Volume 4, Issue 1. Special Collection: Behavioral Addiction to Technology. DOI: 10.1037/tmb0000101
Gaming disorder (GD) has gained tremendous attention in the past 2 decades. Although the 11th revision of the International Classification of Diseases accepted GD as a formal diagnosis in 2018, debate continues about whether this condition constitutes an independent psychiatric disorder. Many scholars observed that we lack reliable information regarding the natural history of GD. Quantitative studies have identified many risk factors related to GD, but those risk factors were rarely connected, provided with context, or mapped into a coherent big picture to explain GD’s pathway and development process. This qualitative study aims to fill the gap by clarifying GD’s course of development in 15 patients. To do so, it adopts a qualitative, longitudinal, and retrospective approach that is based on the life histories and narratives of individuals with GD. Individual in-depth interviews were conducted with 15 young adult participants who were attending a residential, outpatient program specializing in GD treatment. Each interview lasted approximately 2.5 hr and was audio-recorded with the participant’s permission and informed consent. Four categories of research questions that targeted participants’ life stories—specifically how gaming addiction entered and manifested in their lives—guided the interviews and generated follow-up questions during each interview, using a theoretical sampling strategy. Recordings were transcribed, then subthemes and themes were identified, constructed, and organized based on a grounded theory, thematic analysis method. Results revealed 12 subthemes, which can be sequentially and suitably placed into three developmental stages. These stages provide a clearer understanding of how gaming behaviors progress from normal into pathological. Implications for prevention and treatment are discussed.
Keywords: gaming disorder, developmental stages, social vulnerability, co-occurring disorder, self-efficacy
Data Availability: The authors have not made the data publicly available as the data were verbatims transcribed from audio-recordings, which contained identifiable background and narrative information. To protect confidentiality and informed consent protocol, the authors therefore did not make the data publicly available. To better protect confidentiality and avoid identification, the participants’ direct quotes have been altered. Pseudonyms were assigned to direct quotes, with multiple pseudonyms assigned to quotes from the same participant in some cases.
Correspondence concerning this article should be addressed to An-Pyng Sun, School of Social Work, University of Nevada Las Vegas, 4505 South Maryland Parkway, Box 455032, Las Vegas, NV 89154-5032, United States. Email: [email protected]
Gaming disorder (GD) has gained tremendous attention from society and mental health professionals in the past 2 decades. Approximately 90% of American adolescents and 43% of American adults reported that they play video games; a small portion of those players are susceptible to develop GD (Perrin, 2018). The global prevalence of GD was estimated to be 3.3% (Kim et al., 2022) or 3.05% (Stevens et al., 2021), but those estimates dropped to 2.4% (Kim et al., 2022) or 1.96% (Stevens et al., 2021) when including only studies with more rigorous sampling methods. Regardless, disordered gaming results in or is associated with devastating negative consequences, including academic failure or occupational impairments; dysfunctional family or other interpersonal relationships; low self-esteem; mental health and psychiatric issues, such as depression, anxiety, and suicide planning; physical health problems; and other harm to psychosocial well-being (Gentile et al., 2011; Paulus et al., 2018; Van den Eijnden et al., 2018). In 2018, the World Health Organization included GD as a formal diagnosis in its 11th revision of the International Classification of Diseases (World Health Organization, 2020). Despite this progress, scholars continue to debate about the nature of GD and whether GD should be considered an independent psychiatric diagnosis (Rumpf et al., 2018; Van Rooij et al., 2018).
Scholars who oppose classifying problematic gaming as an independent psychiatric disorder argue that heavy or passionate gaming does not necessarily lead to problems, that problematic gaming could be just a secondary disorder or coping behavior to a primary disorder or root problem, and that to label “gaming disorder” as a formal diagnosis would overpathologize normal leisure time activities, causing stigmatization and diagnostic inflation (Van Rooij et al., 2018). On the other hand, many scholars have observed similarities between GD and substance use disorders (SUDs) in terms of their symptoms and neurobiological mechanisms, such as impaired control, craving, negative social impairments, risky use, tolerance, and withdrawal (Giustiniani et al., 2022; Wang et al., 2019; Yuan et al., 2017). Those scholars suggest that GD is a psychiatric disorder in and of itself and should be categorized under the umbrella of addictive behaviors.
Although many previous studies (e.g., Paulus et al., 2018; Rho et al., 2017; Zajac et al., 2020) have documented GD’s symptoms, etiology, risk factors, and treatment strategies, sometimes comparing them to SUD, their results are incomplete, inconclusive, and sometimes inconsistent. For example, citing Rossow and Kuntsche’s study (2013) and Caplan et al.’s study (2009), Beard et al. (2017) noted that GD and SUD may each possess unique characteristics—SUD, for instance, tends to be associated with conduct problems or deviant behavior, whereas GD is more related to internalizing problems like loneliness, depression, and immersion. In addition, although studies have pointed out relationships between GD and risk factors such as neurobiological structure and functionality, mental disorders and comorbid psychopathologies, and personality traits, these studies are not certain about the directionality of the relationships and whether the relationships are causal or just correlative (González-Bueso et al., 2018; Paulus et al., 2018).
As GD is a novel phenomenon, it is critical to use a coherent and longitudinal perspective to study and understand its overall background, natural history, and course of development. However, most currently available GD literature appears to be highly influenced or guided by the SUD theoretical framework (e.g., in diagnostic criteria and clinical treatment methods). This may be appropriate insofar as SUD and GD share similar addictive features (e.g., Giustiniani et al., 2022; Wang et al., 2019; Yuan et al., 2017), but it may also gloss over important unique characteristics of each disorder (e.g., Deleuze et al., 2017; Rømer Thomsen et al., 2018). In addition, currently available GD literature appears to focus on cross-sectional research and perspectives, analyzing important yet isolated discontinuous variables, without providing a comprehensive, dynamic, coherent, and longitudinal perspective to understand GD’s natural history—including sequential stages tracking how GD occurs, develops, and maintains in a person’s life.
