Video Game Addiction, Engagement and Symptoms of Stress, Depression and Anxiety: The Mediating Role of Coping

Abstract

A number of studies have reported a co-occurrence between video game addiction and poorer mental health, but few have contextualised this relationship by identifying mediating variables. Further, there remains uncertainty in how to differentiate high engagement from what may be termed addiction in the context of video gaming. This study examined the mediating role of coping between one measure of video game addiction and engagement, and mental health. An international sample of 552 adult participants (M age 24.9 years, 52.3 % Australian) completed an online survey including the Computer Addiction-Engagement Scale (CAES), Depression, Anxiety Stress Scale (DASS-21) and Approach/Avoidance Coping Questionnaire (BACQ). Multiple mediation analysis showed that coping explained a significant portion of the relationship between video game addiction and symptoms of depression, anxiety and stress. However, even after accounting for coping, a direct relationship remained. Video game engagement, on the other hand, indicated full mediation with no direct connection to declined mental health, except in the case of anxiety. Less use of approach coping strategies and particularly more use of resignation and withdrawal coping strategies were related to poorer mental health. Gaming for distraction was unrelated to mental health. This study identified maladaptive coping as a partial explanation of the relationship between video game addiction and poorer mental health. Also, the findings provide validity for making a distinction between video gaming engagement and addiction. Highly engaged gamers with maladaptive coping styles may be more vulnerable to developing video game addiction.

Full text

Video Game Addiction, Engagement and Symptoms
of Stress, Depression and Anxiety: The Mediating Role
of Coping
Daniel Loton
1
& Erika Borkoles
2,3
& Dan Lubman
4,5
&
Remco Polman
6,7
#
Springer Science+Business Media New York 2015
Abstract A number of studies have reported a co-occurrence between video game addiction
and poorer mental health, but few have contextualised this relationship by identifying mediating
variables. Further, there remains uncertainty in how to differentiate high engagement from what
may be termed addiction in the context of video gaming. This study examined the mediating role
of coping between one measure of video game addiction and engagement, and mental health. An
international sample of 552 adult participants (M age 24.9 years, 52.3 % Australian) completed
an online survey including the Computer Addiction-Engagement Scale (CAES), Depression,
Anxiety Stress Scale (DASS-21) and Approach/Avoidance Coping Questionnaire (BACQ).
Multiple mediation analysis showed that coping explained a significant portion of the relation-
ship between video game addiction and symptoms of depression, anxiety and stress. However ,
even after accounting for coping, a direct relationship remained. Video game engagement, on the
other hand, indicated full mediation with no direct connection to declined mental health, except
in the case of anxiety. Less use of approach coping strategies and particularly more use of
resignation and withdrawal coping strategies were related to poorer mental health. Gaming for
distraction was unrelated to mental health. This study identified maladaptive coping as a partial
explanation of the relationship between video game addiction and poorer mental health. Also, the
Int J Ment Health Addiction
DOI 10.1007/s11469-015-9578-6
* Remco Polman
rpolman@bournemouth.ac.uk
1
Centre for Collaborative Learning and Teaching, Victoria University, Melbourne, Australia
2
Department of Sport and Physical Activity, Bournemouth University, Poole, UK
3
Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia
4
Eastern Health Clinical School, Monash University, Melbourne, Australia
5
Director, Turning Point Alcohol and Drug Centre, Victoria, Australia
6
Centre for Behavioural Change, Psychology Department, Bournemouth University, Poole, UK
7
Institute for Sports, Exercise and Active Living, Victoria University, Melbourne, Australia

