IJERPH, Vol. 19, Pages 16078: Co-Occurrence of Gaming Disorder and Other Potentially Addictive Behaviours between Australia, New Zealand, and the United Kingdom

Approximately 2.9 billion individuals play videogames worldwide [1]. In some Western countries—such as Australia (AU) and New Zealand (NZ)—over 90% of households own a videogame device, and two-thirds of the population play videogames regularly [2,3]. This is not isolated to the Western countries of Australasia, but is also seen in the United Kingdom (UK), which has the largest videogame market in Europe and the sixth-largest videogame market worldwide [4]. Consequently, to better understand the positive and negative aspects of this rapidly growing leisure activity, research into gaming has been increasing at a rapid pace.Understanding the way in which videogames can positively impact those who play them is important. Research has suggested that moderated videogame play can result in improved interpersonal skills, increased positive affect, and positive mental wellbeing [5,6]. Moreover, it has been shown to increase resilience and coping among adolescents [7]. However, it is also important to understand the association between poor mental health and videogaming and to provide insight concerning the intrinsic and extrinsic factors that may precipitate or perpetuate gaming disorder (GD) outcomes [6]. A growing body of research associates excessive gaming with poor mental health [8] and other negative consequences [9]. Therefore, there is a need to improve screening, assessment, definition, and treatment of disordered gaming. 1.1. Gaming DisorderBased on growing research, the American Psychiatric Association [10] included internet gaming disorder (IGD) as a behavioural addiction (warranting further investigation) in the appendix of the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In addition, the World Health Organization [11] has for the first time officially recognized ‘gaming disorder’ (GD) as a disorder with addiction-like properties in the eleventh revision of the International Classification of Diseases (ICD-11). The conceptualisations of each of these constructs overlap significantly. More specifically, the similarities of each indicate that (I)GD comprises a persistent engagement with videogames, to the point it cannot be willingly stopped and impairs individuals’ everyday functioning. It is worth noting that the constructs of IGD and GD have undergone conceptual evolution prior to inclusion in the diagnostic manuals (DSM-5, ICD-11), with several other terms used to describe problematic and disordered gaming (e.g., pathological videogaming [12]). Therefore, to maintain consistency, the term ‘GD’ here refers to the clinically defined measures of the disorder as defined by the DSM-5/ICD-11 and the term ‘disordered gaming’ will be used to describe a range of similar and/or overlapping addictive, compulsive, and/or problematic gaming behaviours which do not fit the clinically defined GD construct. Several studies have associated disordered gaming with mental disorders, such as anxiety [13], depression [14], substance abuse (e.g., alcohol use disorder (AUD) [15,16]), and personality disorders [17]. Findings such as these have stimulated interest into the ways that GD may influence these factors. There have been concerns that for some individuals, playing videogames may be inherently addictive, or that pre-existing vulnerabilities (e.g., anxiety and depression) increase the likelihood of GD behaviours [18,19]. There has been debate in the field as to the validity of the GD diagnosis, with scholars citing the lack of clinical populations, the heterogeneity of the gaming experience, and the risk of pathologizing ordinary gaming behaviour [20,21,22,23]. Indeed, there appears to be evidence that suggests potentially addictive behaviours can be experienced differently by individuals over time. For example, in a longitudinal gambling disorder study, the researchers found that emotionally vulnerable and impulsive gamblers transitioned between the identified gambling subtypes, indicating that these two gambling subtypes had different experiences of problematic gambling [24]. Moreover, it is possible that disordered gaming behaviours are experienced differently across gamers. For example, within massively multiplayer role-playing games (MMORPGs), gamers control an avatar (i.e., virtual character) and whether they have high levels or low levels of interaction with their virtual avatar can influence the development of disordered gaming. In addition, it has been shown that gamers with different levels of social engagement may also present different risks of disordered gaming behaviour—illustrating that the experience of disordered gaming can vary from gamer to gamer in a number of ways [19,25,26]. Disordered behaviours, such as GD, are not created in a vacuum, and can be considered as a collection of complex processes with multiple facets that vary across different behaviours [27,28]. This has been considered a fundamental perspective across the addiction field [29], and