TECHNOLOGY ADDICTION (J BILLIEUX, SECTION EDITOR)
A Systematic Review of the Co-occurrence of Gaming Disorder
and Other Potentially Addictive Behaviors
Tyrone L. Burleigh
&Mark D. Griffiths
&Daria J. Kuss
#The Author(s) 2019
Purpose of Review The playing of videogames has become an everyday occurrence among many adolescents and emerging
adults. However, gaming can be problematic and potentially addictive and problematic gamers can experience co-occurring
behavioral or substance use-related problems. The aims of the present review were to (i) determine the co-occurrence of
potentially addictive behaviors with problematic and disordered gaming, and (ii) elucidate the potential risk factors in the
development and maintenance of co-occurrence within disordered gaming.
Recent Findings The main findings demonstrated that there are few empirical studies (N= 20) examining (i) co-occurrence of
gaming disorder with other addictive behaviors; (ii) longitudinal risk of disordered gaming with co-occurring addictive behav-
iors; and (iii) mechanisms of co-occurrence in disordered gaming with co-occurring potentially addictive behaviors. Results
suggest that disordered gaming can co-occur with a variety of other addictive behaviors (e.g., alcohol use disorder or addictive
use of social media), and that research into the co-occurrence of addictive behaviors and substance use is increasing.
Summary Based on this systematic review, findings suggest that gamers engage in a number of potentially addictive behaviors
and substance use which can have detrimental effects on health and wellbeing. While a majority of the reviewed studies consider
prevalence rates from a range of geographical locations, there are fewer papers which investigate individual and environmental
Keywords Gaming disorder .Internet gaming disorder .Comorbidity .Video game addiction .Problematic gaming .Substance
use .Systematic review .Co-occurrence
Research has begun to investigate the negative consequences
of problematic video gaming in an effort to improve screen-
ing, assessment, definition, and treatment of the disorder .
Such work has contributed to the American Psychiatric
Association (APA)  including Internet Gaming Disorder
(IGD) as a form of behavioral addiction (warranting further
investigation) in the latest (fifth) edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) in
“Section 3”(“Emerging measures and models”). The World
Health Organization  has also recognized “gaming disor-
der”(GD) as an official disorder with addiction like properties
in the eleventh revision of the International Classification of
Prior to the inclusion of GD in the DSM-5 and ICD-11,
several other terms were used to describe problematic video
gaming including videogame addiction, pathological video
gaming, gaming use disorder, and gaming use dependency
[4–7]. Further confusing the issue, online problematic gaming
has also been included within the umbrella terms of internet
addiction, problematic internet use, and pathological internet
use [8–10]. However, the internet addiction umbrella term
encompasses several other problematic online activities, such
as online gambling, online sex, social media use, and online
shopping . In order to maintain consistency throughout the
present review, the term “disordered gaming”will be used to
This article is part of the Topical Collection on Technology Addiction
*Tyrone L. Burleigh
International Gaming Research Unit, Psychology Department,
Nottingham Trent University, Nottingham NG1 4FQ, UK
Department of Psychology, Nottingham Trent University,
Cairnmillar Institute, Hawthorn East, Melbourne, Australia
Current Addiction Reports (2019) 6:383–401
Published online: 7
describe a range of similar and/or overlapping addictive, com-
pulsive, and/or problematic gaming behaviors. When refer-
ring to clinically defined cases, the term “GD”will be used,
in line with DSM-5 and ICD-11. Furthermore, in relation to
other potentially addictive behaviors, the term “problematic”
will be used to describe subclinical conditions that do not fully
meet all the criteria in the DSM-5 or ICD-11 (e.g., problematic
gambling), while the term “disordered”will be used to de-
scribe clinical conditions that meet the requisite criteria in
the DSM-5 and ICD-11.
There has been a growing body of research suggesting that
disordered gaming is associated with a number of other mental
health disorders, such as depression , anxiety , prob-
lematic substance use , and personality disorders .
However, an understudied area in this field is the co-
occurrence of disordered gaming with other potentially addic-
tive substances and behaviors. Within the present review, co-
occurrence refers to when two or more potentially addictive
behaviors (behavioral and/or substance) are engaged in con-
currently. For example, in a systematic review on the preva-
lence of eleven different types of addictions, it was estimated
that approximately 10% of adults with internet addiction may
experience another concurrent problematic behavior or sub-
stance use (e.g., alcohol use or dependence or gambling ad-
Evidence supports the co-occurrence of addiction for both
substances and behaviors (i.e., the presence of a behavioral
addiction increases the propensity for addiction to develop for
other behaviors). Indeed, this may create a cycle of reciprocity,
wherein mutual exacerbation occurs between two or more
problematic behaviors [16–18]. Moreover, those who do ex-
perience co-occurring problematic and addictive behaviors are
at higher risk of poor mental health (e.g., depression) and
physical health [18–20].
In addition, co-occurring problematic behaviors interact to
exacerbate clinical symptoms, which can complicate accurate
assessment and treatment of other psychiatric disorders .
Likewise, disordered gaming may mask problematic sub-
stance use which could hinder diagnostic assessment.
Alternatively, disordered gaming may exacerbate problematic
substance use, causing symptoms of both to alternate which
can impact treatment efficacy . This highlights that the
assessment and treatment of GD should have a broader focus
by not only considering the presenting primary problematic
behavior or substance use and symptoms, but also any poten-
tial co-occurring addictive behaviors or substance use, which
may enforce a cycle of reciprocity.
Consequently, clinicians need to be aware of how poten-
tially addictive behaviors impact or enforce various aspects of
a primary problematic behavior (e.g., disordered gaming), and
be aware of how co-occurring addictions may impact the on-
set, course, and outcomes of interventions. Previous literature
has demonstrated that the prevalence of co-occurring
addictions can be high , suggesting that studies which
consider addiction as only comprising one specific behavior
may be limited in ecological invalidity because individuals
have more complex and varied histories of disordered behav-
iors and co-occurrence .
Although there has been one previous comprehensive re-
view investigating the co-occurrence of eleven behavioral and
substance addictions, this mainly evaluated US studies, did
not examine disordered gaming, and was written almost a
decade ago . Furthermore, this review was limited to clin-
ical measures in relation to co-occurrence, and did not consid-
er any proxy measures (e.g., time spent engaging in the activ-
ity as an indication of problematic or disordered behavior).
Consequently, given the large increase in research examining
disordered gaming in the past decade, there is a need for a
contemporary systematic review examining the co-
occurrence of GD with other potentially addictive behaviors.
