Psychopathological symptoms and gaming motives in disordered gaming—A psychometric comparison between the WHO and APA diagnostic frameworks

Journal of Clinical Medicine, 2019

Christian Montag, Bruno Schivinski, Rayna Sariyska, Christopher Kannen, Zsolt Demetrovics, Halley M. Pontes

Journal of Clinical Medicine, volume 8, issue 10, article 1691, 15 October 2019

  • Open access
  • 1,429 German gamers
  • WHO vs APA frameworks
  • Mediation analysis
  • Open data (OSF)
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Keywords
  • gaming disorder
  • internet gaming disorder
  • World Health Organization
  • American Psychiatric Association
  • ICD-11
  • DSM-5
  • diagnostic frameworks
  • prevalence of gaming disorder
  • video game addiction
  • problematic gaming
  • gaming motives
  • escape motive
  • escapism
  • competition motive
  • coping motive
  • psychopathological symptoms
  • depression
  • loneliness
  • attention problems
  • Gaming Disorder Test (GDT)
  • Internet Gaming Disorder Scale–Short-Form (IGDS9-SF)
  • Motives for Online Gaming Questionnaire (MOGQ)
  • PHQ-9
  • UCLA Loneliness Scale
  • structural equation modelling
  • mediation analysis
  • bootstrapping
  • online survey
  • German gamers
  • Germany
  • self-medication hypothesis
  • clinical assessment
  • behavioural addictions
  • mental health

In 1,429 German gamers, 3.28% met the World Health Organization (WHO) criteria for gaming disorder and 5.74% met the American Psychiatric Association (APA) criteria for Internet gaming disorder, a significant difference. Yet the two frameworks told the same story about why: depression, loneliness and attention problems were linked to disordered gaming mainly through the escape motive.

Key findings

  1. The WHO framework is more conservative. 3.28% of 1,429 German gamers met the WHO criteria for gaming disorder (Gaming Disorder Test) and 5.74% met the APA criteria for Internet gaming disorder (IGDS9-SF); the difference was significant (χ² = 798.32, df = 1, p ≤ 0.001) (Montag et al., 2019).
  2. Escape is the strongest motive behind disordered gaming. Gaming to escape had the largest direct effect on disordered gaming under both frameworks (β = 0.44 WHO, 0.47 APA, p < 0.001), followed by competition (β = 0.16 and 0.21) (Montag et al., 2019).
  3. Skill development and recreation motives are protective. Playing to develop skills (β = −0.09 WHO, −0.08 APA) and for recreation (β = −0.14 WHO, −0.09 APA) was linked to fewer disordered gaming symptoms under both frameworks (Montag et al., 2019).
  4. Psychopathology works through gaming motives. Depression, loneliness and attention problems were linked to disordered gaming mainly through the escape motive; for example, the indirect effect of depression through escape was β = 0.36 (WHO) and 0.39 (APA), p < 0.001 (Montag et al., 2019).
  5. The two frameworks largely agree. Direct, indirect and total effects were highly comparable across the WHO and APA frameworks; total effects were slightly stronger under the APA framework (depression β = 0.39 vs 0.49) (Montag et al., 2019).

At a glance

Design
Cross-sectional online survey; study registered on the Open Science Framework with the dataset made freely available
Participants
1,429 German gamers recruited through www.gaming-disorder.org (80% male; mean age 29.74, SD = 12.37; range 12–82)
Disordered gaming
WHO framework: Gaming Disorder Test (GDT, 4 items); APA framework: Internet Gaming Disorder Scale–Short-Form (IGDS9-SF, 9 items)
Predictors and mediators
Depression (PHQ-9), loneliness (UCLA Loneliness Scale, version 3), attention problems; seven gaming motives (MOGQ): social, escape, competition, coping, skill development, fantasy, recreation
Analysis
Two structural equation mediation models (one per framework) controlling for weekly gaming time, age and gender; ML estimation with 5,000 bootstrap samples (Mplus 8.3)

Figure 1. The mediation model tested

DepressionLonelinessAttention problemsSocialEscapeCompetitionCopingSkill developmentFantasyRecreationDisordered gamingWHO (GDT) or APA (IGDS9-SF)PSYCHOPATHOLOGYGAMING MOTIVES (MEDIATORS)OUTCOMEControls: weekly gaming time,age, gender
Depression, loneliness and attention problems predict seven gaming motives, which in turn predict disordered gaming; direct paths from each symptom to disordered gaming were also estimated. The model was run twice, once with the WHO measure (GDT) and once with the APA measure (IGDS9-SF), controlling for weekly gaming time, age and gender. Drawn from the article’s Methods; the article itself has no figures. The highlighted path (escape) had the largest effect.