findings provide validity for making a distinction between video gaming engagement and
addiction. Highly engaged gamers with maladaptive coping styles may be more vulnerable to
developing video game addiction.
Keywords Video game addiction
.
V ideo game engagement
.
Coping
.
Mental health
Preliminary empirical and anecdotal evidence suggests excessive video gaming, commonly
called video game addiction, may have some similar characteristics to other more well-
established addictive conditions (King et al. 2013). The preliminary ‘internet gaming disorder’
(IGD) has been included in the Diagnostic and Statistical Manual of Mental Disorders to
prompt further topical research (5th ed.; DSM-5; American Psychiatric Association 2013). An
important issue in accurately defining IGD, however, is to distinguish it from an intense but
ultimately benign or even healthy interest and prioritisation of gaming, sometimes referred to
as ‘engagement’ (Charlton and Danforth 2007). One key feature that should denote addiction
is negative consequences. Where video game addiction would be expected to be associated
with a range of negative consequences including mental, physical and social decline, high
levels of engagement would not (Seok and DaCosta 2014). In particular, video game addiction
has been associated with increased symptoms of stress, anxiety and depression (e.g., Mentzoni
et al. 2011). While several studies have established a cross-sectional relationship between
video game addiction and poorer mental health in terms of increased symptoms of stress,
anxiety and depression, few studies have yet tested for the importance of mediating or
moderating variables. Testing for these may identify the conditions under which video game
addiction is most associated with harm (Preacher and Hayes 2008). Coping is one possible
mediator, with video game addiction often being described as a form of maladaptive and
primarily escape- based coping (Beranuy et al. 2013; Tejeiro et al. 2012; Wan and Chiou 2006;
Yee 2006). The present study, therefore, examined relationships between video game addic-
tion, engagement and mental health (in terms of symptoms of stress, anxiety and depression),
and tested whether coping is a potential mediator in these relationships.
Whether a time-consuming and intense psychological and behavioural prioritisation of
video gaming can be considered a new mental illness is a vexed issue. Agreement is limited
on the precise defining characteristics of what can be termed video game addiction, whether
it should be considered an officially diagnosable mental illness and the requisite supporting
evidence (King and Delfabbro 2014;Kingetal.2013;Petry2013; Petry et al. 2014;
Starcevic 2013). Most research has applied some form of ‘general ’ addiction theory, which
facilitates the application of addiction to any activity, when defining and measuring video
game addiction (Brown 1997; Griffiths 2005). Closely reflected in the recently proposed
diagnostic criteria for IGD, such models have some variations (King et al. 2013), but
broadly suggest video game addictio n is char acterised by six factors: Salience (video
gaming dominates a person’s cognitions and behaviour), Euphoria/Mood Modification
(receiving a ‘buzz’ from gaming), Tolerance (spending increasing amounts of time p laying
video games to achieve ‘buzz’), Withdrawal (unpleasant emotions o r physical effects when
video gaming is stopped), Conflict ( with others, self or major responsibilities) and Relapse/
Reinstatement (inability to cut b ack or stop play). Many studies have applied these factors to
video g ame playing in the form of short scales and found varying levels of self-reported
preval
ence (King et al. 2013; Mentzoni et al. 20 11).
Int J Ment Health Addiction