While several studies have considered the impact of co-
occurrence of neurodevelopmental and mood disorders on
the onset, course, and maintenance of GD , there is limited
integrative research examining addiction comorbidities.
Furthermore, failure to integrate treatments which consider
co-occurring addictions may lead to a “ping pong effect,”
wherein an individual may bounce back and forth between
problematic or disordered behaviors and/or substance use
and treatment programs .
There are several studies within the behavioral and sub-
stance addiction literature that support the efficacy and bene-
fits of treating co-occurring addictions concurrently [24,25].
Therefore, in order to integrate contemporary research, it is
important to conduct a systematic review highlighting extant
findings concerning the co-occurrence of addictive behaviors,
which specifically considers problematic and disordered gam-
ing and not the often-used broader construct of “internet ad-
diction.”This may aid in the development of effective models
that identify and aid clinicians to treat disordered gaming
alongside other co-occurring addictive behaviors.
The primary goal of the present study was to review em-
pirical research over the past decade, providing up-to-date
information that considers the impact of addiction to other
behaviors on GD, and to provide recommendations for future
research. More specifically, the aims of the present review
were to (i) determine the co-occurrence of potentially addic-
tive behaviors with problematic and disordered gaming, and
to (ii) elucidate the potential risk factors in the development
and maintenance of co-occurrence within GD.
A systematic review was employed to examine the co-
occurrence of potentially addictive behaviors with disordered
gaming. While disordered gaming has been conflated with
Curr Addict Rep (2019) 6:383–401
internet addiction in the past, it is important to note that only
papers that considered assessed gaming and/or gaming disor-
der (i.e., problematic gaming) were considered. A systematic
review contains key elements, such as an overview of the
literature, summary of the findings, dissemination of out-
comes, and identification of gaps in the literature . The
present review utilized a five-stage model of conducting a
rigorous systematic review, which included (i) identifying
the research question, (ii) identifying relevant studies, (iii)
study selection, (iv) dissemination of outcomes, and (v) sum-
marizing and reporting the results .
The inclusion criteria for the present review were as fol-
lows: (i) empirical studies containing primary data, (ii) studies
that assessed the co-occurrence of and potential “cross-addic-
tion”or “addiction hopping”within the problematic or disor-
dered gaming literature; (iii) studies published in peer-
reviewed journals, (iv) written in English, and (v) published
within the past decade. ProQuest, Scopus,andWeb o f S ci enc e
were searched, including the following databases:
PsychARTICLES, PsychINFO, Scopus, Web of Science Core
Collection, and MEDLINE. The search included a number of
terms related to disordered gaming that have been used over
the past decade. In addition to this, several terms were devel-
oped to explore cross-addiction and co-occurrence in the be-
havioral addiction literature, which led to the following search
strategy: (patholog* OR problem* OR addict* OR compul-
sive OR dependen* OR disorder* OR excess*) AND (video
gam* OR computergam* OR internet gam* OR online gam*)
AND (“cross addiction”OR “addiction hopping”OR “expres-
sion hopping”OR “substitution hypothesis”OR “switching
hypothesis”OR “co-occur*”OR comorbid* OR “dual diag-
nosis”). Each study’s title, abstract, and paper content were
screened for eligibility. The full texts of potentially relevant
studies were retrieved and screened for eligibility.
A total of 4160 papers were identified in the initial search.
The ProQuest database contained 2507 papers
(PsychARTICLES n = 1749; PsychINFO n = 799); Scopus
contained 1271 papers; and Web of Science contained 341
papers. Duplicate studies were removed, leaving a total of
3915 papers. These papers had their journal of publication,
titles, and abstracts screened, resulting in the exclusion of
3845 papers that were not relevant to the present review, leav-
ing a total of 70 papers, which were eligible for further review.
Of these, 54 were excluded as they were not written in English
(n= 3), did not asses disordered gaming (n=1
5), did not as-
sess cross-addiction or co-occurrence (n=16),didnotconsid-
er disordered gaming in conjunction with another behavioral
or substance addiction/disorder (n=17), or were review pa-
pers (n= 3). The remaining 16 papers were considered eligible
for further analysis as they met all the inclusion criteria.
Furthermore, four additional relevant papers were included
from the reference lists of the identified papers, bringing the
total to 20 papers. The present paper followed the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
guidelines (PRISMA statement; Moher, Liberati, Tetzlaff,
Altman, & the PRISMA Group, 2009), which includes the
use of a PRISMA flow diagram (see Fig. 1).
The 20 papers that met the inclusion criteria were divided into
specific categories. A total of 16 papers were considered as
papers that had assessed co-occurrence prevalence of prob-
lematic or disordered gaming with other addictive behaviors
and had explored their commonalities with various related
and/or unrelated risk and/or protective factors. Of these 16
papers, ten were categorized as “prevalence of co-occurrence
in GD and other potentially addictive behaviors.”The papers
within this category each featured validated psychometric
measures which provided an indication of severity risk for
disordered gaming and other potentially addictive behaviors.
The other six papers that assessed prevalence were catego-
rized as “proxy indicators of GD prevalence and other poten-
tially addictive behaviors.”Unlike the papers in the first cate-
gory, these papers did not use psychometric measures as a tool
to assess severity for both problematic or disordered gaming
and the co-occurring problematic or disordered behavior and/
or substance use. Instead, these studies assessed the frequency
of the behavior (e.g., sexual activity; “how many times have
you engaged in sexual activity in the last week?”) or the con-
sumption of substance (e.g., number of alcoholic drinks;
“How many alcoholic drinkshave you had inthe past week?”)
as an indicator of use and assessment. The remaining four
papers were categorized as “assessing the etiology of disor-
dered gaming and other potentially addictive behaviors.”
These papers investigated specific relationships between GD
and the mechanisms which may contribute to the understand-
ing of the development, maintenance, or exacerbation of GDs
with other potentially addictive behaviors (e.g., coping strate-
gies and personality factors).