within this process, personality traits (e.g., instability, impulsivity) have also been shown to play a part [30,31]. More specifically, research suggests that personality factors, such as low emotional stability, low agreeableness, and low conscientiousness are associated risk factors within addiction, including gaming disorder [32] and substance abuse [33]. It has also been suggested that these personality traits can vary across different disordered behaviours [29]. For example, gambling is positively associated with low emotional stability (i.e., neuroticism [34]), while gaming is negatively associated with extraversion [35]. However, at times the relationship between personality and disordered behaviours can be ambiguous, such as extraversion within problematic social media use, and excessive studying behaviours [29]. Therefore, understanding the personality nuances within these behaviours may help give a more holistic view of associated risk and protective factors. In addition, it has also been suggested that different coping strategies may be a result of, or partially attributed to, a diverse set of risk and protective factors among gamers [36,37]. It is important to understand how coping may vary across different gamers and how this may also be influenced by personality factors. 1.2. CopingCoping can be defined as the cognitive and behavioural response that occurs when an individual processes and manages stressful life events and emotions [38]. The association between gaming and coping has been considered by various scholars [37]. Among these, there have been three main domains that have been explored: problem-focused coping, emotion-focused coping, and dysfunctional coping [39,40,41]. In brief, problem-focused coping involves an active attempt to provide and implement solutions to reduce the life stressor (e.g., planning), and emotion-focused coping involves an attempt to engage and manage the unwanted negative emotions caused by the life stressor (e.g., humour [39]). Finally, dysfunctional coping involves an attempt to avoid or disengage the unwanted negative emotions or life stressors (e.g., denial [40,41]). A number of scholars have explored coping and its association with disordered gaming [36,41], with some pointing to a potential link. For instance, those with dysfunctional coping strategies tend to have an increased risk of psychopathology (e.g., depression, anxiety [42]), disordered behaviour, disordered substance use [37], and high neuroticism [43]. In a recent study conducted among a sample of Polish students, researchers found that participants who utilise media-focused coping strategies (e.g., gaming) to regulate their everyday life stressors appeared to have a higher risk of maladaptive coping behaviours. They concluded that dysfunctional coping strategies can exacerbate GD symptomology [41]. This finding is supported by a study which examined over 800 secondary students, whose disordered gaming behaviour was significantly associated with denial and behavioural disengagement—two coping styles which fall under the broader dysfunctional coping strategy domain [36]. This suggests that gamers play videogames in order to destress and to escape, and therefore some scholars suggest that this may fulfil a compensatory function in supporting individuals to cope with psychosocial problems [44]. These findings have led researchers to posit that disordered gaming may be, in part, better characterised as a manifestation of maladaptive coping strategies which have the potential to be exacerbated by other psychosocial issues [36]. For example, disordered gaming has been frequently associated with a pattern of escapism among individuals with depression [14]. Consequently, the continued use of gaming to escape may become an over-relied upon strategy resulting in negative long-term consequences with respect to the ability to cope with subsequent situations in which the primary coping strategy is not available. This may encourage an individual to seek other maladaptive habits in order to cope [37]. This may, in turn, further exacerbate psychopathological disorders such as depression and anxiety [41]. Indeed, research suggests that disordered gaming, like other behavioural disorders (e.g., gambling), can co-occur with problematic behaviours or substance use [37]. Additionally, disordered gaming appears to interact and/or co-occur with other conditions, which may result in complications for both risk assessment and diagnosis [37]. Therefore, it is important to consider the impact gaming has on individuals who have (or are at-risk of) disordered behaviours [19]. 