The validity of using these factors as the main determinants for video game addiction is
equivocal. Some of these components may not be inherently deleterious and likely to be present in
the intense interest and prioritisation of any pursuit (Charlton and Danforth 2007). These
researchers have termed this intense interest ‘engagement’, in what may also be described as a
lifestyle choice, hobby, or enthusiasm. Based on a theoretical review Charlton and Danforth
concluded that behavioural salience, withdrawal, internal and external conflict, and relapse/
reinstatement were part of video game addiction as they are inherently negative whereas cognitive
salience, euphoria/mood modification, and tolerance were part of engagement. This possible
distinction between addiction and engagement was investigated in relation to general computer
use (Charlton 2002), and playing a specific online video game (Charlton and Danforth 2007). In
both cases factor analyses supported the distinction, and some preliminary external validity has
also emerged with differences apparent in personality (Charlton and Danforth 2010), academ ic
performance (Skoric et al. 2009) and attentional profiles (Metcalf and Pammer 2011) for those
being classified as addicted versus highly engaged. Although, Seok and DaCosta (2014) recently
did not find significant differences in the social life of engaged and addicted online adolescent
gamers in Korea. These researchers, however, argued that the age of their sample might have
influenced their results and that future studies should consider older adult gamers.
Some researchers argue that the key differentiating feature of video game addiction is that it
causes negative consequences (Griffiths 2008). Poorer mental health in terms of higher
prevalence of symptoms of stress, depression and anxiety has been repeatedly associated with
measures of video game addiction in studies across countries. A large Norwegian study (N=
2500) of 15–40 years olds showed a significant relationship between severity of video game
addiction and symptoms of depression and anxiety (Mentzoni et al. 2011). A Dutch study of
13–16 year olds also found that video game addiction was associated with higher levels of
depressed mood (Van Rooij et al. 2011). Similarly, in a sample of 412 adult Australian video
game players, there was a small but significant relationship between severity of video game
addiction and symptoms of depression, anxiety and stress (King et al. 2011). Another
Australian-led study with an international sample of 1945 participants, most between 14 and
30 years of age, reported the 156 (or 8 %) participants diagnosed as addicted showed
significantly higher scores on all dimensions of the Symptom Checklist 90 (SCL-90) than
non-addicts; pa rticularly obsessive-compulsive, interpersonal sensitivity and depression
(Starcevic et al. 2011). Finally, a rare longitudinal study tracked Singaporean youth for 3 years
and identified depression, anxiety, social phobia and school grades as negative consequences,
as they worsened after development of the condition (Gentile et al. 2011). Whereas video game
addiction has been associated with poorer mental health the distinction put forward by
Charlton and Danforth (2007) would suggest that engagement would not result in reduced
mental health. Yet there is currently limited empirical evidence to support this.
Beyond testing for differential relationships between addiction and engagement, few studies
have identified variables which might contextualize reported relationships between video game
addiction and poorer mental health in terms of increased symptoms of stress, depression and
anxiety. A potential mediator could be coping. Coping refers to ‘constantly changing cognitive and
behavioral efforts to manage specific external and/or internal demands that are appraised as taxing
or exceeding the resources of the person’ (Lazarus and Folkman 1984, p. 141). Although there are
many different coping strategies, they are often conceptualised under the higher order dimensions
‘approach’ (i.e.,
concentrated efforts to manage a stressful event, such as planning) and ‘avoidance’
coping (Krohne 1993). The latter includes activities or cognitive changes to avoid situations via
diversion (cognitive distancing) or withdrawal (Finset et al. 2002). Health psychology literature
Int J Ment Health Addiction

indicates that a systematic lack of coping, or over-reliance on avoidance coping, predicts numerous
negative health consequences, even without the presence of other conditions. Specifically, high
avoidance coping combined with less approach coping has been associated with poorer mental
health outcomes (Clark and Hovanitz 1989; Folkman et al. 1986).
In a number of qualitative studies video game addiction has been associated with a lack of
coping skills, or described, by both researchers and gamers, as an escape-based coping strategy
(Allison et al. 2006; Beranuy et al. 2013; Wan and Chiou 2006; Wood and Griffiths 2007).
Several studies have also reported associations between video game addiction and a desire to
escape (Gentile et al. 2011; Tejeiro et al. 2012;Yee2006). Earlier studies have indicated that
the use of avoidance coping strategies (withdrawal or wishful thinking) are associated with
increased problematic internet use in Chinese college students (Li et al. 2009) and American
undergraduate students (Hetzel-Riggin and Pritchard 201 1). A more recent study showed that a
sample of clinically diagnosed internet addicts from Turkey used significantly less problem
focused coping (e.g., active coping, planning) and emotion focused (e.g., positive reinterpre-
tation, emotional social support) strategies but more avoidance coping strategies (e.g., behav-
ioral disengagement, denial) compared to a control group (Şenormancı et al. 2014). However,
a limitation of generalized internet addiction studies is that they do not distinguish between
different internet-based activities. Accessing pornography and even gambling, for which there
is already a distinct diagnosable condition, may be among these internet activities. While there
may be some shared components, it is also highly likely that such activities qualitatively differ
from online video game playing. Further, these studies did not include a theorized negative
consequence of internet addiction, such as reduced mental health, and test whether coping
altered that relationship. As such it is unclear whether such findings can be generalized to the
domain of coping, video game addiction and mental health.
To date no study has explicitly examined the relationship between video game addiction or
engagement, coping and mental health. In particular, the possible mediating role of coping
warrants testing because coping skill training is already a common empirically supported
component of interventions for additive disorders (Witkiewitz et al. 2005) and in improving
mental health more generally (Taylor and Stanton 2007). Video game addiction researchers
have called for more studies with adults (Seok and DaCosta 2014).
In this study we have investigated whether coping mediates relationships between video game
addiction, or engagement, and mental health in terms of symptoms of stress, depression and anxiety in
adult problem video gamers. Based on prior studies of coping and mental health (Folkman et al. 1986),
and the distinction put forward by Charlton and Danforth (2007), we predicted that higher levels of
video game addiction would be associated with increased symptoms of stress, depression and anxiety ,
particularly when paired with lower approach and higher avoidance coping. The effect of addiction on
symptoms of stress, depression and anxiety will be direct (i.e., partial mediation). On the other hand
engagement would have no direct effect on symptoms of stress, depression and anxiety, except via
lower approach and higher avoidance coping.
Method
Participants
In total 576 participants fully completed the survey. Responses that indicated lack of fluency in
English (n=5) or were deemed to be spurious (n=4) were discarded. A number of participants
Int J Ment Health Addiction