Various experts have also observed such a gap in the current GD literature. Paulus et al.’s (2018) review of 252 publications catalogued both internal and external risk factors associated with GD, and noted that various models have been developed to explain GD, but they concluded, “So far, the concept of [GD] and the pathways leading to it are not entirely clear. In particular, long-term follow-up studies are missing” (p. 645). Similar concerns motivated the treatment of GD in Diagnostic and Statistical Manual of Mental Disorders, fifth edition. One reason Diagnostic and Statistical Manual of Mental Disorders, fifth edition includes internet GD only under Section III is because they felt that “an understanding of the natural histories of cases, with or without treatment, is still missing” (American Psychiatric Association, 2013, p. 796).
Considering GD is a relatively novel disorder, Kuss et al. (2013) suggested a qualitative research approach. Currently available qualitative studies, however, did not explore GD’s natural history. For example, Beranuy et al. (2013) reported six phenomena and three gaming motivations associated with playing massively multiplayer online role-playing games. Marshall et al. (2022) provided information on risk factors and the impact of GDs on development. In assessing the qualitative research on GD natural history, King and Delfabbro (2020) summarized that“there has been a predominant focus on the phenomenological experience of gaming use and associated negative consequences. […] Fewer attempts have been made to document the progression of normal healthy Internet and gaming use to more problematic types of behavior. ”They recognized that “[o]ne of the key issues is determining the role of preexisting issues … in affecting the development of problematic gaming” (p. 68).
Typically, natural histories of diseases follow several clinically defined stages: susceptibility; exposure; pathologic changes (stage of subclinical disease); onset of symptoms; usual time of diagnosis; clinical disease; and recovery, disability, or death (Centers for Disease Control and Prevention, 2012). There are multiple ways to collect longitudinal data (quantitative or qualitative, prospective or retrospective) to better understand the natural history of a disease and its course of development. Our study adopts a qualitative, retrospective approach (Neale, 2016). Specifically, we focus on the lived experiences, life histories, and narratives of participants with GD to understand when and how gaming activity entered their lives, when and how normal gaming behavior progressed to become abnormal and pathological, when and how problematic gaming behavior worsened and was maintained, and the contexts involved in each participant’s eventual choice to seek treatment. All of this information can facilitate an understanding of GD’s own natural history; the next section details those methods.
A qualitative research approach that explores individuals’ lived experiences and life stories—with particular sensitivity to issues, contexts, and processes related to how GDs entered and manifested in their lives—was adopted. In-depth interviews were conducted, recorded, and transcribed (see Data Collection section). A grounded theory approach, with an inductive and thematic analysis strategy (Chapman et al., 2015), was used (see Data Analysis section). The research protocol was approved by the host university’s institutional review board (IRB). All four of the study’s authors have rich experiences conducting research (1st and 3rd authors) or are experts specializing in clinical practice (2nd and 4th authors) in the area of GD. The first author also specializes in qualitative research methods and has previously conducted numerous qualitative studies in the areas of substance and behavioral addictions.
The data analyzed here are part of the data collected for a larger qualitative research project implemented at a residential, outpatient treatment program in the United States that specializes in GD treatments. The treatment program staff relayed the research project information to individuals who meet the inclusion criteria, using a standard recruitment script. The inclusion criteria were male or female individuals with GD, at least 18 years of age, who are currently receiving or previously received treatment for GD. The standard recruitment script includes information such as the purpose of the study, length of each interview (2.5 hr or so), and compensation ($30). The compensation for participants was sponsored by the university’s Faculty Opportunity Award grant received by the first and third authors. Individuals who expressed interest in participating in the study were contacted to arrange interviews.
This present study includes 15 participants who sought treatment, mostly at the urging of their parents, for their gaming problems. They were all male with a mean age of 23 years (range = 18–31). In terms of their ethnic/racial backgrounds, the sample included one African American participant, three Asian participants, and 11 White participants. Educationally, two participants were high school graduates who did not attend college, four dropped out of college in their first year, and nine dropped out of college early in their second year. All 15 participants’ treatments were self-financed or paid for by their parents.
The one-on-one, in-depth interviews were conducted by the first author (APS.) in a private room assigned by the treatment program. Only APS and the participant were present during each interview. APS does not know the participants, did not have any interaction or relationship with them prior to this study, and does not have any authority over them. Informed consent was secured by APS prior to each interview: Voluntary participation and confidentiality were accentuated, and participants were informed that (a) their relationship with the treatment program would not be affected by their participation or nonparticipation and (b) they could withdraw from the study at any time. They were also given ample time to ask questions, to help them make informed decisions about whether to participate in the study. Addiction is usually associated with stigma, so on our IRB application we requested a waiver of the usual requirement for participants’ signatures on the informed consent forms. IRB approved this adjustment. Each participant received $30 cash at the end of the interview.
Each interview lasted about 2.5 hr and was audio-recorded with all the participants’ permission and informed consent. Four groups of research questions, open-ended and semistructured, guided the interview and generated follow-up questions during each interview:1What are the basic backgrounds of the participants, such as their age, gender, race/ethnicity, and mental disorder diagnosis, other than internet addiction/GD? 2 In what ways has internet addiction/GD entered and manifested in their lives? 3 What phenomenological features and clinical courses of internet addiction/GD have the participants experienced? 4 What factors led them to seek and receive treatment? What have they experienced during their treatments and recovery journeys?
With the research goal in mind to understand the natural histories and clinical courses of GD, and based on participants’ narrative responses to the above initial guiding questions, follow-up questions were asked to further clarify or elaborate on important issues each participant addressed. These follow-up questions also included questions guided by the grounded theory “theoretical sampling” method (Braun & Clarke, 2020; Ligita et al., 2020). As Ligita et al. (2020) pointed out, when “data are analyzed, questions arise, and potential gaps in the data and/or the evolving grounded theory are identified.” Theoretical sampling allows more data to be collected based on the analysis of previous data, which can “help address these gaps and expand upon emerging concepts” (Ligita et al., 2020, p. 117). Following the principles of theoretical sampling, the data collection for this study involved constant analytical comparisons between data collected earlier and later in the same interview, between data collected across different participants, and between the knowledge the interviewer already had regarding the topic and the data newly collected. This process aims to confirm commonalities and to reconcile contradictions or differences between various data and insights. The intention is to achieve saturation and to ultimately develop a coherent and meaningful theory grounded in the collected qualitative data.