Figure 2. Direct effects of gaming motives on disordered gaming, WHO vs APA

−0.2+0.2+0.40Standardised direct effect on disordered gaming (β)Escape+0.44+0.47Competition+0.16+0.21Coping+0.07 (n.s.)+0.08Social+0.03 (n.s.)+0.04 (n.s.)Fantasy+0.01 (n.s.)+0.05 (n.s.)Skill development−0.09−0.08Recreation−0.14−0.09WHO framework (GDT)APA framework (IGDS9-SF)open bar: not significant (p ≥ 0.05)
Standardised direct effects (β) from Table 2 of the article. WHO model: χ²(986) = 5488.32, CFI = 0.91, TLI = 0.90, RMSEA = 0.05; APA model: χ²(1226) = 6941.63, CFI = 0.90, TLI = 0.90, RMSEA = 0.05.

Prevalence of disordered gaming by diagnostic framework

WHO framework (GDT)3.28%APA framework (IGDS9-SF)5.74%
Share of the 1,429 gamers classified as disordered gamers under each framework (Table 1 of the article). The difference was statistically significant.

Tables

Table 1. Main sociodemographic characteristics and related gaming behaviors among the sample
N = 1429
Gender (Male, %) 1229 (80)
Age, Years (Mean, SD) 29.74 (12.37)
Relationship Status (in a Relationship, %) 749 (52.41)
Employment Status (Unemployed, %) 986 (68.99)
Time Spent Gaming on Weekdays (Mean, SD) 19.15 (14.69)
Time Spent Gaming on Weekends (%) 42
Preferred Mode of Play (online, %) 798 (55.84)
In-game Social Membership (Participation, %) 548 (38.34)
Intention to Become a Professional Gamer (yes, %) 82 (5.74)
Experienced Significant Problems due to Gaming (yes, %) 150 (10.5)
Attention Problems (Mean, SD) 6.43 (2.52)
Depression Severity (Mean, SD) 13.58 (4.13)
Loneliness Severity (Mean, SD) 6.12 (2.98)
GD Symptom Severity (Mean, SD) 8.46 (3.42)
IGD Symptom Severity (Mean, SD) 19.36 (6.62)
GD Prevalence (n, %) 47 (3.28)
IGD Prevalence (n, %) 82 (5.74)
Item-Related Descriptive Statistics (Mean, SD)
GDT item 1 2.29 (1.04)
GDT item 2 2.60 (1.09)
GDT item 3 1.95 (1.09)
GDT item 4 1.62 (.92)
IGDS9-SF item 1 2.53 (1.15)
IGDS9-SF item 2 1.71 (1.01)
IGDS9-SF item 3 1.94 (1.07)
IGDS9-SF item 4 1.90 (1.06)
IGDS9-SF item 5 1.89 (1.11)
IGDS9-SF item 6 1.83 (1.09)
IGDS9-SF item 7 1.61 (.96)
IGDS9-SF item 8 2.21 (1.21)
IGDS9-SF item 9 1.34 (.80)
Table 2. Summary of the mediation analysis according to the World Health Organization (WHO) framework for Gaming Disorder (GD) and American Psychiatric Association (APA) framework for Internet Gaming Disorder (IGD)
GD β GD t-value GD p-value IGD β IGD t-value IGD p-value
Direct effects
Depression → Social 0.37 11.96 0.001 0.37 12.03 0.001
Depression → Escape 0.81 48.88 0.001 0.81 49.40 0.001
Depression → Competition 0.28 9.78 0.001 0.28 9.84 0.001
Depression → Coping 0.61 24.29 0.001 0.61 24.43 0.001
Depression → Skill development 0.34 11.67 0.001 0.34 11.72 0.001
Depression → Fantasy 0.62 26.33 0.001 0.62 26.57 0.001
Depression → Recreation 0.30 9.67 0.001 0.30 9.75 0.001