only completed some of the survey. Although excluded from the final analysis, one-way t-tests
were conducted to compare the partially completed surveys for which subscales could be
computed (n=31) with the completed surveys. No significant differences (all p>0.05) were
observed. IP addresses were checked to identify duplicate responses, but none were found. An
additional 15 cases were removed as outliers (detailed below), leaving a final sample of 552.
The mean age of the final sample was 24.90 years (SD=7.28) and ranged from 18 to
59 years (28.1 %≤ 20 years of age, 58.20 % between 21 and 30 years, 10.80 % between 31 and
40 years, 2.59 % aged between 41 and 54). The majority resided in Australia (52.3 %), with
the rest divided among several European countries (33 %), the USA (4.2 %), Brazil (4.2 %)
and smaller cohorts from a number of other countries.
Instruments
The computer engagement/addiction scale (CEAS) (Charlton and Danforth 2007)wasusedto
measure levels of video game engagement and addiction. In this study, the term ‘Asheron’sCall’
was replaced with the generic ‘video games’. Inclusive of Brown’s components model of addiction,
the CEAS has been found to have a good factorial structure and reliability as well as some
convergent validity across a number of studies (Charlton 2002; Charlton and Danforth 2007, 2010;
Metcalf and Pammer 2011;Skoricetal.2009). The present study obtained good reliability
(Chronbach’s α=0.85 for engagement and 0.86 for addiction) including an absence of inverse
inter-correlations among items.
Mental health symptoms were assessed using the 21-item Depression Anxiety Stress Scale
(DASS-21), which has been found to have very good validity and reliability in past studies (Lovibond
and Lovibond 1995). In the present study the subscales demonstrated good reliability (α=0.92 for
Depression, 0.78 for Anxiety and 0.84 for Stress). Although the DASS-21 does not provide a clinical
diagnosis, it describes severity ratings (normal, mild, moderate, severe and extremely severe), with
higher scores indicating more severity of symptoms.
Coping was measured using the 12-item Brief Approach-Avoidance Questionnaire (BACQ).
The BACQ measures Approach coping and Avoidance (Resignation, Withdrawal and Diver-
sion) coping and has shown good predictive validity and reliability (Finset et al. 2002). In the
present study the BACQ had acceptable reliability with Chronbach’s α of 0.69 for Approach,
0.71 for Resignation and Withdrawal and 0.62 for Diversion scale. Although some of the
factors of the BACQ had low levels of internal consistency it was decided to include these in the
statistical analysis. As previously stated by Billings and Moos (1981), one coping strategy
might be adequate to relieve stress and as such would not require additional responses from
either the same category or other categories of coping. Therefore, Bpsychometric estimates of
internal consistency may have limited applicability in assessing the psychometric adequacy of
measures of coping^ (Billings & Moos, p. 145). In addition, it is worth considering that
calculation of Chronbach Alpha coefficient is influenced by the number of items, and when
the avoidance coping scales are separated into two sub-scales (resignation and diversion), as
they were in this study, each sub-scale is only 3 items, and as such this likely influenced the
Chronbach Alpha values.
Procedure
Adult video game players were recruited via online video gaming forums and a communica-
tions campaign, which included media coverage and exposure of the study to a global public
Int J Ment Health Addiction