Prevalence of Gaming Disorder Co-occurrence
with Other Addictive Behaviors
Of the ten studies examining prevalence [10,27–35], six ex-
amined adult populations (e.g., general populations), three
examined adolescent populations (e.g., middle school stu-
dents; see Table 1), and one examined both adolescents and
adults. Six [27–30,32,35] of these studies focused on the co-
occurrence of GD with problematic substance use (i.e., nico-
tine and cannabis use) and alcohol use. While there has been
some exploration of other potentially addictive behaviors,
such as buying, phone use, eating, gambling, exercise, sexual
behavior, and social media use, these were usually a part of a
larger investigation of substance use or disordered substance
Curr Addict Rep (2019) 6:383–401 385
use, which did not consider disordered gaming as the primary
focus. Consequently, their findings lack nuanced consider-
ation of disordered gaming and the wider implications within
the gaming studies field. Four studies [10,31,34,80]inves-
tigated the co-occurrence of GD with other “technological
addictions”(e.g., social media addiction and internet
Prevalence was investigated in eight geographical loca-
tions, including Norway (n=2) [33,35•], Hungary (n=1)
, Netherlands (n=1) , the USA (n=2) [27,32],
Italy (n=1), Germany (n=1) , South Korea (n=1)
, and Portugal (n=1). Sample sizes ranged from 128
to 21,053 participants. However, the type of surveyed popu-
lations was relatively narrow, with the majority of the studies
considering school students (n= 5), and to a lesser degree the
general population (n= 3) (see Table 1).
Six studies investigated the prevalence of problematic or
disordered gaming within adult populations. Lee et al. 
investigated the relationship between attention-deficit hyper-
activity disorder (ADHD), cigarette smoking, problematic
gaming, and the frequency of playing videogames in an online
American adult sample (N= 2801). Their results suggested
that ADHD, cigarette smoking, and frequency of playing
videogames had a significant impact on problematic gaming.
This finding was consistent with previous studies, such as
Ream et al.’sstudy, who found a significant correlation
with nicotine, alcohol, caffeine, cannabis use, and problematic
videogame use in a large American sample of adult gamers
(N= 2885). Furthermore, among gamers, 64% used caffeine
and 41% of those caffeine users had consumed caffeine while
gaming; 26% of their sample used nicotine and 61% of
smokers had smoked cigarettes while gaming; 34% of partic-
ipants consumed alcohol, and 38% of those had drank alcohol
while gaming; and 5.6% of their sample smoked cannabis and
80% of those had smoked cannabis while gaming.
Similarly, Na et al.  surveyed South Korean adults (N=
1819) online, and found that 21% experienced both problem-
atic alcohol use (i.e., scoring over 20 on the Korean version of
Alcohol Use Disorders Identification test [AUDIT-K]) and
problematic gaming. This group also had higher cigarette
smoking rates (44.8%) than participants in the problematic
alcohol group (31.6%) or problematic gaming group (26%),
which is consistent with the American sample above.
Furthermore, their results indicated that those participants
who reported both drinking alcohol and gaming demonstrated
higher scores on psychometric tests (which indicated poorer
mental health outcomes) than any other group (i.e., control,
alcohol group, and gaming group), lending support to the
notion that co-occurring substance use and activities and po-
tentially addictive behaviors are associated with maladaptive
clinical outcomes .
Müller et al.  investigated exercise dependence (EXD)
in a German sample of participants attending a fitness center
(N= 128). Their results found that out of the ten males (7.8%)
who were at risk of developing EXD, two experienced prob-
lematic gaming. One participant was at risk of an eating
Fig. 1 Flow diagram of paper
selection process for the
Curr Addict Rep (2019) 6:383–401
Table 1 Prevalence rates of co-occurrence of problematic and disordered gaming using psychometric measures
Paper Aims Sample Behavior/
et al., 2016
To investigate the associations between
disordered use of technologies and
comorbid psychiatric disorders
n= 23,533 (M= 35.8;
SD = 13.3) 17 to
88 years of age.
Bergen Facebook Addiction Scale 
(BFAS; 6 item); Game Addiction Scale for
Adolescents (GASA; 7 item);The
Adult ADHD Self-Report Scale 
(ASRS-Version 1.1; 18 items); The
Inventory-Revised  (OCI-R; 18 item);
Hospital Anxiety and Depression Scale
 (HADS; 14 item)
- There was a weak interrelationship between
SNS addiction and disordered gaming
- Results suggest that internet use disorder as
a unified concept is not warranted as there
are enough differences and motivations
between SNS addiction and disordered
gaming to warrant separate classifications
Erevik et al.,
To investigate the levels of problems
associated with gaming/gaming
investment and problematic alcohol use.
n= 5217 (M= 25.8)
Gaming Addiction Scale for Adolescents
(GASA; 7 item); Alcohol Use
Disorder Identification Test (AUDIT;
10 item); Mini-International Personality
Item Pool  (Mini-IPIP; 20 item);
Hopskins Symptoms Checklist 
(HSCL-25; 25 item)
- Low level gaming and problematic alcohol
- High levels of gaming act as a protective
factor for problematic alcohol use
Kiraly et al.,
To examine the interrelation and the overlap
between problematic internet use (PIU)
and problematic online gaming (POG) in
terms of sex, school achievement, time
spent using the Internet and/or online
gaming, psychological well-being, and
preferred online activities.
of adolescent gamers;
N= 2073 (M= 16.4,
SD = 0.87)
Problematic Online Gaming Questionnaire
Short-Form (POGQ-SF; 12 item);
adapted Internet Use Questionnaire 
(PIUQ-6; 6 items); short-form Center of
Epidemiological Studies Depression
Scale  (CES-D; 6 item); Rosenberg’s
Self-Esteem Scale  (RSES; 10 items)
problematic gaming; 8.8% experienced
problematic internet use; and 6.7%
experienced both problematic gaming and
problematic internet use
- Internet use was a common activity among
adolescents; online gaming was engaged
in by a much smaller group
- POG and PIU appear to be two
conceptually different behaviors, thus
providing evidence that Internet addiction
and IGD are separate nosological entities
Lee et al., 2018
To explore the relationship of various
correlates of problematic and disordered
Adult Sample, n= 2801;
SD = 4.70)
Internet Addiction Scale (20 items);
Problem Videogame Playing Scale (8
items); Conners’Adult ADHD Rating
Smoking Behavior and Video Game Use
- ADHD symptomatology, smoking
behavior, and the amount of video game
use have a significant impact on PVP
- For every additional cigarette smoked, an
individual’s problematic gaming score
increased by 0.022 (p< .05).
- Smoking and PVP had a significant
Mérelle et al.,
To identify which health related problems
are most important for adolescents that are
at risk for problematic gaming or social
Sample; n= 21,053
(M= 14.4, SD =1.3).
Problematic Video-gaming Use (6
items); Problematic Social Media Use
(6 items); General Health (1
item); Strengths and Difficulties
Questionnaire  (25 items); Life Events
(2 items); Lifestyle Questionnaire [57–59]
(13 items); Substance Use (4 items)
- Smoking is strongly associated with
Problematic Video Gaming
- A substantial number of adolescents
reported some (addictive) problems with
gaming (5.7%) or social media use (9.1%)
- There is a weak association with substance
Curr Addict Rep (2019) 6:383–401 387
Tab l e 1 (continued)
Paper Aims Sample Behavior/
Monacis et al.,
To investigate the extent to which identity
styles and attachment orientations account
for three types of disordered online
Italian Students; n= 712
SD = 3.90).
