce possible negative attitudes, unreasonable expectations,
and criticism towards adolescents’ videogame use.
4.2. Peers and school-related factors
Relationships with peers and the school environment are also crucial
environmental factors in the aetiology of GD. Social integration in one’s
environment and peer group is of special importance for adolescents,
who are in the life stage of identity formation and individuation from the
family of origin [156]. Research shows that self-reported well-being at
school, as well as social integration in class are protective factors [144]
and these results are in agreement with other studies reporting a relationship
between poor social skills and problematic gaming
[32,157,158]. Furthermore, according to a systematic review [159], GD
symptoms among adolescents were correlated with problems with peers
(both being bullied and bullying others), having friends whose gaming
was also problematic, having low educational and career achievements
(skipping school classes, truancy, and having low school grades), and
having poor social skills, low competence, and a low level of integration.
These findings were supported by a recently published meta-analysis
[160], showing that interpersonal problems, bullying perpetration,
and victimization are all important risk factors for GD. Additionally, the
importance of peer relationships were reported in a one-year longitudinal
study [161], where the possible bidirectional effect of perceived
parent-adolescent and peer attachment were tested. In this study, father
or mother attachment did not predict GD at the follow-up, while peer
attachment had a bi-directional association with GD.
Findings suggest that children and adolescents who have difficulties
with making friends and who reported low levels of school-related wellbeing
may use gaming as a compensation. The invisibility, anonymity,
and equal/fair chances provided by virtual game worlds may be very
tempting for children who are otherwise excluded and harassed by their
peers because they can experience self-efficacy while playing and feel
recognized by fellow gamers [144]. However, such a compensation
might increase the risk of long-term psychological consequences
(including the risk for GD) because real life difficulties and failures are
not addressed but avoided [113].
In addition to peers, teachers also play an important role in adolescents’
lives, psychosocial well-being, and identity formation. One
important responsibility of teachers is to provide autonomy support for
children, which refers to the extent to which students feel that their
teachers offer opportunities for choice and decision-making regarding
learning and classroom life (e.g., teachers ask their students what they
want to learn about). According to a longitudinal study conducted
among Chinese students [162], teacher autonomy support perceived in
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7
7th grade increased basic psychological needs satisfaction (i.e., the need
for competence, autonomy, and relatedness) in the 8th grade, which in
turn increased school engagement (i.e., behavioural, emotional, and
cognitive engagement) in 9th grade, which ultimately decreased problematic
gaming in 9th grade. Additionally, teacher autonomy support in
7th grade had a direct effect on school engagement two years later,
which in turn decreased problematic online gaming. These findings
suggest that teacher autonomy support is also an important protective
factor for the risk of adolescent GD, and school engagement and basic
psychological needs satisfaction are important mediators in this
association.
4.3. The broader context of culture
Research shows that GD is a global concern. Indeed, research related
to GD has been carried out worldwide [163] (although there is a lack of
research conducted in Africa, the continent with the lowest internet
penetration rate, with the exception of few epidemiological studies
[164]). In the meta-analysis by Stevens et al. [64], higher pooled
prevalence rate was found for the prevalence of gaming disorder in
Asian countries (5.08%) compared to Europe (2.72%). Cultural differences
appear to determine the prevalence rates of GD, but mainly not
affecting the gender ratio of GD, as it seems to be maledominated in
almost all countries, with the exception of India, where more females
were reported as experiencing GD symptoms [21]. Furthermore, according
to a meta-analysis of 84 independent samples comprising almost
60,000 participants from 20 countries and seven geographic regions, the
associations between GD symptoms and psychological problems were
moderately strong across the countries suggesting the universality of
this association [163]. In line with this finding, a cross-cultural study of
gamers from ten cultures (from Europe, Iran, Peru and Korea) found
similar patterns of associations between variables such as GD, psychiatric
symptoms, gaming motives, and gaming time across cultures
[165,166].