We used a grounded theory approach, with an inductive, thematic analysis strategy for data analysis. This strategy usually involves four stages: transcripts familiarization and organization, possible themes identification, structures identification and development, and theoretical model construction (Chapman et al., 2015). In their article, Chapman et al. (2015) also demonstrated examples of “generation of codes from raw data from semi-structured interviews” (p. 202) and of “generation of a theme from several related codes” (p. 203).
Our data analysis reflects the method presented by Chapman et al. (2015). First, the audiotapes were transcribed verbatim, resulting in transcripts averaging 30 single-spaced pages for each interview or per participant. Next, the transcripts were reviewed to generate an initial overview of their overall content. Each interview transcript was then reread in detail, and units (we labeled them subthemes; Chapman et al., 2015 labeled them “codes”) or themes that connote meaning were identified and coded. Commonalities and differences within and between transcripts were also identified and organized. Multiple subthemes and concepts were revealed; for this article, we focus on factors related to the occurrence of GD. Via an inductive process, a higher level set of “structures” or “themes” was formed, each of which was supported by the relevant identified concepts or subthemes. Based on these structures and themes, a final theoretical model was constructed. In Figure 1, we presented all the identified concepts or subthemes in rectangles at the bottom, all the “structures” or “themes” in ovals in the middle, and the final theory in a triangle at the top.
Participants’ life stories revealed 12 subthemes, grouped here into three major themes that correspond with three developmental stages in the occurrence and development of GD and other internet-related disorders. As Figure 1 illustrates, these stages are as follows: early exposure (preschool and elementary school); continuous and progressive engagement (middle and high school); and pathological use, emergence of symptoms, and treatment-seeking (post high school/early college). Most participants had been exposed to gaming in proximal environments since an early age, via pro-gaming parental practices (Subtheme 1) and/or childhood playmates (Subtheme 2). Such gaming behavior was particularly pronounced among participants who perceived that they “struggled socially” (Subtheme 3) when growing up. According to the participants, this early exposure did not necessarily create problems or addiction at the time. Instead, later in life their continuous and excessive gaming engagement led to addiction.
Participants’ repeated and progressive engagement during their middle and high school years may originate from their intention to self-medicate the pain associated with psychiatric disorders (Subtheme 4), trauma and crisis (Subtheme 5), and/or poor self-efficacy and insufficient social skills (Subtheme 6). The pure enjoyment they gained from gaming, as well as a sense of belongingness from gaming communities (Subtheme 7), further reinforced their gaming behavior. The resulting excessive use during their middle and high school years intensified and eventually resulted in pathological symptoms, impairments in life domains, and seeking treatment. This third stage coincided with leaving home for college, a time when they were expected to become independent from their parents. Accordingly, they not only carried the psychological burdens from their previous gaming behavior but they also had to face new demands and challenges related to human development, such as a lack of parental supervision/accountability (Subtheme 8), a more difficult college curriculum (Subtheme 9), lack of problem-solving skills and low self-efficacy (Subtheme 10), lack of social support (Subtheme 11), and perceiving the situation as “too far gone” (Subtheme 12).
The following sections elaborate on the course of the internet gaming addiction development, including excerpts from the participants’ narratives that substantiate each of the 12 subthemes, and show how the 12 subthemes support their respective major themes.
Most participants stated that they were exposed to internet gaming, video games, and/or other computer-related entertainment early on in life. Eight of the 15 participants started such activities before the age of 7.
Parents’ values of, attitudes toward, and practice of pro-technology and computer-related activities may directly or indirectly facilitate a child’s gaming behavior. Participant A perceived his father as a geek who was passionate about technology. He said:“Video game … digital media in general … Most interactions in my childhood involves something like that. Some of my earliest memories are my dad … showing me little educational video games that I would play. From then on, those were very real activities for me … through school, friends, and family, all my interactions with them were games. ”
Participant B said, “My parents thought it [playing games] was a good thing, and they also thought it was something to calm me down. … It was just a way for me to stop crying.” Growing up, he continuously received gifts related to gaming consoles and computers. He also accessed pornography and online role-playing chat rooms. Because of the long hours he spent on gaming, he barely passed high school. Although he enrolled in college, he soon relapsed to gaming addiction again and had to drop out.
Participant C was introduced to computer games before Age 6 and considered himself already addicted to gaming at Age 9. He said his father “always wanted to update the computer … because there was something newer and better out there.” Participant C said, “[my father] always thought that the time I spent on gaming would somehow translate into future usefulness. He said, you know, computers are the future.”
Childhood playmates who share the same interest in gaming may also facilitate gaming behavior. Participant D played games with his childhood friend, but said that his parents curbed his gaming behavior during his childhood:“My neighbor, who was my age, would come over and we would play video games together. I did seem to enjoy it a lot more than other kids did. I was more drawn to them. What was really keeping me from going overboard was the [parental] limitations that were put on me at that age. ”
He said that he and the neighbor “would hang out and play together all the time. He had a few gaming consoles, I had a few gaming consoles, so whenever we would go to somebody’s house, we would always have a different one to play.” Throughout his elementary school years, school and games were Participant D’s two major activities.
Many participants stated that they often had trouble making friends and started struggling socially at a young age. For many of them, this “struggling socially” phenomenon continued during later stages of middle/high school, as well as after high school and in early college. Participant E, who had an autism spectrum disorder (ASD) diagnosis, recalled,“I remember there were plenty of games like that, that were really just kids’ games, and I realized through that time I was struggling socially, I started to go to chat rooms and socialize there at around eight or nine years old, and even younger I was on the computer. ”
Along the same lines, Participant F recalled,“I had issues as a child with socializing and when I first started school, I didn’t do very well. But my sibling was fine. My friends played video games, their friends didn’t. My friends, when they came over, we played video games together. Their friends would come over and just hang out, or go out somewhere and do something. ”
Participant G had problems making friends since childhood. He said,“I was very lonely. I had a lot of anxiety going to another school. I started to notice that I had a hard time making friends. Looking back now. … I wasn’t close with anyone, I just knew who everyone was. ”
His anxiety over making friends was intensified by his parents’ extremely high expectations for him. With this pressure to perform well academically, plus his struggles to fit in socially, he indulged in computer-related activities—including comics and games—in an attempt to cope and escape.