Split into two groups:
Adolescent (n= 267;
SD = 1.04) and
Adults (n= 445;
SD = 3.55)
Italian Internet Addiction Test [50,60](IAT;
20 items); Internet Gaming Disorder
Scale-Short Form [61,62](IGDS9-SF; 9
items); Bergen Social Media Addiction
Scale (BSMAS; 6 items); Revised
Identity Style Inventory  (ISI-5; 36
items); Attachment Style Questionnaire
- Internet addiction, online gaming
addiction, and social media addiction
were interrelated and predicted by
common underlying risk factors
- Online gaming addiction was associated
with two identity risk factors:
informational and diffuse-avoidant
Müller et al.,
To assess how many participants were at risk
for Exercise Dependence (EXD) and if the
rates differ by gender. Also, to explore the
correlations between symptoms of EXD
and various correlates and the differences
in behavior in men and women.
n= 128; 18 years and
over (M= 26.5,
- Eating Disorder
- Alcohol Use
Exercise Dependence Scale [65,66](21
items); Eating Disorder Examination
Questionnaire [67,68](28 items);
Compulsive Buying Scale [69,70](7
items); Assessment of Pathological
Computer-Gaming (15 items);
Hypersexual Behavior Inventory [72,73]
(15 item); Alcohol Use Disorders
Identification Test [43,74](10 items)
10.9% reported eating disorder pathology,
2.3% pathological buying, 3.1%
hypersexual behavior, and none of the
participants suffered from pathological
- EXD symptoms were positively correlated
with both eating disorder pathology and
pathological buying, but not with
pathological video gaming
- Eating Disorder pathology was found to be
positively correlated with pathological
Na et al., 2017
To investigate videogame usage patterns and
clinical characteristics of Internet Gaming
Disorder (IGD), Alcohol Use Disorder
(AUD), and their comorbid status within a
South Korean Adults
n= 1819; 20s–40s
- Alcohol (AUD)
- Internet Gaming
DSM-5 Internet Gaming Disorder Criteria
(9 items); Alcohol Use Disorders
Identification Test (10 items);
Dickman Impulsivity Scale (23
items); Brief Self-Control Scale (13
items); Symptom Check-List 90
Items-Revised  (23 items [Depression
13 items, and Anxiety 10 items]);
Behavioral Inhibition System/Behavioral
Approach System Scale (20items)
- 14.1% of participants presented with
- 37.9% of participants presented with
problematic alcohol use
- 21.2% of participants experienced both
problematic alcohol use and internet game
- The Comorbid group had higher smoking
rates (44.8%) compared to the alcohol
group (31.6%) or problematic gaming
- The comorbid group had significantly
higher AUDIT-K scores than that of the
To investigate the interplay between SNS
addiction and IGD and to ascertain how
they can uniquely and distinctively
contribute to increasing psychiatric
distress when accounting for potential
effects stemming from sociodemographic
and technology-related variables.
n= 700; 10–18 years
SD = 1.64)
- Internet Gaming
Bergen Facebook Addiction Scale (6
items); Internet Gaming Disorder
Short-Form (9 items); Depression,
Anxiety, and Stress Scale (21items)
- SNS can exacerbate the symptoms of IGD
- IGD can exacerbate the symptoms of SNS
Curr Addict Rep (2019) 6:383–401
disorder and at risk of problematic gaming, while the other
had problematic alcohol use and problematic gaming, and at-
risk pathological buying. While this example is not statistical-
ly significant, it does illustrate that problematic gaming can
co-occur with other potentially addictive behaviors.
Moreover, the research indicates that problematic or disor-
dered gaming does not always co-occur with problematic sub-
In a Norwegian university sample (N= 5217), Erevik et al.
[35•] reported that 44.9% of participants who had low engage-
ment in gaming were more likely to experience the co-
occurrence of problematic alcohol use than those who did
not play video games (46.1%; however, this difference be-
came non-significant when controlling for demographic vari-
ables, personality, and mental health), while the 4% of partic-
ipants who experienced high levels of videogame engagement
were found to be less likely to experience problematic alcohol
use. A larger Norwegian online survey by Andreassen et al.
 sampled 25,533 participants and found that 7% experi-
enced problematic gaming and 13.5% experienced problem-
atic social media use. Furthermore, there was a positive asso-
ciation between symptoms of problematic gaming and prob-
lematic social media use, demonstrating common risk factors
(e.g., impulsive personality, comorbid psychopathology) and
the potential for co-occurrence. This finding was corroborated
in a study by Monacis et al.  which considered the com-
monalities in shared identity styles in co-occurring online be-
haviors. In their sample of university students (N=445)aged
over 20 years, they found that social media addiction and GD
shared common identity styles (i.e., informational and diffuse-
avoidant), further demonstrating the potential for these prob-
lematic behaviors to co-occur.
However, disordered gaming and problematic substance
use are not limited to the adult population. Similar results have
been found in adolescent populations. For example, in a large
survey of 21,053 Dutch adolescents by Mérelle et al. ,
5.7% of the sample reported some problematic gaming
(5.7%) and 9.1% reported problematic social media use.
Smoking cigarettes was strongly associated with problematic
gaming. Although their results suggested a high co-
occurrence of problematic social media use and smoking cig-
arettes with problematic gaming, there was a weak association
with other substance use.
Pontes  investigated how disordered gaming and social
media addiction uniquely contributed to psychological dis-
tress, and how these behaviors exacerbate distress when they
co-occurred in a population of Portuguese middle school stu-
dents (N= 700). The results demonstrated thatboth disordered
gaming and social media addiction can exacerbate the symp-
toms of each other when they co-occur and contribute to de-
terioration of psychological health as indicated by increased
scores on depression, anxiety, and stress scales. In Király
et al.’s nationally representative study , of 2073
Tab l e 1 (continued)
Paper Aims Sample Behavior/
Ream et al.,
To investigate if videogame engagement
while using substances contributes to
substance abuse problems
n= 2885; Over
18 years and over
(M= 40.4, SD = 15.7)
National Survey of Drug Use-based
questionnaire (46 items); Consumer
Involvement in Video Games; Problem
Video Game Play (10 items)
- Problem Play significantly correlated to
problematic: Caffeine, Tabaco, alcohol,
cannabis use. Males consumed more
caffeine and alcohol, while females
consumed more nicotine
- There is a potential for “drug interaction”
between self-reinforcing behaviors and
addictive substances, with implications
for the development of problem use.