Loneliness → Social 0.17 5.43 0.001 0.17 5.50 0.001
Loneliness → Escape 0.52 21.85 0.001 0.52 22.13 0.001
Loneliness → Competition 0.12 4.26 0.001 0.13 4.36 0.001
Loneliness → Coping 0.33 11.36 0.001 0.33 11.44 0.001
Loneliness → Skill development 0.14 4.99 0.001 0.15 5.02 0.001
Loneliness → Fantasy 0.42 15.93 0.001 0.42 16.05 0.001
Loneliness → Recreation 0.08 2.59 0.01 0.08 2.66 0.01
Attention → Social 0.66 27.37 0.001 0.66 27.30 0.001
Attention → Escape 0.67 28.86 0.001 0.67 29.03 0.001
Attention → Competition 0.51 20.26 0.001 0.51 20.23 0.001
Attention → Coping 0.78 38.85 0.001 0.78 38.89 0.001
Attention → Skill development 0.66 30.78 0.001 0.66 30.67 0.001
Attention → Fantasy 0.68 30.19 0.001 0.68 30.27 0.001
Attention → Recreation 0.65 28.42 0.001 0.65 28.35 0.001
Social → GD 0.03 1.02 0.30 0.04 1.40 0.16
Escape → GD 0.44 10.47 0.001 0.47 12.28 0.001
Competition → GD 0.16 5.397 0.001 0.21 7.42 0.001
Coping → GD 0.07 1.74 0.08 0.08 2.10 0.03
Skill development → GD −0.09 −2.78 0.005 −0.08 −2.76 0.006
Fantasy → GD 0.01 0.035 0.97 0.05 1.39 0.16
Recreation → GD −0.14 −4.28 0.001 −0.09 −2.90 0.004
Indirect effects
Depression → Social → GD 0.01 1.02 0.30 0.01 1.38 0.16
Depression → Escape → GD 0.36 9.86 0.001 0.39 11.43 0.001
Depression → Competition → GD 0.04 4.71 0.001 0.06 5.93 0.001
Depression → Coping → GD 0.04 1.73 0.08 0.05 2.08 0.03
Depression → Skill development → GD −0.03 −2.69 0.007 −0.03 −2.67 0.01
Depression → Fantasy → GD 0.01 0.035 0.97 0.03 1.39 0.16
Depression → Recreation → GD −0.04 −3.88 0.001 −0.02 −2.77 0.006
Loneliness → Social → GD 0.01 1.02 0.30 0.01 1.42 0.15
Loneliness → Escape → GD 0.21 9.35 0.001 0.23 10.74 0.001
Loneliness → Competition → GD 0.02 3.37 0.001 0.02 3.77 0.001
Loneliness → Coping → GD 0.02 2.08 0.03 0.03 2.57 0.01
Loneliness → Skill development → GD −0.01 −2.36 0.01 −0.01 −2.36 0.01
Loneliness → Fantasy → GD 0.01 0.56 0.57 0.02 1.96 0.05
Loneliness → Recreation → GD −0.01 −2.24 0.02 −0.01 −2.00 0.04
Attention problems → Social → GD 0.01 0.64 0.52 0.02 0.82 0.41
Attention problems → Escape → GD 0.28 9.32 0.001 0.30 10.80 0.001
Attention problems → Competition → GD 0.09 5.16 0.001 0.11 6.80 0.001
Attention problems → Coping → GD 0.07 2.02 0.01 0.08 2.28 0.02
Attention problems → Skill development → GD −0.07 −2.84 0.01 −0.07 −2.98 0.003
Attention problems → Fantasy → GD 0.01 0.23 0.81 0.03 1.54 0.12
Attention problems → Recreation → GD −0.11 −4.34 0.001 −0.07 −3.23 0.001
Total effects
Depression → GD 0.39 16.03 0.001 0.49 22.07 0.001
Loneliness → GD 0.24 12.81 0.001 0.31 15.92 0.001
Attention → GD 0.28 9.82 0.001 0.41 15.72 0.001
Controls
Age → GD −0.08 −3.33 0.001 −0.09 −3.90 0.001
Gender → GD −0.06 −2.53 0.01 −0.03 −1.55 0.11
Gaming time → GD 0.25 9.43 0.001 0.22 8.94 0.001