Early exposure did not necessarily immediately lead to gaming addiction among the participants, but rather their continuous and progressive engagement later in life did. Participant H remarked, “The amount of time spent on unproductive computer activities and games from elementary to middle school, middle school to high school, college … definitely a gradual progression throughout.” Participant I said, “I think the first couple of years in high school, [I played] four hours a day. Then, my senior year, it started to become more.” He said that he would stop going out with friends on the weekend, stop returning their calls, and stay up late playing games. His daily gaming time went up to 6–8 hr a day during his senior year of high school, then jumped to 14 hr a day in college: “Just getting up and getting on the computer and stay on it on the entire day,” he said.
Participants’ repeated and augmented gaming, as they transitioned from elementary school to middle and high schools, may result primarily from their intention to self-medicate. They were experiencing significantly negative feelings related to life and developmental issues, including (a) having a co-occurring disorder (COD), (b) encountering traumas and crises, (c) lacking social skills, and (d) having low self-efficacy and low self-esteem. This prompted them to immerse themselves in gaming and gaming communities, where they often gained a sense of belonging and formed social relationships.
About half of the participants had at least one other independent disorder in addition to GD. These disorders ranged in severity (mild, moderate, or severe) and included depression, anxiety, bipolar, schizophrenia, gender identity disorder, attention-deficit/hyperactivity disorder, ASD, and a physical disability. Participant J said:“It’s an addiction to keep using it and try to socialize outside of normal means, because socializing face to face wasn’t normal to me. I was diagnosed with depression, ASD and severe ADHD at a young age. I was on a strong dose of medication. I was in and out of hospitals. I couldn’t socialize with anyone. I couldn’t function. ”
He said his parents would buy things for him, including video games, because they were emotionally indulging him and would give him whatever he needed to calm himself. He remembered his online gaming behavior got worse during his mid-teen years. Participant J said that it was not that bad until he started getting teased a lot in school by his peers, as well as being teased at home by his siblings. In his words, “I didn’t have social skills. It took me years to catch up.” Prior to his mid-teen years, he only played video games occasionally, but afterward, he said,“Everything I did involved video games. Like my friends were only there to play video games with me. My social life was watching TV or going online. Every day after coming home from school, I would just drop my stuff and get on the computer and start playing. ”
For his part, Participant K has been bothered tremendously by mood change problems, which include sad and angry feelings, sometimes combined with psychotic features. He found that alcohol, shopping, gambling, or sex all failed to help. However, gaming, particularly “competitive games,” worked for him to deal with random mood changes. He said,“I had depression and I was suicidal when I was around early teen years. After that I started using the internet and video games to cope with that just to take my mind off of it. After doing that it became a go-to whenever I felt bad. Whenever something was too difficult I would use internet or video games to help cope. ”
However, he concluded, “after a while it would stop working and I’d get kind of bored of playing and I would just sit in my room. I wouldn’t get out of bed.”
Participant L pointed out a similar bidirectional relationship between depression and gaming addiction. He noted,“It was I am depressed, and I am an addict, and the gaming makes me more depressed. And when I am depressed, I play more games. Each one gets worse and worse. I started anti-depressants. Nothing ever got better because I was still gaming. So even though I am starting to deal with depression, the gaming keeps fueling it and … and never really gets better. ”
Other co-occurring issues may include, for example, gender identity disorder and physical disability. Participant M, who comes from a very conservative family, has long experienced confusion and distress regarding his sexuality and what he would want to be. He became severely addicted to pornography. Participant N has a physical disability, which has caused him low self-esteem since childhood. Growing up, he used marijuana and other illegal drugs, as well as engaging in online gaming, to prevent himself from “living a sober life,” as a sober life would force him to face too much pain triggered by his disability.
In addition to a COD, trauma and crisis also triggered self-medication during the participants’ adolescent years. Self-medication led to excessive and repeated use of gaming to escape or cope with the negative emotion. The negative effects of trauma and crisis worsened when combined with an existing COD. All 15 participants appear to have suffered some forms of life crisis, trauma, loss, and grief. These crises are elaborated below.
The death or terminal illness of significant family members, such as a parent or beloved grandparent, can be traumatic to an adolescent. Participant O’s father passed away during his middle teens. Using a scale of 1–10, with 10 representing the utmost severity of his gaming indulgence, he said, “I would say 2 before [my father] died, and then it went up to 8 after he died. When I went to college it turned into 10.” Participant O considers his father the most important person to him in the world. Not only did Participant O mourn the loss of his father but his father’s death also made him feel uncertain about whether he will ever get what he wants out of his life. He said that, before his father died, he would participate in baseball, was a leader in his peer groups, and was well respected in school. However, he continued:“After my father died is … when my use really accelerated. I started to withdrawal from my friendships, it all became about just sitting in front of a computer screen for all day. I don’t think I had a plan for the future at all. I was pretty hopeless … really fatalistic … feel very unprepared for adult life. ”
Some other participants also reported being traumatized by the death or critical illness of their significant family members. They stated that these crises prompted their excessive use of internet and gaming. Participant P was very close to his aunt, who has always been supportive and served like a cornerstone for the family when his parents did not have a good marital relationship. The death of his aunt triggered overwhelming sadness and hopelessness. Similarly, Participant Q had a strong relationship with his father, but when a sudden critical illness changed his father from being a very active person to one who could barely walk, Participant Q was unable to deal with that new reality.