- Statistical models suggested that gaming an
enthusiastic hobby (i.e., video game play
frequency, enjoyment, and consumer
involvement) could potentially be a third
variable that was associated with
co-occurring use of caffeine, nicotine, and
alcohol and problematic gaming
Items in italics represent relevant measure
Curr Addict Rep (2019) 6:383–401 389
adolescents, 4.3% experienced problematic gaming, 8.8% ex-
perienced problematic internet use, and 6.7% experienced
both problematic videogame use and internet use. Their re-
sults demonstrated an overlap in problematic internet use and
problematic gaming but verified that these are two distinct
problematic behaviors that have the potential to co-occur with
one another, and which may lead to the exacerbation of prob-
lematic internet use and/or problematic gaming .
Proxy Indicators of Prevalence of Gaming Disorder and Other
Potentially Addictive Behaviors
Other studies have focused on prevalence of disordered gam-
ing and other potentially addictive behaviors using proxy in-
dicators (e.g., using number of alcoholic drinks consumed per
day or per week to assess severity of alcohol use). Of the six
studies that assessed proxy measures of potentially addictive
behaviors [42,82–87](Table2), two studies [84,99]exam-
ined general adult populations (e.g., national surveys) using
proxy indictors of problematic use, two [85,86]considered
both adolescents and adults, while the latter two [82,87]ex-
amined adolescent populations (e.g., secondary school stu-
dents). A total of five of six studies [82–84,86,87] using
proxy measures investigated alcohol use and substance use,
while four considered smoking cigarettes [82,84,86,87], and
one investigated gambling . The geographical locations
also varied with papers based in the USA (n=2) [83,87],
Italy (n=1) , Canada (n=1) , the Czech Republic
(n=1), and France (n=1).
In regard to prevalence within the adolescent populations,
two studies showed a positive correlation between the fre-
quency of video game use and substance use, demonstrating
a strong association [82,87]. More specifically, Gallimberti
et al.  found in their adolescent sample (N= 1156) that
16.4% experienced problematic gaming, and within this co-
hort, 41.2% had smoked cannabis, 23.2% had consumed an
energy drink (i.e., caffeine), 21.7% had smoked a cigarette
(i.e., nicotine), and 21.3% had drank alcohol (in their lifetime),
demonstrating an association between gaming and use of
Van Roo i j e t al.  also suggested that higher scores on the
Video Game Addiction Test (VGAT; which assesses problem-
atic videogame use) indicated an increase in frequency of sub-
stance use. Their research showed that 36.4% of online gamers
in their sample (n= 8478) consumed alcohol, 34% smoked
cigarettes, and 44.6% smoked cannabis. This is in line with
studies that exclusively used psychometric measures to asses
use and severity of other potential addictions. A similar trend
was found in a large sample of Czech online gamers (N= 3952)
 which investigated gamers and the influence of psychoac-
tive substances. They found that while gaming, caffeine was the
most frequently used substance (74.2%), followed by alcohol
(40.4%), nicotine (25.3%), and illicit substances (14.5%).
Similarly, Konkolÿ Thege et al.  surveyed 6000 adults
and found that those who experienced problematic gaming
(2.1%), 1.2% experienced problematic alcohol use, while
31.1% experienced problematic nicotine use, and 13.5% ex-
perienced problematic cannabis use. This was calculated using
a single self-report question “Thinking back over your life,
have you ever personally had a problem with [problematic
behavior or substance use]?”with 3 possible responses—
“No,”“Yes, but not in the past 12 months,”and “Yes, in the
past 12 months.”Using this question, the researchers also
considered potentially addictive behaviors that co-occur with
disordered gaming. Their results suggested that 37.2% of their
participants had experienced the co-occurrence of problematic
work, 36.6% had experienced problematic eating behaviors
(i.e., eating too little or too much), 14.1% had experienced
problematic sex (i.e., excessive sexual behavior), and 12.3%
had experienced problematic gambling. The latter finding was
in line with a study by McBride et al. , which reported that
11.4% of disordered gamers within in their sample experi-
enced problem gambling, and which is consistent within the
wider literature [100,101]. Finally, a study by Ivory et al. 
on US college students (n= 533) suggested that gaming was
not significantly associated with nicotine or substance use.
However, taken as a whole, the aforementioned studies tend
to indicate that disordered gaming appears to frequently co-
occur alongside problematic substance use, and there are com-
plex associations between the co-occurring problematic sub-
stance use and potential behavioral addictions.
Assessing the Etiology of Gaming Disorder and Co-occurring
Potentially Addictive Behaviors
Four [7,33,102,103] out of the 20 eligible studies identified
for review were classified as etiological papers and defined as
papers that attempted to explore the underlying mechanisms
that may contribute to co-occurrence of GD with other poten-
tially addictive behaviors and possible etiological pathways
(see Table 3). These papers also have diverse geographical
locations, including Norway , Spain , Australia ,
and Germany .
Dysfunctional coping strategies have been used to explore
how underlying cognitive mechanisms contribute to the de-
velopment and maintenance of co-occurring behavioral and
substance addictions and understand etiology. Schneider
et al.  utilized the Brief COPE  to assess different
subdomains of coping styles (i.e., a range of cognitive and
behavioral responses that are utilized in stressful situations)
. They surveyed 823 Australian high school students
(M= 14.3, SD = 1.4) and found that coping may play a pivotal
role when considering co-occurring risk behaviors. They
highlighted a tendency toward denial and behavioral disen-
gagement coping styles—which were positively correlated
with substance use—within those who scored higher on
Curr Addict Rep (2019) 6:383–401
Table 2 Prevalence rates of co-occurrence problematic anddisorderedgamingusing proxy indicators
Paper Aims Sample Behavior/
Gallimberti et al.,
The aim of the study was to investigate the
association between problematic gaming and
substance abuse in children and young
- Problematic Use
of Video Games
Pinocchio Survey (136 items - Family, Peer,
Personality, and behavior domain factors
[which included Smoking, Alcohol, Energy
Drink [Caffeine], and Cannabis);
Problematic Use of Video Games scale 
(adapted from the DSM-5; 6 items)
- Smoking (nicotine & cannabis), alcohol, and
energy drink consumption are associated with
Ivory et al., 2017
To explore the potential role videogames may
have on the unique health risk environment of
college and university campuses. To
predictions of the risk, incapacitation, and
inconsequential approaches to the possible role
of video games
- Substance use
- Disordered eating
Adapted and amalgamated version of the
National College Health Risk Behavior
Survey and the National College Health
Assessment (24 items)
- Video game play was largely unrelated to
disordered exercise, nicotine, and other
- Video game play was related to higher weight,
but reduced rates of disordered eating
et al., 2016 
To describe the prevalence of single versus
multiple addiction problems in a large
representative sample and to identify distinct
subgroups of people experiencing problematic
or disordered behaviors.