1.3. Co-Occurrence of Addictive BehavioursCo-occurrence occurs when two or more potentially addictive behaviours (behavioural and/or substance-related) are engaged in concurrently or in close temporal proximity. In a recent review of co-occurrence of GD with other disordered behaviours, it was found that the presence of co-occurring disordered behaviour—or substance use—exacerbated symptomology of GD [37]. For example, Na et al. [45] found that South Korean adults who engaged in both problematic alcohol use and problematic gaming exhibited higher cigarette smoking rates than those who engaged in problematic alcohol use or problematic gaming alone. This was also supported by Ream et al.’s study [46], who investigated an American sample of adult gamers who had significant correlations between substance use and problematic videogame use, noting that the substances were often consumed while gaming.The overlap in potentially addictive behaviours appears to create a cycle of reciprocity [47,48,49], in which mutual exacerbation occurs between two or more problematic behaviours. This may explain why individuals who experience more than one disordered behaviour display poorer outcomes in relation to physical and mental wellbeing [14,49,50]. Consequently, the mutual exacerbation can create complications within clinical symptomology—confounding accurate assessment, diagnosis, and treatment of psychiatric disorders [51]. Similarly, GD may exacerbate existing addictive behaviours (e.g., substance use), causing symptomology of each behaviour to alternate—and therefore impacting treatment efficacy [52]. Therefore, clinicians and scholars should be aware of the way in which addictive behaviours may impact or enforce various aspects of a presenting disorder (e.g., GD), and consider how co-occurrence and contextual factors (e.g., coping strategies) may impact the onset, course, and outcomes of interventions.Although there is an association between coping, co-occurrence, and GD, additional research is needed into how these may be influenced across varying cultural contexts [46]. There is research to suggest that co-occurring disordered behaviour or substance use can vary based on geographical location [37], and that one’s country of origin can moderate disordered gaming [53]. Consequently, the field would benefit from the exploration of the cultural nuances found in co-occurring disordered behaviours, coping strategies, and gaming behaviour [54]. 1.4. Gaming and CultureScholars have consistently asserted that culture can impact psychopathology [54,55,56]. Further research indicates that it can impact the experience and understanding of psychosocial, addictive, and psychopathological disorders [8]. Moreover, several studies have explored cross-cultural variations in videogame playing behaviour, suggesting that the culture context the individual is based in can impact GD severity [6,57]. Therefore, it is important that the field develops an understanding of how GD may be experienced across differing regions, in an attempt to better understand the development and maintenance of disordered gaming behaviours [53,54,58]. In a broader context, culture might be described as patterns of behaviour that are explicitly and implicitly acquired and are communicated through symbols and/or practices, which are shared by those who accompany a collective/social identity [59]. There has been research conducted into the way cultures accept and interreact with technology, with Hofstede’s [60,61] proposed cultural dimensions being reliable in the field of information technology [62,63]. Hofstede’s cultural dimensions [60,61] attempt to categorise dominant cultures by systematically differentiating them from each other across six dimensions: power/distance, femininity/masculinity, uncertainty/avoidance, individualism/collectivism, long-term orientation, and indulgence. The present study focuses on cultures which present with high individualism as opposed to collectivism through the lens of Hofstede’s proposed cultural dimensions. Individualistic societies tend to be more loosely socially connected, and individuals in these cultures tend to identify as an ‘I’ rather than a ‘we’. Consequently, they tend to prioritise themselves and their immediate families rather than those with whom they are unfamiliar [60,61]. Hofstede’s [60,61] cultural dimensions provide a general understanding of the way in which a national culture expects, perceives, and assesses the values of its members. However, the theory has been criticised because it oversimplifies national culture—neglecting multicultural trends and individual differences found within each culture [64]. Nevertheless, there have been a number of studies which have considered cross-cultural comparisons in the GD literature [54,56], with a specific focus on the dichotomy between individualistic and collectivist cultures. Consequently, the nuance of either culture is not explored in depth. This is an important factor to consider because research suggests that within individualistic cultures, substance use and behaviours can differ depending on the geographical location of the culture [37]. For example, the United Nations’ ‘World Drug Report 2020′ [65] estimates that 1.3% of Australians use amphetamines, while England (including Wales) and NZ have rates of 0.6% and 0.8%, respectively. In addition, estimates of problematic behaviours and their co-occurrence can also differ across culturally diverse groups of individuals [37,66]. Therefore, understanding the way in which cultural context