Some participants believed that their dysfunctional relationships with their parents or their parents’ poor relationships with each other drove them to seek gaming and other internet activities for refuge. Participant R said, “I’ve definitely been hurt by [tension between my parents]. … I tried to isolate [myself] from my family when my parents were fighting, I just play video games to zone out, to escape.” Participant S’s father has an alcohol use disorder, and Participant S perceived his father as being “cruel” to him, saying that “It really hurts because it wasn’t a family based on love, it was a family based on doing stuff and getting paid back.”
Another aspect of dysfunctional family relationships may have led to identity distress in the participants. Some participants suffered extreme pressure originating from their parents’ unrealistically high expectations for them. Participant T experienced significant stress from not being able to measure up to his parents’ expectations and standards, and he subsequently resorted to gaming to escape the stress. His parents wanted him to pursue science or medicine, despite the fact that he did not like those subjects at all. He said, “I just know that it was important that I always had to do it. Just you have the standards, you have to meet them. They are just there.”
Being bullied was also mentioned by participants, and it is often intertwined with other risk factors such as dysfunctional family relationships, CODs such as ASDs, and a lack of social skills. Participant U said that playing video games helped him escape from his parents’ fighting, but he recalled that “it wasn’t that bad until I remember being in school and being teased a lot. I didn’t have social skills. It took me years to catch up.” Participant U believed that his isolation from his family decreased his social skills and ability to interact with others, further isolating him from his peers, like a snowball effect. He said isolation from both his family and peers resulted in his indulging in online activities. Participant V said:“I have trauma … things like bullying, physical, things like that from other kids. For me, I look for alternatives when I was afraid of the world, so I looked into gaming … and that’s for most addictions, you escape a feeling. That feeling of pain … I escape that by getting online. ”
Participant V started noticing the pain from the outside world since he was 6 or 7 years old, and that pain continued into his adolescent years.
Participant W said he has problems feeling connected with others, and he thinks it was because of his ASD diagnosis. He said his sibling’s friends would “be making fun of me right in front of me. They would just make fun of things I say. They would just belittle me and mock me.” The bullying Participant X experienced made him avoid going to school. He said, “I felt I couldn’t go [to school] anymore because all the feelings I had were really strong. I started associating the feeling with the environment I was in, so I wanted to get out of that environment.” He continued,“I just didn’t like myself; I was just secluded and just was trying to think but at the same time trying to not think by playing video games. There were times when I would pretty much wake up, go play and go back to sleep. Full day. ”
All 15 participants perceived themselves as lacking social skills, having difficulty making friends, and/or feeling inferior to their siblings or friends. Many experienced such difficulty since childhood; others became more sensitive to interpersonal rejections when entering adolescence. Some participants considered their autism to have a bearing on their social difficulties. They used the words “introverted,” “struggling socially,” or even “bad social mannerism,” and “weirdo” to describe themselves.
The participants consistently said that they got along much better with individuals who also play games. Some had resorted to chat rooms and other online platforms for “fake” friendship since elementary school. Many, who may have had real-world friends initially, gradually moved to having more and more online friends as they got older. Participant Y said:“I mean that’s how I was always taught from … well not taught, but I learned in childhood. And that was a good way to relate with people. Or relate game and media that relate, that we both share interests in. And that’s just how I carried myself throughout my life. It’s always an easy way to bond with people, talking about games and video games. ”
Participant Z said,“I would take the character from the anime and make a story of my own with other people. It made me feel good. It made me feel I could interact with people. It made me feel like I had a skill I could do something with. ”
Participant AA, who had an autism diagnosis, considers that his gaming addiction led him to an extremely dysfunctional lifestyle. He attributed his severe game addiction to poor social skills and a lack of “normal” friends, the fun and addictive nature of the games, the opportunities to make friends via gaming circles, as well as the facts that games allow him to prove he can be better than other people and thus distract him from the negative thinking of being rejected or isolated by peers in the real world. As he put it, “So basically the things that excite me, running around and exploring as well as fighting people and prove that I am better than them. Also, it’s just exciting kind of getting new items. … the engagement is leveling up and being the best.” He clarified, “The reason I play a game is for distraction. The excitement of it keeps me playing. So, playing it will keep me playing, but the whole reason I got on is to get away from the real world.” He said gaming allows him to escape unhappy relationships with his parents and “friends that I didn’t have over the years. The pain I felt inside, the shame, the guilt. I don’t feel that I fit in.”
Also diagnosed with ASD, Participant BB said,“When I first meet someone, it’s hard for me to be like, ‘yeah I can understand you’ … Because every guy’s story is different. And I have bad social mannerisms. I worry about that a lot. I say things that come out as rude. I don’t mean them to be rude. I just can’t. It’s hard. ”
He said he “didn’t do any socializing in middle school or high school, and was always the awkward guy.” He would often be acting like he was doing an essay assignment, but he was actually role-playing and he would get a euphoric feeling. He said he feels like there were people who understood him there, and he was not alone. Participant CC, another participant with an ASD diagnosis, said,“I have problem with feeling connected with others. And feeling intimate with others. And a lot of things I think it was because of my diagnosis with ASD. Because you’re supposed to have a hard time with that. Nobody actually explained ASD to me. They said that I don’t have friends for particular reason, like it’s all my fault! Everybody thinks I’m weirdo. ”
He mourned that he was not respected by his family, and that his thoughts and emotions have seldom been validated since childhood. He also fears social rejection, mentioning his fear “when somebody doesn’t interact with me.”