Alberta Addiction Survey (10 items);
Personal Wellbeing Index (8 Items)
- 29.8% reported a problem use with one
substance or behavior; 13.1% reported
co-occurrence of two; 7.9% reported the
co-occurrence of three or more.
- Excessive video game playing frequently
co-occurred with smoking, excessive eating
- The highest co-occurring problem behaviors to
the lowest (n= 127): Work (37.2%), eating
(36.6%), nicotine (31.1%), sex (14.1%),
cannabis (13.5%), gambling (12.3%),
shopping (4.9%), alcohol (1.2%), cocaine
McBride et al.,
To examine commonalities between gambling
behavior and problematic gambling among
video game players and between video game
playing and addicted playing among gamblers
old; M= 18.69,
- Game Addiction
Gambling Activities Questionnaire (12
Video Game Activities questionnaire (12
items); Problem Gambling (12 items);
Gaming Addiction Scale (21 items)
- Video gaming was associated with gambling
- 11.4% (4) of addicted gamers (n= 35)
experienced problem gambling
Škařupová et al.,
To explore levels and patterns of online gaming
while under the influence of various substances
- Illicit drugs
- Online Gaming
Addiction Engagement Questionnaire [92,93]
Drug use while gaming (2 items)
Caffeine was the most commonly co-occurring
substance used by 74.2%, followed by alcohol
40.4%, nicotine 25.3%, and 14.5% used illicit
substances while gaming
- Substance use was positively associated with
intensity of gaming and both addiction and
van Rooij et al.,
The current study explored the nature of
problematic video gaming (PVG) and the
association with game type, psychosocial
health, and substance use
- Problematic Video
Video Game Addiction Test (14 item);
Psychoactive Substance Use/Non-Use;
Self-Esteem Scale (10items);
Loneliness Scale  (10 items); Depressive
Mood List  (6 items);
Revised Social Anxiety Scale for Children 
(Subscales: Social Avoidance & Distress [6
items] and Social Avoidance & Distress in
educational Performance (1 item)
- Higher scores on PVG indicated higher use of
nicotine, alcohol and cannabis
Items in italics represent relevant measures
Curr Addict Rep (2019) 6:383–401 391
Table 3 Cross-sectional papers assessing the etiology of disordered gaming
Study Aims Sample Behavior/
Andreassen et al.,
To investigate behavioral addictions
and how they relate to the main
dimensions of the five-factor
model of personality
n = 218
(M= 20.7 years;
- Mobile Phone
Bergen Facebook Addiction Scale (BFAS; 6 items);
Game Addiction Scale for Adolescents (GASA; 7
items); Young’s Diagnostic Questionnaire (YDQ; 8
items); The Exercise Addiction Inventory (EAI; 6
items); Mobile Phone Addiction Index (MPAI; 8
items); Compulsive Buying Scale (CBS; 13 items);
Study Addiction Scale (7 items; adapted from the
Bergan Work Addiction Scale); Revised NEO Five-Factor
Inventory-Revised  (60 items)
- Conscientiousness was negatively
associated with video game
- Conscientiousness seems to be a
protective factor for unproductive
behavioral addictions (i.e., Facebook
use, video gaming, Internet use,
- The distinction between unproductive
and productive behavioral addictions
bears some resemblance to the
distinction between impulsive
control disorders and OCD
Estévez et al.,
To examine the relationship of
emotional regulation and
attachment, with disordered
substance use, disordered
behaviors in adolescents and
Difficulties in Emotion Regulation Scale [108,109](28
items); Inventory of Parent and Peer Attachment [110,111]
(Mother: 16 items Father: 16 items; Peer: 16 items);
Multicage CAD-4 (Alcohol [4 items] & Substance
Abuse [4 items] Subscales); Problematic Internet Use 
(10 items); Video Game-related Experience Questionnaire
(17 items); South Oaks Gambling Screen for
Adolescents (12 items)
- Emotional regulation is predictive of
all addictive behaviors
- Attachment is predictive of
- Males scored significantly higher in
gambling disorder and videogame
Schneider et al.,
To investigate Internet gaming
disorder (IGD) in relation to
coping, including emotion- and
problem-focused coping styles
Internet Gaming Activities Survey; Internet Gaming Disorder
Checklist (12 items); Brief COPE (28 items)
- IGD was significantly correlated with
denial and behavioral disengagement
- Age was positively associated with
substance use coping
Walther et al.,
To investigate co-occurrence and
shared personality characteristics
of problematic computer gaming,
problematic gambling and
Substance Use Frequencies (3 items); South Oaks Gambling
Screen - Revised for Adolescents (12 items); Video
Game Dependency Scale (10 items); Personality
Factors (Each original scale was reduced to 4 items);
Adapted Depression scale; Inventory of Impulsivity, Risk
Behavior and Empathy ; Personality Questionnaire;
Scale for General Self-Efficacy ; Scale for
self-efficacy in Social Situations ; Social Anxiety
Scale for Children Revised ; Rating Scale for
Attention-Deficit/Hyperactivity Disorder ; Rating
Scale for Oppositional Defiant/Conduct Disorders ;
Loneliness Scale ; Rosenberg-Self-Esteem Scale
; Satisfaction with Various Domains of Life 
- Alcohol, nicotine, and cannabis were
all positively correlated
- Problematic gambling and
problematic gaming were positively
- Problematic gaming co-occurred with
- Problematic gambling co-occurred
with alcohol, nicotine, and cannabis
- High impulsivity was associated with
all five addictive behaviors
Items in italics represent relevant measures
Curr Addict Rep (2019) 6:383–401
disordered gaming, suggesting that adolescents may employ
avoidant coping strategies.
In a sample of 472 Spanish students (aged 13–21 years),
Estévez et al.  assessed the relationship between emotional
regulation and attachment in several addictive behaviors, in-
cluding disordered gaming. The study found that attachment
style was predictive of behavioral addictions, but not sub-
stance addictions. Poor peer attachment predicted gaming
and gambling disorders, and poor maternal attachment pre-
dicted problematic internet use.