The question

The APA (DSM-5, 2013) and the WHO (ICD-11, 2019) define disordered gaming differently: the APA proposes nine criteria for Internet gaming disorder, of which five must be met, while the WHO defines gaming disorder through impaired control, increasing priority given to gaming and continued gaming despite negative consequences. Researchers did not know whether the two frameworks produce different prevalence rates, or whether they lead to the same conclusions about how mental-health symptoms and gaming motives relate to disordered gaming.

Implications

Practical implications

Prevalence estimates depend on the diagnostic framework and tool, so studies and health reports should state which one they use and avoid comparing rates across frameworks. In treatment, clinicians should look at why clients play (especially gaming to escape negative feelings) rather than only at how much time they spend gaming; time spent can instead track progress in therapy. Helping clients understand their life goals and gaming motives may reduce urges and cravings.

Theoretical implications

The study supports the conceptual and psychometric feasibility of the WHO framework for gaming disorder and its measurement with the German GDT, since results closely matched the established APA framework. It shows that gaming motives mediate the link between psychopathological symptoms and disordered gaming regardless of framework, and frames the role of the escape motive within the self-medication hypothesis of addictive disorders.

Limitations and future research

  • The cross-sectional design does not allow causal inferences about gaming motives and symptoms.
  • The convenience sample of German gamers, recruited through mass-media advertising, may be affected by self-selection, so prevalence rates may not generalise to all German gamers or other cultures.
  • Self-reports can be affected by memory recall bias and social desirability.
  • Future research should study specific populations (e.g., professional and e-sports gamers, clinical groups such as people with autism spectrum disorder), use longitudinal designs, and distinguish positive and negative forms of escapism.

Questions this paper answers

Do the WHO and APA criteria give different prevalence rates for gaming disorder?

Yes. In 1,429 German gamers, 3.28% met the WHO criteria (Gaming Disorder Test) and 5.74% met the APA criteria (IGDS9-SF), a statistically significant difference (Montag et al., 2019).

Which gaming motive is most strongly linked to gaming disorder?

Escape: playing to avoid real-life problems had the largest direct effect on disordered gaming under both the WHO (β = 0.44) and APA (β = 0.47) frameworks (Montag et al., 2019).

Can some gaming motives protect against gaming disorder?

Playing for skill development and for recreation was associated with fewer disordered gaming symptoms under both frameworks (β between −0.08 and −0.14) (Montag et al., 2019).

How are depression and loneliness related to gaming disorder?

Depression, loneliness and attention problems were associated with disordered gaming, largely through the escape motive: people with more symptoms play more to escape, which in turn predicts more disordered gaming (Montag et al., 2019).

Key concepts

Gaming disorder (WHO, ICD-11)
A pattern of gaming marked by impaired control, increasing priority given to gaming over other interests and activities, and continuation despite negative consequences, with significant impairment over 12 months.
Internet gaming disorder (APA, DSM-5)
A condition proposed for further research in the DSM-5, diagnosed when five or more of nine criteria (such as preoccupation, withdrawal, tolerance and loss of control) are met over 12 months.
Gaming motives
The reasons people play; the Motives for Online Gaming Questionnaire measures seven: social, escape, competition, coping, skill development, fantasy and recreation.
Self-medication hypothesis
The idea that people engage in addictive behaviours to relieve painful emotional states, used in the article to explain the role of the escape motive.

Open science and materials

How to cite

Montag, C., Schivinski, B., Sariyska, R., Kannen, C., Demetrovics, Z., & Pontes, H. M. (2019). Psychopathological symptoms and gaming motives in disordered gaming—A psychometric comparison between the WHO and APA diagnostic frameworks. Journal of Clinical Medicine, 8(10), Article 1691. https://doi.org/10.3390/jcm8101691

Open access under a Creative Commons CC BY 4.0 licence.

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