may influence problematic substance use, behaviours, and subsequent co-occurrence is of particular importance. Due to the intra-cultural differences found in behaviour and substance use, factors which influence coping styles (e.g., denial, escapism) within each country may also vary. This impacts the way individuals use videogames in relation to life stressors and the potential of co-occurring problematic use. A recent review by Burleigh et al. [37] reported four studies which considered coping in relation to disordered gaming. This demonstrates the need for further empirical evidence to better understand how individuals may utilise coping in a gaming context as a risk or protective factor against co-occurrence. Therefore, to gain a better understanding of how cultural dimensions may apply to disordered gaming, and to address the need of nuanced investigation of intra-cultural dimensions, in the present study, three countries considered individualist were explored [67], with a focus on gaming, personality factors, coping styles, and disordered substance use and/or behaviours and their potential co-occurrence. 1.5. The Present StudyThere has been evidence to suggest that gamers can have varying experiences of problematic gaming behaviours [25,26]. These varying experiences have been suggested to be due to coping mechanisms and how they can act as risk or protective factor for the development and/maintenance of disordered behaviours [36]. Furthermore, coping mechanisms can also shed light on the way an individual interacts and or engages in disordered behaviours—with research suggesting that dysfunctional coping strategies can result in exacerbating disordered behaviours through a cycle of co-occurrence and reciprocity [41]. A particular area of interest is how this may manifest across different countries. A number of studies have considered the dichotomy between individualistic and collectivist countries [54,55,56], focusing on the individualistic/collectivist attributes (e.g., competitiveness) that citizens in each country possess and how they differ. However, in doing so, they have overlooked the nuanced differences in disordered behaviours, personality factors, coping strategies, and the potential of co-occurrence found across similar countries in very different geographical locations [37]. This is an important facet to consider because understanding the interplay of these potential risk and protective factors within each of these countries will aid identifying and preventing disordered behaviours. Researchers have explored a number of these facets (e.g., gaming and coping [37]) using a variable-centred approach. This is an approach which provides specific information on the importance of each factor on the outcome variable [68]. However, these methods can be somewhat flawed when the assumption of homogeneity is applied to the sample [69]. Therefore, the present study considers a person-centred approach which is suited to examining the similarities and differences across participants, while considering how variables interact with one another [70]. This approach has a number of advantages because it can (i) assess whether distinct groups of individuals can be identified through naturalistic grouping of factors; (ii) offer complex combinations among all possible factors at all possible levels of each factor; and (iii) be clinically appropriate because decisions concerning assessment and treatments often focus on the individual rather than on the variable or factor [71]. In conjunction with the person-centred approach, the present study utilises latent profile analysis (LPA) to identify groups of individuals within each country that have similar profiles for multiple dimensions of psychopathology and disordered behaviours. LPA is used to define unobserved subgroups based on observed variables without specifying the number of profiles in advance. Therefore, it is believed to be a more appropriate method to address research questions that are exploratory in nature and to understand the diversity and complexity of multiple risk factors within psychopathology [72].

Consequently, the present study seeks to identify profiles of individuals characterized by unique patterns of disordered behaviours (e.g., gaming, substance use, etc.), personality factors (e.g., neuroticism), co-occurrence, and coping strategies across individualised countries. It is hypothesised that (i) a profile with higher co-occurrence across all disordered behaviours will be identified (H1); (ii) a profile with risk of disordered behaviours will be identified (H2); (iii) dysfunctional coping strategies, low agreeableness, low emotional stability, and low conscientiousness will be strongly associated with the profiles that have higher scores on disordered behaviours (i.e., behavioural and substance use variables), and least strongly associated with profiles with low risk of disordered behaviours (H3); and (iv) a profile of disordered behaviours differentiating between countries will be identified (H4).

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