audience. After being directed to a website hosting the study, participants were asked whether
they either feel that they may play video games too much, or that they have some sort of
problem with their video game playing. This open-ended description was designed to capture
the most problematic self-identified gamers without being overly prescriptive. These descrip-
tions align with BI think I play video games too much^ and BI think I have some type of problem
associated with my video game playing^, which have been shown to be endorsed significantly
more by people who met polythetic criteria for video game addiction (Tejeiro and Morán 2002).
As such, this sample is intentionally biased towards the more severe self- identified problematic
gamers. All participants who completed the online survey at every time point were placed into a
draw to win AU$500.
Analysis
To investigate the prediction that the relationship between video game addiction and mental
health would be mediated by coping, a multiple mediation method was used. A bootstrap
(5000) resample procedure calculated the direct and indirect effects of video game addiction or
engagement (independent factors) on mental health (dependent factors: stress, anxiety and
depression). Six models in total were generated, examining whether approach, withdrawal and
distraction coping fully or partially mediated the relationships between addiction or engage-
ment and depression, anxiety and stress. All statistical analyses were conducted using SPSS V.
20 and a macro for SPSS, which facilitates multiple mediation analysis. This provided the
direct, indirect, and total effects, and bias corrected and accelerated (BCa) confidence intervals
(CI) (Preacher and Hayes 2004, 2008).
Outliers Univariate outliers were identified on the basis of z>3.29 (p<0.001). Only four
cases of very high anxiety and two cases of very low engagement were identified on this basis.
These six cases were removed. Multivariate outliers were then screened by calculating
Mahalanobis’ distance for each case based on all eight measures employed, and nine cases
were identified based on a probability of less than p<0.001 on a Chi-Square distribution
(Tabachnick and Fidell 2013). All eight measures were then regressed onto a dummy variable
denoting these nine outliers, with results indicating this group had significantly lower addiction
(standardized beta coefficient (β)=−0.12, p=0.04). In addition, these nine participants had
either zero or only one hour or video game play time in the past month. The researchers believe
these cases are explained by only very occasional video gamers taking part in the study out of
interest. As the study advertisements were explicit in inviting gamers to take part who feel that
they may play video games too much, and the very low scores on engagement and little or no
gaming time for these nine participants suggest they hold very little to no interest in video
games (at least at the time of the study), they were excluded from the present analysis (final
sample N=552).
Results
Table 1 provides an overview of the mean and standard deviations of the scales used in the
present study. Table 2 provides the details of the mediation analysis for video game addiction
and mental health. The mediation analysis identified that coping was a partial mediator
Int J Ment Health Addiction

between addiction and stress, anxiety and depression (See Fig. 1a, b & c). There was a
significant total effect of addiction on stress, anxiety and depression (path c; p<0.01), and a
significant but smaller direct effect of coping on stress, anxiety and depression adjusted for the
mediators (path c’; p<0.01) indicating partial mediation. The total indirect effects had a BCa
CI which was different from zero. Approach and resignation and withdrawal coping were
significant partial mediators between addiction and anxiety and depression whereas resignation
and withdrawal coping was a partial mediator between addiction and stress. Diversion coping
Table 1 Descriptive statistics for the measures
Scale M SD Skew Kurt α Range
DASS-21
Depression 6.76 5.77 0.72 −0.57 0.92 0–21
Anxiety 4.07 3.88 1.08 0.55 0.78 0–21
Stress 6.55 4.62 0.58 −0.37 0.84 0–21
CEAS
Addiction 29.58 7.08 0.15 –0.11 0.86 13−50
Engagement 46.00 6.97 0.20 –0.22 0.85 16−64
BACQ
Approach 20.31 4.23 −0.29 −0.20 0.69 6−30
Diversion 9.44 2.58 −0.21 −0.21 0.62 3–15
Resignation / withdrawal 8.50 3.07 0.11 −0.79 0.71 3–15
Note. Skewness standard error 0.10 and kurtosis 0.22
Table 2 Multiple mediation analysis of video game addiction and DASS subscales (stress, anxiety, depression)
mediated by approach, diversion, and resignation and withdrawal coping
Multiple mediation model Point estimate Product of coefficient BCa 95 % CI
SE Z Lower Upper
Indirect effects – addiction and stress
Approach 0.02 0.01 1.69 0.00 0.03
Diversion 0.00 0.00 0.31 −0.01 0.01
Resignation / withdrawal 0.12*** 0.02 6.75 0.08 0.15
Total 0.13*** 0.02 8.11 0.10 0.17
Indirect effects – addiction and anxiety
Approach 0.02* 0.01 2.26 0.00 0.03
Diversion 0.00 0.00 0.20 −0.01 0.01
Resignation / withdrawal 0.09*** 0.01 6.14 0.06 0.12
Total 0.11*** 0.01 7.77 0.08 0.14
Indirect effects – addiction and depression
Approach 0.08*** 0.01 6.03 0.06 0.11
Diversion 0.00 0.00 0.32 0.00 0.00
Resignation / withdrawal 0.19*** 0.02 9.21 0.16 0.24
Total 0.28*** 0.02 11.14 0.23 0.33
Note: * p<0.05; ** p<0.01; ***p<0.001
Int J Ment Health Addiction