Several participants talked about feeling inferior to their siblings; they perceived that their siblings were more popular among peers and that their parents preferred their siblings over them. Participant DD felt that his parents liked his sibling more than him because he and his sibling have very different personalities. He said, “I was kinda weird. … I was non-sociable and used to not talk at all. … I much prefer to be alone rather than with other people. My [sibling] was outgoing and extroverted, and good at sports. I would always compare myself to my [sibling] and they were far better.” Participant EE likewise said:“I always compare myself to my [sibling]. They had nothing wrong with them. They don’t have any addictions, they don’t have any mental disorders, they don’t have anything like that. [My sibling] was always this person I wanted to be, but I could never be. ”Participant FF said,“ My [sibling] doesn’t want to be anything like me. Ever since we were little, [my sibling] didn’t want to be associated with me. I felt that [my sibling] was insulted by being related to me. Like I was something bad, something was wrong with me. ”
All 15 participants enjoyed the appetitive effects of online gaming and/or other digital media. They also mentioned that those activities provide opportunities to interact more comfortably with people who share the same interest in games, as well as to develop a sense of belonging to a community. Participant GG said, “I always realize that I shouldn’t be doing this [gaming], but I did it anyway, because it was easier, it was more fun, it provided more short-term enjoyment than doing the work.” Similarly, Participant II, who perceived himself as a person who is without friends and has a poor relationship with parents, said: “Well, it was like an escape. Everything else fades away and I am having fun because I am playing a game.”
Participant HH said,“I like being a part of a group … excelling and being a part of a group and feeling like I belonged was a big reason why I got into gaming. Because I liked playing with my friends, and I wanted them to see I was good at something. ”
Participant II said that he and his [sibling] had different groups of friends. He and his friends would always play video games, whereas his sibling’s friends preferred to go out and do something when they came over. Participant JJ said:“I just didn’t really like [their] friends that much. I didn’t feel like they were my friends, so I just felt uncomfortable when I hung out with them. It wasn’t until when I made friends that played video games that I felt like I had friends. ”
Participant KK said,“I learned in childhood … that was a good way to relate with people … that we both share interest in game and media. And that’s just how I carried myself throughout my life. It’s always an easy way to bond with people, it’s about talking about games and video games. ”
The third major theme is the intensified and pathological engagement in gaming and other online activities, its subsequent surge of symptoms, and treatment seeking. This mostly occurred during the participants’ first or second year of college or the first year after graduating high school for two participants who did not enter college. All 15 participants demonstrated this theme. Participant LL said,“What basically brought me here [treatment program] was losing the balance in my life. … Video games have always been like a part of my life, but I really started playing and losing track of other things was in my first semester of college. I wasn’t able to continue playing games and continue school at the same time. I didn’t want to give up games because I thought they were too fun, and I didn’t want to give up school because I thought, you know, if I give up school then it’s giving up everything.”
Participant MM said that he kept trying to do a balancing act, but it never worked out. It became a real frustration to his family and himself. He said, “They always realized it was a problem. I was never really willing to accept it.” Participant NN, whose prior therapist has suggested that he play “in moderation” after he “detoxed,” found it unfeasible to play in moderation. He said,“I tried in moderation, um, and it very quickly became … went from 2 hours of play, then 3 and 4, and so on, until I was just sneaking in time and not telling anyone about it. … I dropped out of school and was having a hard time continuing my education. ”
Five subthemes emerged from the data, identifying factors that lead to the intensification of GD symptoms and treatment seeking. All these factors interact with each other, as well as with other distress factors such as new traumas encountered after attending college, while the old traumas, CODs, and addiction carried from previous stages aggravate the gaming addiction. These five subthemes (factors) are elaborated below.
Eight of the 15 participants conveyed this theme. They consistently emphasized how their lack of self-control was worsened by all the freedom and free time they gained after leaving home and being away from their parents’ monitoring and supervision. Participant OO said, “I went away to college so, you know, there was nobody to comment on how much I was gaming. So [gaming] was much more available basically.” Participant PP said,“Once I settled down and integrated, then I was bored again. I had free time, and even more free time, and, also, my parents weren’t around to pay attention anymore, so I could go on for as long as I wanted. ”Participant QQ said his parents only allowed him to play games during weekends when he was in high school, but “when I went up to college, I didn’t have parental supervision, so I can play as much as I wanted. … That’s how it became more obsession.” Participant RR said that he played games heavily even before high school but was still managing high school well because, he said,“ I think a lot of that is my parents were [holding me] accountable. My parents would be like, ‘I see that you are on your computer. Did you finish your homework? How are your grades?’ If my grades slipped, I lost the computer, if I didn’t finish my homework, I got off the computer. ”
Seven of the 15 participants mentioned this subtheme. They stated that they could still manage schoolwork while gaming in high school, but not after entering college. They attributed this to the fact that college academic content is more challenging than high school curricula. For example, Participant SS loved arts during high school but was uncertain whether he could excel in the field, as achieving that goal requires being the best of the best. He finally chose a computer-related major after entering college, since he had spent so much time online and was very familiar with computers. However, he realized too late that his chosen field actually involved a lot of math. In his words, “I am bad in math. It sucked! I was struggling.” SS later dropped out of college.
Participant TT, who played 11–13 hr a day at worst, accepts the fact that his excessive engagement in online activities led to his quitting college. He said,“I did very badly because I was spending all my time on the internet playing video games, to the point that I wasn’t doing homework anymore or sleeping properly. I wasn’t doing any work outside of going to classes, and usually falling asleep because I wasn’t sleeping. ”
Participant TT said he could still manage his high school homework even though he played a lot of video games then, but he struggled while in college. He said:“[T]he work wasn’t that difficult; it shouldn’t have been that difficult. I knew I was capable of doing it, but I was locked in these patterns that distracted me for too long, so I never got to do the work. A lot of it was procrastination. ”
Some participants lost their old friends and old social supports after moving away from home to college. Participant UU said:“I went to college, and all the friends I had from when I was a kid were no longer there. So I was away from my family and old friendship, I didn’t seem to be capable of making new friendships. I was totally dependent on my computer and my online relationships, which were kind of fake. I would spend all day on my computer. I would not go to class ever. ”
Participant VV, although he was accepted to some colleges, still “got turned away other universities that my other friends got into … so. … I was kind down about that.” VV said, “When I was in high school, I had a lot of friends, because I was on a sports team … and I had a whole bunch of other friends. Moving away for college, you lose a lot of those people!”