With regard to personality, Andreassen et al. found
that social media addiction, internet addiction, and disor-
dered gaming were all negatively associated with consci-
entiousness among a small sample of Norwegian universi-
ty students (n= 218). Walther, Morgenstern and
Hanewinkel  also proposed that co-occurrence be-
tween substance and behavioral addictions could be ex-
plained via personality traits. Their results indicated that
impulsivity and social anxiety were associated with sub-
stance users, gamblers, and gamers. The high impulsive-
ness trait (i.e., doing things without thinking them through)
characterized individuals who engage in problematic sub-
stance use, problematic gambling, and problematic gam-
ing. However, while low social anxiety was predictive of
problematic substance use and problematic gambling, the
reverse was true for problematic gaming, where those with
high social anxiety were at higher risk for problematic
gaming behavior. It should also be noted that social anxiety
has been associated with dysfunctional coping strategies (
, which in turn has been implicated in addiction [128,
129]. Furthermore, the researchers noted that while prob-
lematic substance users have high co-occurrence to other
addictions, each addiction to one substance showed asso-
ciations with personality traits (i.e., high impulsivity and
high extraversion) and mental health problems (e.g., high
depression, low social anxiety). Problem gamers showed
overlap in some of these traits (i.e., impulsivity and social
anxiety) with problematic gamblers.
The aim of the present paper was to review and describe the
literature on co-occurrence within the field of gaming disorder
(GD) published over the past decade. The review considered
the prevalence rates in empirical studies that investigated the
potential co-occurrence of potential behavioral addictions
and/or substance use in those with GD. It also described the
use of psychometrically validated assessment instruments and
proxy measures in assessing prevalence rates, as well as the
etiological studies that investigated the development and
maintenance of co-occurrence of potentially addictive behav-
iors among those with GD.
Ten papers considered GD and a co-occurring potential
behavioral addictions and/or substance use and employed val-
idated psychometric measures to assess the prevalence, fre-
quency, and severity of the behaviors studied. Six papers in-
vestigated adult populations [27,29,30,32,36,130], four
papers investigated adolescents [10,28,31], and one consid-
ered both .
Ream et al.  investigated a North American sample and
found that of those who consume psychoactive substances
(e.g., nicotine and/or coffee) also engaged in concurrent use
of gaming. The surveyed literature also suggested that
smoking nicotine or drinking alcohol can have an impact on
problematic gaming scores [27,30]. The broader literature
suggests an overlap between various substance and behavioral
addictions, suggesting it is a relatively common occurrence
 among adults. Collectively, the reviewed literature also
demonstrates that adults who play video games engage in
concurrent use of psychoactive substances, which may result
in co-occurring problematic use and engagement in potential-
ly addictive behaviors.
The surveyed literature on adolescents also reflects a range
of prevalence rates. In a nationally representative Hungarian
sample, it was shown that 4.3% experienced problematic gam-
ing, 8.8% experienced problematic internet use, and 6.7%
experienced both problematic gaming and internet use .
Andreassen et al.’s results suggest that 7% of Norwegian
adults reported problematic gaming. A similar result was
found among a Dutch sample, which reported 5.7% of their
sample experienced some problematic gaming and 9.1% re-
ported problematic social media use, both of which were
strongly associated with nicotine consumption . Pontes
 had a similar finding in Portuguese middle school stu-
dents, which suggested that the co-occurrence of problematic
gaming and problematic social media use can lead to the de-
terioration of psychological health more so than either prob-
lematic behavior on its own. The studies also suggest that
disordered gaming shares underlying risk factors (e.g., identi-
ty styles ) with problematic social media use and internet
addition, suggesting that co-occurring problematic behaviors
may share common identity styles, which act as risk factors in
the co-occurrence of problematic online behaviors (i.e., gam-
ing, social media, and internet use).
These results were consistent with the wider literature in
regard to the association with potentially addictive behaviors
and/or substance use [131,132], while the findings
concerning disordered gaming also showed parallels with oth-
er behavioral addictions and substance disorder fields (e.g.,
gambling [133,134]). However, the variation in the consump-
tion of substances or frequency of behaviors within the sur-
veyed literature may indicate that traditional approaches in
psychiatric comorbidities  and problem behavior theory
 may not be a viable approach when assessing disordered
consumption of substances and resulting behaviors. Gamers
Curr Addict Rep (2019) 6:383–401 393
may instead be making pragmatic choices involving their con-
sumption of substances, which may not be an indication of
uncontrolled behavior . For example, having increased
amounts of caffeine or using “smart”drugs could be used to
provide a competitive edge while gaming, which could be
particularly true for those who play games professionally
. This may explain why illicit substance use (as opposed
to legal substance use) varies in the surveyed literature, be-
cause it may be a choice by gamers to prolong their gaming
with stimulants such as caffeine or nicotine . However,
gamers may choose to consume substances irrespective of
videogame participation , which would explain the high
rate of nicotine use  and alcohol use insomesam-
ples of gamers. For example, if an individual is trying to quit
smoking, they may increase their alcohol consumption (which
has been associated with disordered gaming ). In an at-
tempt to offset their need for nicotine, they may engage in
other potentially addictive behaviors (e.g., alcohol consump-
tion), which may then co-occur with an addiction, such as GD.
This suggests an underlying association with disordered sub-
stance use, which can be seen in other disordered behaviors,
such as gambling disorder [137,138].
Based on the empirical studies reviewed, problematic
gamers consume a variety of substances while engaged in
videogames. More specifically, while gaming, between 23.3–
74.2% of gamers consumed caffeine [82,86], 21.7–25.3%
smoked cigarettes [82,86], 41.2–44.6% smoked cannabis [28,
82], 21.3–40.4% consumed alcohol [82,86], and 14.5% con-
sumed illicit substances . In regard to problematic and dis-
ordered behavior, the findings suggested that problematic gam-
bling , problematic shopping, problematic sex, and prob-
lematic work  were associated with disordered gaming,
while disordered exercise was not related [29,83].
Indeed, the presented evidence suggests that the co-
occurrence of potentially addictive behaviors is not uncom-
mon and is associated with a number of maladaptive outcomes
for both adults  and adolescents [31,139]. There appears
to be a clear divide between the experience of co-occurrence
among adults and adolescents. The literature demonstrates
that adults with disordered gaming frequently feature co-
occurring problematic or disordered substance use (e.g., alco-
hol use [30,32,35]), while disordered eating appears less
frequently. However, the opposite appears to be true for ado-
lescents, who appear to experience co-occurring disordered
behaviors, such as social media addiction or problematic in-
ternet use [10,31]. The discrepancy between adults and ado-
lescents may be explained due to the scarcity of available
substances due to age-related factors  because disordered
substance use is seen to increase as adolescents get older
, allowing them to purchase alcohol or nicotine legally.