Nevertheless, even if the disorder is a global phenomenon and some
of the major links of it appear to be global, culture most certainly plays
an important role in the emergence, development, and maintenance of
the disorder, as well as in the efficiency of prevention and treatment
practices. For instance, Asian and Western cultures tend to view and
address GD differently. While the former considers it a major public
health threat, the latter are far less coercive. This disparity has deep
cultural roots. In Asian countries, there is a particularly strong pressure
on children and adolescents regarding academic performance because
competition in employment is high. Given that videogame playing is an
immersive and time-consuming leisure time activity, parents, educators,
and policymakers view gaming as a severe threat for academic performance
and as therefore, a dangerous activity, which may undermine an
individual’s career chances. In contrast, in Western cultures, academic
pressure is less severe and therefore, gaming is not concerned as a public
“enemy”, but as a common hobby. Accordingly, in Asian countries,
several policy actions have been taken at governmental level, which
mostly target adolescents regardless of their degree of problematic
involvement and usually aim to decrease time spent on gaming [167].
Moreover, there are numerous state-financed treatment centres across
Asia. In Western countries, on the other hand, the problem is mostly
addressed by the private sector, which provides expensive treatment
programs for those who can afford them [23].
Some papers (seemingly using the same dataset) examined the
assumed moderating role of vertical individualism (one type of cultural
orientation which refers to the acceptance of social inequality as a byproduct
of perceived hierarchical structures within a society), on the
association between GD symptoms and comorbid stress, inattention, and
depression symptoms, respectively, in a sample of massively multiplayer
online (MMO) game players mostly from the US and Australia
[168–170]. Results showed that gamers with a more vertically individualistic
cultural orientation had stronger links between GD symptoms
and comorbid stress, inattention, and depression symptoms, respectively,
than gamers, who reported lower vertical individualism scores. A
plausible explanation may be that more vertical individualism stresses
competition and achievement as the measure of personal value, and
therefore such individuals are more disposed to engage excessively in
MMO games which offer the opportunity to gain recognition among
peers by being a successful gamer. These players may use videogames as
a means to cope with their comorbid stress, inattention, and depression
symptoms, which in turn may increase the risk of problematic use [e.g.,
116]. Furthermore, in a large European study [171], the protective effect
of social policies (i.e., benefits for families and children such as child
payments, allowances and parental leave payments) were found, while
economic inequality was a risk factor for GD at the cross-national level.
To gain insight in the role of sociocultural factors on the empirical
applicability of different hypotheses derived from three major theoretical
perspectives on GD, Cheng et al. [163] performed a meta-analysis of
20 countries from seven geographic regions. Based on the literature, the
authors claimed that GD has been defined by researchers in three
different ways. According to the comorbidity hypothesis, GD is a pathology,
which co-occurs with psychological problems and poor psychological
well-being. According to the interpersonal impairment
hypothesis, GD is a maladaptive coping with interpersonal problems
rather than a pathology per se. Finally, the dilution effect hypothesis
states that GD is a deficient self-regulation with the underlying motive to
restore psychological and social well-being. As aforementioned, the results
of the meta-analysis provided some support for the globality of the
comorbidity hypothesis because moderately strong positive associations
between GD symptoms and psychological problems were found across
countries. However, the other two hypotheses appear to be impacted by
cultural factors differently. The interpersonal impairment hypothesis
was more defensible in countries lower in power distance (democratic
countries) than in countries with higher acceptance of status differences
and stronger social hierarchy. The dilution effect hypothesis, on the
other hand, was more sustainable in countries higher in national life
satisfaction and lower in cultural masculinity (i.e., the extent to which
members of a society embrace success and achievement as key values).
4.4. International growth of esports
Finally, the phenomenon and fast increasing popularity of esports
needs to be mentioned. Esports is an abbreviation of ‘electronic sports’
and refers to the professional competitive videogame playing where
teams or individuals compete against each other [172]. Esports started
to gain popularity in the 2000s and has skyrocketed since then with an
estimated audience of 532 million individuals in 2022. Revenues in the
esports sector globally were estimated to $1.38 billion (US) in 2022.
However, this immense popularity is not unified, and varies across regions.