This subtheme was supported by many participants. Participants’ lack of problem-solving skills precipitated their self-medication by using gaming to escape from life difficulties, a pattern they showed since early adolescence. It was worsened when they transitioned from adolescence to young adulthood, where they faced more developmental life task challenges and higher demands to become independent. Participant WW said that he had always thought of himself as a “social gamer” and that he liked to play the games his friends were playing. Most of his friends were gamers and they all lived in the same dormitory. It ended up, however, that while his gamer roommate friends could still go to classes every day, he could not. In addition to attributing this difference to an addiction predisposition, WW emphasized that he had never learned how to face and solve problems, so he used gaming to help him deal with life issues after going to college. He said,“When I got stressed out as a kid, I would run into my computer and hide in my games. And, so, the same thing started happening in college when I started getting stressed out by papers or finals, or when I’m missing class and I’m feeling depressed. All of this is just making me want to hide so I just keep gaming. ”
Participant XX said:“It kind of created a snowball effect that when I would, I feel very stressed out, I just need the game right now to not feel stressed out. Oh my God, I missed class, now I feel really creepy because I missed class, because I was gaming, and so I had to get more [gaming] to get around that, and that just kind of kept building and building until when I dropped out of college. ”
Although the participants’ ages ranged from 18 to 31, some of them have already lost hope and are in despair, perceiving their online/gaming addiction, academic failure, and other life issues as too far gone to be repaired. Participant YY, who was in his early 20s, stated that “I was too far behind, to make any differences.” He continued:“My grades were so low, I won’t be able to bring them up … that kind of hopelessness just kind of draws me to more gaming. I feel shameful, I feel stupid, I couldn’t understand the subject. … I was so behind, I just feel bad, I can’t handle what’s going on right now, so I just try to play games, to ignore [the situation]. ”
Participant ZZ said:“Everybody tells me that there are still opportunities ahead of me, as I’m so young. I think it is easy for them to say that because they are speaking from an older point of view … but from where I am standing, you know, when I was 11 years old, it’s hard to picture yourself as an adult. When you are 20, it’s hard to picture yourself as 40. ”
ZZ continued:“So, for me, it’s like when I was having problems, I couldn’t really picture anything in the future. All I can picture is big problems in front of me, like gaming problems or not doing well at school. Those are probably my biggest issues. It’s just very hard for me to pass that. ”
The results of our qualitative study highlighted five important concepts that explain the course of gaming addiction along three developmental stages—early childhood, adolescence, and emerging young adulthood. These concepts are as follows: (a) an early exposure to gaming and the internet; (b) low social competency; (c) CODs and stressful life events (SLEs); (d) challenges faced in transitioning from adolescence to emerging adulthood; and (e) low self-efficacy and a sense of being “too far gone.” Our findings are consistent with, but expand, the existing research findings by providing (a) an estimated timeline mapping these phenomena onto specific developmental stages and (b) a more detailed and in-depth understanding of the contexts and processes where those concepts are embedded.
More than half of our participants had their first contact with gaming and the internet before the age of 7. This finding is consistent with previous quantitative studies connecting early exposure to (and an infatuation with) internet use or gaming—particularly when it interacts with other risk factors—to the later development of gaming addiction (Nakayama et al., 2020). Next, we found that “struggling socially” is a fundamental factor related to problematic gaming. Many participants tended to lack social skills and to have difficulty making friends since early childhood. This tendency continued throughout their middle and high school years, as well as after high school. For some individuals, this social vulnerability was related to or worsened by their COD and other adversities in life.
The literature has consistently identified a strong relationship between social skills deficiency and GD (e.g., Fumero et al., 2020; Paulus et al., 2018; Peeters et al., 2018; Wichstrøm et al., 2019). Social needs are innate in humans and are especially relevant to adolescents; online gaming or other virtual activities offer individuals with low social competency in the real world an opportunity to fulfill those unmet needs. Gaming activities that involve multiple players, or those that establish a community, enhance social interactions, and facilitate a sense of belonging, subsequently reducing a person’s feelings of loneliness, boredom, and isolation (Paulus et al., 2018; Peeters et al., 2018). Gaming creates more rewards for socially vulnerable adolescents than for their counterparts who are socially competent (Peeters et al., 2018).
CODs and SLEs are two risk factors that emerged during the participants’ adolescent years. Adolescence is a critical period featuring rapid physiological and psychological change, as individuals transition from childhood into adulthood. Adolescents are less able to cope with adverse life situations than adults; when encountering negative mental health symptoms or another SLE, an adolescent may develop maladaptive coping strategies, including engaging in gaming to escape or regulate negative emotion (Zhao et al., 2017). Although CODs and SLEs permeate all three developmental stages, they appear to be most prominent during adolescence. These factors, when interacting among themselves or with the abovementioned social vulnerability factors, exacerbate addiction intensity.
The literature has identified a set of mental health issues comorbid with internet/gaming addiction, including depression, anxiety, ADHD, and autism (Bickham, 2021; González-Bueso et al., 2018; Vadlin et al., 2016). Over half of our participants who described themselves as having low social competency had an ADHD, ASD, or an ADHD–ASD COD. Individuals with GD and ADHD have a poorer prognosis than those with GD only (Lee et al., 2021; Mathews et al., 2019; Wartberg et al., 2019). Several theories explain the linkage between gaming addiction and ADHD. First, individuals with ADHD tend to be more impulsive and more responsive to incoming stimuli (such as sound, sight, and touch), which together makes them more sensitive to video games’ reinforcing stimuli. Similarly, the in-game reinforcement schedules and structures (e.g., fixed and/or variable ratios) may contribute to a gamer’s continued play. Third, individuals with gaming addiction and ADHD are more apt to choose smaller immediate rewards (e.g., positive reinforcement obtained from playing games) over larger, more delayed rewards (e.g., school work that demands more effort; Evren et al., 2019; Mathews et al., 2019). The addiction risk may be further worsened by symptoms that characterize ADHD, such as difficulties with time management, organization, and prioritizing. Finally, individuals with ADHD may be very impatient with the activities they consider boring, but they may have a hyperfocus on activities they enjoy and thus play games for a prolonged time (Hupfeld et al., 2019; Mathews et al., 2019).