did not contribute to the indirect effects above and beyond approach and withdrawal and
resignation coping. Lower levels of addiction were associated with greater use of approach
a
N
ote. ***= p<.001; **p <.01; *p<.05. R2=.35 Adjusted R2=.34
b
N
ote. *** = p<.001; **p <.01; *p<.05. R2=.33 Adjusted R2=.32
c
N
ote. *** = p <.001; **p < .01; *p < .05. R2 = .55; Ad
j
usted R2= .55.
Video game
addiction
Diversion
Approach
Resignation /
withdrawal
Stress
-.20
***
.07
***
.22
***
.18
**
-.08
.02
.54
***
Video game
addiction
Diversion
Approach
Resignation /
withdrawal
Anxiety
-.20
***
.07
***
.22
***
.15
** *
-.09
*
.01
.40
***
Video game
addiction
Diversion
Approach
Resignation /
withdrawal
Depression
-.20
***
.07
***
.22
***
.09
*
-.40
***
.09
.89
***
Fig. 1 a: Multiple mediation analysis of video game addiction and stress symptoms mediated by approach,
diversion, and resignation and withdrawal coping. b: Multiple mediation analysis of video game addiction and
anxiety symptoms mediated by approach, diversion, and resignation and withdrawal coping. c: Multiple
mediation analysis of video game addiction and depression symptoms mediated by approach, diversion, and
resignation and withdrawal coping
Int J Ment Health Addiction

coping, which in turn was associated with lower levels of anxiety and depression. Higher
levels of addiction on the other hand were associated with greater use of resignation and
withdrawal coping and higher levels of stress, anxiety and depression.
Coping was found to be a full mediator between engagement and stress and depression and
partial mediator for anxiety (see Table 3 and Fig. 2a, b, & c). There was a significant total
effect of engagement on stress and depression adjusted for the mediators (path c; p<0.01), but
no direct effect (path c’; p>0.05). The total indirect effects for stress and depression were
different from zero. The mediation analysis showed that coping was a partial mediator between
engagement and anxiety with a significant total effect of engagement on anxiety (path c;
p<0.01), and a significant but smaller direct effect of coping on anxiety adjusted for the
mediators (path c’; p<0.01). The significant effect of video game engagement on anxiety,
adjusted for by the mediators, was smaller than the effect of engagement on anxiety, indicating
partial mediation. Approach and resignation and withdrawal coping were significant mediators
between engagement and stress, anxiety and depression symptoms, but diversion coping was
not. Lower levels of engagement were associated with more approach coping, which in turn
was associated with lower levels of stress, anxiety and depression. Increased levels of
engagement were associated with greater use of resignation and withdrawal coping, which
was in turn associated with higher levels of stress, anxiety and depression.
Discussion
This is the first study, to our knowledge, which tested the potential mediating role of coping in
the relationship between video game addiction, or engagement, and symptoms of stress,
Table 3 Multiple mediation analysis of video game engagement and DASS subscales (stress anxiety, depres-
sion) mediated by approach, diversion and resignation and withdrawal coping
Multiple mediation model Point estimate Product of coefficient BCa 95 % CI
SE Z Lower Upper
Indirect effects−engagement and stress
Approach 0.01 0.01 1.90 0.00 0.03
Diversion 0.00 0.00 0.47 −0.01 0.01
Resignation / withdrawal 0.08*** 0.01 5.66 0.06 0.12
Total 0.10*** 0.02 6.23 0.07 0.13
Indirect effects – engagement and anxiety
Approach 0.01* 0.01 2.26 0.00 0.03
Diversion 0.00 0.00 0.17 −0.01 0.01
Resignation / withdrawal 0.06*** 0.01 5.47 0.04 0.09
Total 0.08*** 0.01 6.12 0.06 0.11
Indirect effects – engagement and depression
Approach 0.06*** 0.01 4.98 0.04 0.09
Diversion 0.00 0.00 0.51 −0.01 0.01
Resignation / withdrawal 0.12*** 0.02 6.11 0.08 0.16
Total 0.18*** 0.03 7.05 0.13 0.23
Note: * p<0.05; ** p<0.01; ***p<0.001
Int J Ment Health Addiction