Asia, and especially China, has the most esports players and
viewers, and the hype surrounding the esports phenomenon is also the
highest in this part of the world [173]. Although information regarding
the impact of esports on GD is scarce, Chung et al. [174] argued that the
further promotion of videogame playing under the umbrella of esports
would likely increase the prevalence of hazardous gaming and GD.
Indeed, an environment, in which electronic sports is a national sport
and esports players are highly paid celebrities, may further increase
youth’s interest in gaming, both as a leisure time activity and as a career
opportunity [175]. Montag and colleagues [176] investigated this and
found that professional gamers as well as videogame users with the
intention to become esports players reported slightly higher level of GD
severity and also higher levels of gaming motives then non-professional
gamers without a plan to become one. Thereby attention should be paid
to children and adolescents pursuing esports career to prevent possible
future impairment.
To sum up, there is evidence that culture plays a role in the aetiology
and maintenance of the disorder and may also influence the efficiency of
prevention and intervention practices. While GD is a global concern with
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8
seemingly global symptoms, its manifestation, evaluation, and management
vary across cultures. Therefore, it is essential for prevention
and treatment programs to be adjusted to local circumstances to maximize
efficiency. Nevertheless, more research is needed in this area, both
regarding general cultural aspects and regarding the impact of esports.
5. Future research directions
Based on the gaps identified in the present review, future studies
should focus on specific aspects of aetiology. For instance, there is a
great need for studies exploring structural game characteristics and
monetization techniques because videogames are continually changing
and advancing using newer behavioural mechanics that appear to
manipulate gamers to play more and spend more. Relatedly, neurobiological
processes associated with these seemingly manipulative techniques
should also be further investigated alongside other individual
factors such as genetic predisposition, motivational factors, and comorbid
psychopathology. The latter is crucial in terms of treatment
because comorbid disorders can significantly hinder recovery if not
treated in parallel. In addition, cultural aspects such as the parental
attitude towards gaming as a hobby, the esports environment, and local
policy measures are all important aspects which influence the aetiology
of GD and need to be further examined empirically.
Moreover, future research needs to explore the specific interactions
between the three aetiological factors outlined in the present review. It
is plausible to assume that there are particular interactional profiles
which need specific types of prevention and treatment. This is in line
with Ko et al.’s [177] clinical observations who argued that there are
common types of GD patients, such as male patients with ADHD, patients
with dysphoria and dysfunctional coping skills, or isolated patients
with social anxiety. Future studies should be conducted to explore
such profiles to help develop personalized treatment protocols.
6. Conclusion
Three interrelated factors play a role in the development and maintenance
of gaming disorder: gaming-related factors, individual factors,
and environmental factors. Videogames are designed in a way to
maximize player engagement by involving numerous psychological
mechanisms such as operant conditioning. Individual factors play a
crucial role in the development and maintenance of gaming disorder
through the individual’s psychological and neurobiological vulnerabilities.
Last, environmental factors such as the family or even the broader
cultural environment heavily influence how individuals play and
whether gaming may become problematic. Consequently, prevention
and intervention of gaming disorder at both the community level and the
individual level require multi-professional action (e.g., from caregivers,
educators, researchers, therapists, policymakers) due to its multifactorial
nature regarding aetiology.
Funding sources and acknowledgements
ZD’s contribution was supported by the Hungarian National
Research, Development and Innovation Office (KKP126835; K128614;
FK134807). OK was supported by the J´anos Bolyai Research Scholarship
of the Hungarian Academy of Sciences.
Conflict of interest declaration
MDG has received research funding from Norsk Tipping (the gambling
operator owned by the Norwegian government). MDG has received
funding for a number of research projects in the area of gambling education
for young people, social responsibility in gambling and gambling
treatment from Gamble Aware (formerly the Responsibility in Gambling
Trust), a charitable body which funds its research program based on
donations from the gambling industry. MDG undertakes consultancy for
various gambling companies in the area of social responsibility in
gambling. The University of Gibraltar receives funding from the
Gibraltar Gambling Care Foundation, an independent, not-for-profit
charity.
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