Studies have likewise shown a relationship between ASD and gaming addiction (Liu et al., 2017). Explanations for such a relationship may include (a) individuals with ASD experience a core deficit in social competences, such as social interaction and communication (Bickham, 2021); (b) they tend to be more impulsive and less able to regulate their emotions (Leo et al., 2021; Liu et al., 2017); (c) they have restricted interests and engage in repetitive behaviors; (d) low social competency often brings on anxiety and depression; and (e) ASD often co-occurs with ADHD. The risk of developing internet addiction is higher for individuals with both ADHD and ASD than those with ADHD or ASD only (Bickham, 2021; Coutelle et al., 2022; Engelhardt et al., 2017; Liu et al., 2017).
Quantitative studies have reported an association between SLEs and problematic gaming among adolescents and young adults (Yan et al., 2014; Zhao et al., 2017). Several studies that link childhood (or young adulthood) trauma and GDs indicate a direct or an indirect relationship between the two, mediated by depression and/or anxiety (Kircaburun et al., 2019; Richard et al., 2021; Shi et al., 2020). Those studies suggest that people use maladaptive coping strategies, such as internet gaming, to cope with the pain of childhood trauma and its associated negative emotions, such as depression and anxiety (Shi et al., 2020). Kircaburun et al. (2019) found that gamers with a history of childhood emotional trauma tend to have a higher level of depressive symptoms than gamers without such a history, and that depressive symptoms predict internet GD (Kircaburun et al., 2019). Childhood trauma may also include bullying victimization. Richard et al. (2021) reported a relationship between bullying victimization and gaming addiction and noted that such a relationship is mediated by mental health issues.
Numerous studies have consistently pointed out a relationship between poor familial factors and problematic gaming among adolescents (Lee et al., 2021; Paulus et al., 2018; Schneider et al., 2017). Paulus et al.’s (2018) systematic review indicates that internet GD is associated with family violence, negative parental role models, inadequate parenting care, and dysfunctional parent–child relationships. Furthermore, hostile and oppressive parents, as well as single-parent or broken homes, can contribute to adolescents’ increased screen time use (Paulus et al., 2018). Schneider et al.’s (2017) found that compared to regular gamers, problem gamers perceive more parental hostility and less parental warmth, spend less time engaging in social activities with their parents, and report receiving poorer quality parenting. Sela et al.’s (2020) revealed that depression mediates between negative family environment and problematic internet use, in that poor family support predicts depression of adolescents, which in turn predicts their problematic internet use symptoms.
Low self-efficacy, challenges faced in transitioning from adolescence to emerging adulthood, and the perception of being “too far gone” are three concepts characterizing participants’ post high school and early college years, based on our qualitative data. Self-efficacy is defined “as one’s belief or confidence in one’s ability to cope with demands in a variety of contexts. … Individuals with stronger self-efficacy are more likely to meet goals or devote effort to a task” (Chung et al., 2020, p. 2). Previous studies have indicated a relationship between low self-efficacy/resilience and gaming or internet addiction among adolescents and young adults (Chung et al., 2020; Lin et al., 2021). Consistent with those studies, our findings suggest that participants experienced low self-efficacy both during the middle/high school period and the post high school/early college period. Its impact was stronger in the later period, where it interacted with new challenges participants faced in transitioning from adolescence to emerging adulthood. Low self-efficacy is usually combined with reduced parental restrictions and less access to their hometown social support systems. Other new challenges such as a more difficult college curriculum, likewise intensified participants’ reliance on gaming as a coping mechanism. Some participants reported that the more they fell behind in their academic or other life tasks, the more they would play in order to escape the distress. Not being able to face and resolve their academic difficulties or other challenges, then resorting to indulgence in gaming, created a vicious cycle: the more they played, the more they would get behind, and thus the more mental distress and depression they would feel, prompting them to play even more.
Many studies have revealed a bidirectional relationship between depression and problematic gaming (e.g., Jeong et al., 2019; Lau et al., 2018). Gaming can not only be a symptom of depression but its root. Depression that follows gaming addiction may be a mixture of a young adult’s distress and mourning over the loss of their life dreams and goals, on top of the inherent withdrawal symptoms related to addiction. Many participants consider that their chronic and problematic gaming have left them “too far gone” and that it is unlikely for them to recover from the addiction and repair the damages caused by their gaming (e.g., failing grades). This creates despair, leading to more gaming to cope with a life without meaning and without hope. Zhang et al. (2019) found that “purpose in life” is negatively correlated with internet GD symptoms, and that “purpose in life” has the long-term effect of alleviating college students’ GD vulnerability.
Our study has limitations in that we only included young men from medium or high-socioeconomic status backgrounds, so the results are more relevant to this population. Future studies should cover female participants, as well as individuals with more diverse socioeconomic backgrounds. Also, our study is qualitative and based only on 15 subjects. More qualitative and quantitative studies are needed to replicate our findings. Nonetheless, our study extends the existing knowledge by mapping risk factors onto an individual’s developmental stages and providing contexts where those risk factors are embedded. Our findings make unique contributions by clarifying the process by which normal gaming behaviors progress into a pathological GD.
Although multiple factors have been identified by previous quantitative research to be related to GD or problematic gaming, our qualitative findings expand the literature by mapping those factors onto an individual’s developmental stages. Although more studies are needed to replicate our findings, our study provides preliminary suggestions regarding prevention and treatment. Social competence, healthy social activities, and social support should be nurtured by parents, schools, and the community, starting in childhood and going throughout adolescence and young adulthood. CODs need to be screened for and treated during childhood and adolescence, while professional intervention should help minors who face trauma more effectively process and better cope with the adversity. For individuals in the post high school or college stage, vocational counseling, academic guidance and assistance, and interpersonal relationship consultation and support are essential to cultivating a sense of healthy identity and self-efficacy, as well as for developing life goals and a meaningful life. It is critical for college social workers, psychologists, and counselors to help newly admitted college students better transition into college life by identifying early signs of addiction and referring students to professional treatment. GD is not only a symptom of depression but it is a disorder in and of itself.