anxiety and depression in adults. Consistent with our predictions, coping was found to be a
mediator between video game addiction and symptoms of all three conditions, as well as
between engagement and these conditions.
a
N
ote. *** = p<.001; **p <.01; *p<.05. R2=.29. Adjusted R2=.29
b
N
ote. *** = p<.001; **p <.01; *p<.05. R2=.28. Adjusted R2=.28
c
N
ote. *** = p<.001; **p<.01; *p<.05. R2 = .54; Ad
j
usted R2= .54.
Video game
engagement
Diversion
Approach
Resignation /
withdrawal
Stress
-.15
***
.07
***
.12
***
.04
-.09
*
.03
.70
***
Video game
engagement
Diversion
Approach
Resignation /
withdrawal
Anxiety
-.15
***
.07
***
.12
***
.06
***
-.10
*
.01
.53
***
Video game
engagement
Diversion
Approach
Resignation /
withdrawal
Depression
-.15
***
.07
***
.12
***
-.01
-.42
***
.03
.98
***
Fig. 2 a: Multiple mediation analysis of video game engagement and stress symptoms mediated by approach,
diversion, and resignation and withdrawal coping. b: Multiple mediation analysis of video game engagement and
anxiety symptoms mediated by approach, diversion, and resignation and withdrawal coping. c: Multiple
mediation analysis of video game engagement and depression symptoms mediated by approach, diversion and
resignation and withdrawal coping
Int J Ment Health Addiction

The three mental health conditions measured in the present study have been validated as
distinct constructs. In the context of the DASS, the authors indicate depression as characterized
by low positive affect, loss of self-esteem and incentive, and a sense of hopelessness; anxiety
by autonomic arousal and fearfulness; and stress by persistent tension, irritability, and a low
threshold for becoming upset or frustrated (Lovibond and Lovibond 1995,p.80).Itmustbe
noted however that these conditions, while psychometrically and theoretically distinct, do have
a high rate of co-occurrence (Lovibond and Lovibond 1995). Our analysis found a direct effect
between video game addiction and symptoms of each condition measured, with anxiety
showing the largest relationship followed by stress and depression. This is in line with several
other studies which have found associations between video game addiction and poorer mental
health (Gentile et al. 2011;Kingetal.2011;Mentzonietal.2011; Starcevic et al. 2011).
Coping partially mediated the relationship between video game addiction and symptoms of the
mental health conditions measured, but a substantial direct connection remained even after
accounting for coping. As coping was not a full mediator in the case of addiction and these
symptoms, future studies should explore additional underlying mechanisms in addition to
coping. Also studies attempting to predict mental health outcomes in cases involving video
game addiction, or similar conditions such as internet addiction, should also consider including
coping behaviours in quantitative models.
Individuals with higher levels of video game addiction reported greater use of the avoidance
oriented coping dimension resignation and withdrawal, and less use of approach coping.
Higher levels of stress, anxiety and depression, in turn, were strongly associated with higher
resignation and withdrawal coping. Higher anxiety and depression were also associated with
less approach coping. Resignation and withdrawal coping strategies are considered maladap-
tive and passive, comprising of acquiescence, withdrawal and disengagement (Finset et al.
2002). Uses of such strategies have been associated with increased levels of distress, thwarted
goal attainment, symptoms of burnout and negative emotions (Clark and Hovanitz 1989;
Nicholls et al. 2012; Polman et al. 2010). As such clinicians working with individuals who
exhibit positive signs of possible video game addiction should consider coping strategies as
part of their intervention strategies.
Interestingly, diversion coping was not found to be a partial mediator between video game
addiction and symptoms of stress, anxiety or depression. This suggests that addictive video
gamers using gaming as a distractive activity to escape from problems are less likely to
experience increased symptoms of stress, anxiety and depression. It may be that using gaming
as a diversion can be adaptive. Studies have reported similar relationships with distraction-
based electronic media use, including video gaming, to regulate negative emotions and reduce
stress (Grüsser and Rosemeier 2004; Reinecke 2009). Rather, in the case of video game
addiction, the results of this study highlight the distinction between diversion and resignation
coping. In the case of depression and both engagement and addiction, the correlation with this
coping dimension was almost complete. As this dimension involves withdrawing from friends
and a sense of having given up trying to deal with stressors, it suggests the mental decline
occurring with video game addiction or engagement has a more serious basis than escape-
based diversion coping. The mediating effect of lower approach coping also suggests fewer
attempts to communicate with others about stressors and make active efforts to solve problems
contributes to increased symptoms of stress, anxiety and depression.
In contrast to addiction, engagement was directly related to anxiety but not stress and
depression when accounting for coping, and the pathway to anxiety was smaller than in the
case of addiction (0.06 compared with 0.15). The lack of a direct path for stress and
Int J Ment Health Addiction

depression, and smaller path to anxiety, partially supports the distinction put forward between
the two constructs of video game engagement and addiction (Charlton and Danforth 2007).
Increased levels of engagement were associated with less use of approach and increased use of
resignation and withdrawal coping strategies. Although avoidance coping strategies might
provide temporary relief and be adaptive in the right context, they often involve deferring
problem solving to the future, which, if used in excess, can result in poorer health and well-
being (Folkman et al. 1986;Polmanetal.2010). Our results suggest that both video game
addiction and high levels of engagement are associated with less use of approach coping
strategies and more use of resignation and withdrawal coping. Increased engagement paired
with maladaptive coping may identify individuals at risk of transitioning into video game
addiction. With increasing endorsement of video game addiction criteria, coping strategies
may change to reflect an increasing reliance on withdrawal and resignation rather than
approach coping strategies. This in turn is likely to result in an inability to make a difference
in one’s situation.
Our research identified that addiction had a direct effect on symptoms of stress, anxiety and
depression, whereas engagement had only a direct effect on anxiety but not stress or depres-
sion, after accounting for coping. This finding contributes to previous discussions on when
intense gaming may or may not become problematic (Charlton and Danforth 2007;Gentile
et al. 2011;Mentzonietal.2011;Petry2013). The current study also confirms the co-
occurrence of increased symptoms of stress, anxiety and depression with video game addiction
and maladaptive coping. Similarly, coping skills training may also provide a portal to
intervention. Future studies should examine whether coping interventions, which increases
the use of approach and decreases avoidance coping strategies among excessive video gamers
are able to improve mental health outcomes. Future studies should also explore the role of
coping in the relationships between other intense hobbies (including various media consump-
tion) and mental health.
A limitation of the present study is that it is cross-sectional. Longitudinal studies are
required to confirm the directionality of relationships in the present analysis, particularly
between video game addiction and symptoms related to mental health. The generalizability
of the results is limited given the targeting of self-identified problem gamers. The use of self-
report measures is a further limitation; clinical interviews would have been an ideal means of
triangulating findings.
In conclusion, this is one of the first studies providing partial support for the
distinction between video game addiction and engagement in terms of its relationship
to symptoms of stress, anxiety and depression and the in fluence of cop ing. Findin gs
demonstrated that coping is an important partial mediator in the relationship between
video game addiction and mental health, but does not explain the entire relationship.
Alternatively, video game engag ement was only directly connected to anxiety, and to a
lesser extent than addiction. The use of maladaptive coping strategies provides some
additional context for the many cross-sectional relationships reported between video
game addiction and poorer mental health, but also a portal for intervention. Researchers
may benefit from the inclusion of coping as a variable in models predicting mental health
outcomes in relation to conditions such as video game addiction. Clinicians may also
consider interventions that are shown to b roaden and foster a daptive coping, and be
mindful of the relative unimportance of diversion coping, with results instead indicating
that a lack of approach and increase in withdrawal and resignation coping are both
strongly related to symptoms of stress, anxiety and depression.
Int J Ment Health Addiction

All procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation (institutional and national) and with the Helsinki
Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients
for being included in the study.
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