It is also worth noting that many of the problematic behaviors
co-occurring with disordered gaming are ones that can be per-
formed concurrently with gaming. For example, the surveyed
literature shows that problematic exercise and problematic gam-
ing co-occur. This may be attributed to the fact that gaming does
not typically facilitate exercise,asgamingislargelyasedentary
behavior, whereas exercise requires vigorous physical activity
, which acts as a protective factor in GD . This idea is
also corroborated by the way the literature consistently shows
that smoking and alcohol use co-occur with GD [27,30,32,
130]. This may arise because the gaming context can facilitate
the concurrent use of alcohol and smoking (i.e., nicotine or can-
nabis), especially if used as part of a coping strategy .
Coping strategies were one of the three ways (i.e., (i) cop-
ing strategies, (ii) emotional regulation and attachment, and
(iii) personality characteristics) in which the development and
maintenance of co-occurrence was considered in behavioral
and substance addictions. Schneider et al.  considered
coping strategies to be a key element in the development
and maintenance of co-occurrence in an adolescent sample.
Their results suggested that behavioral disengagement was a
common coping strategy by those who experienced disor-
dered gaming. One proposed reason of this resulting behavior
is the self-medication hypothesis. This hypothesis suggests
that in addiction-related disorders, individuals use substances
in order to overcome painful affective states as well as related
mental disorders , and this has been a common area of
interest in problematic internet use [143,144]. It may also
indicate that maladaptive coping strategies (i.e., emotional
avoidance and/or behavioral disengagement) may play a key
role in the development of co-occurring behaviors within dis-
ordered gaming. Furthermore, when these coping strategies
co-occur, it is evident that these strategies will exacerbate
disordered gaming symptoms, more so than either one on their
own . However, while there has been some literature to
suggest that maladaptive coping strategies play an important
role in problematic internet use [8,145], further research is
needed in the case of disordered gaming.
Estévez et al.  suggested that disordered behavior (e.g.,
disordered gaming) and substance use may be explained utilizing
emotional regulation and attachment theory. It has been sug-
gested that low levels of emotional regulation are associated with
an increase in risky behaviors, such as GD  and substance
use . Furthermore, emotional regulation is also predictive of
addictive behaviors (but not substance addiction), suggesting that
individuals with difficulty in emotional regulation may engage in
addictive behaviors such as gaming to avoid (i.e., behavioral
disengage) or regulate negative feelings or emotions (i.e., the
self-medication hypothesis [7,145,148]). Moreover, Estévez
and colleagues’research suggests that attachment may also pre-
dict co-occurring use, specifically in behaviors that are potential-
ly addictive. Poor peer-attachment was found to predict GD and
gambling disorder, and poor maternal attachment predicted prob-
lematic internet use. Individuals with a secure attachment are
characterized by a self-acceptance of emotional needs.
However, an individual with a non-secure attachment style
Curr Addict Rep (2019) 6:383–401
may pay little attention to their emotional needs and feel they
have a lack of support . This may then cause them to avoid
interpersonal relationships , lending support to the notion
that behavioral addictions may be understood as a form of escape
and compensation for poor relationships . Indeed, it could
be suggested that individuals employ maladaptive behavioral
coping strategies in response to poor emotional regulation or
attachment, which may in turn aid in the development and main-
tenance of co-occurring at-risk behaviors.
Another dimension that has been considered in the develop-
ment and maintenance of co-occurrence in GD is personality
traits and factors. Low conscientiousness has been found to be
associated with behavioral addictions (e.g., SNS addiction and
GD ). This suggests that people who experience problem-
atic or disordered gaming may have low conscientiousness and
may have a low priority of duties and obligations , lack of
planning ability , low self-control, weakness for tempta-
tions , and experience procrastination . This is in line
with Walther et al. , whose results suggested that individ-
uals that experience problematic or disordered gaming also
have high impulsiveness (i.e., a lack of self-control), which
has been associated with problematic or disordered behavior,
and/or substance use . Furthermore, problematic gamers
only shared a small overlap in personality factors with problem
gambling (i.e., problematic behavior), even though problematic
gambling shares more of an overlap in personality factors with
problematic substance use than problematic gaming. However,
problematic gamers reported higher scores on ADHD symp-
toms, high irritability/aggression, high social anxiety, and low
self-esteem than any other addiction in Walther et al.’s paper
, suggesting that gaming may take a unique dispositional
position within the examined addictive behaviors here. The
aforementioned studies indicate that personality traits or factors
may impact the likelihood for co-occurrence to manifest in
people experiencing problematic or disordered gaming.
The literature reviewed represents important examples of the
next logical step in the progression of research beyond preva-
lence rates of co-occurrence. Each of the reviewed studies ex-
plored either specific psychological, sociological, and/or physio-
logical factors. This in turn can guide future research into pre-
senting a holistic representation of the specific risk factors (e.g.,
coping strategies and identity styles), which may contribute to
developing, maintaining, or exacerbating co-occurring potential-
ly addictive disorders. Furthermore, future research could help
inform public policy and guide the development of treatment that
encompasses the full clinical presentations of patients. However,
only four recent studies [7,80,102,103] have taken the extra
step to investigate the etiology and mechanisms of co-occurring
Understanding these processes is needed to further the un-
derstanding of addictive disorders. Nevertheless, the extant
findings are beneficial in advancing the field and providing a
framework for how to consider the mechanisms of co-occurring
addictive behaviors in a multifaceted manner. Furthermore, the
present review also highlights the potential for differing mech-
anisms of action, despite similar observed effects, suggesting
that behavioral and substance addictions, and their co-
occurrence involve complex processes. In understanding these
factors, treatment efficacy may be increased by targeting com-
mon etiological mechanisms across multiple disorders (e.g.,
coping mechanisms , or personality factors ), much
like the direction of the literature within the substance disorders
Co-occurrence Within Disordered Gaming Compared
to the Substance Disorder Literature
Arguably, GD is one of the newer behavioral disorders to be
investigated. Nevertheless, past substance use disorder literature
can be used to provide a reference point on how to advance the
co-occurrence research into disordered gaming. The drug and
alcohol abuse literature appears to focus on the epidemiology
of co-occurrence as it appears to be commonly studied , a
trend that the GD literature is following. Furthermore, within the
substance abuse literature, co-occurring behavioral and substance
addictions appear to be commonly considered in both the general
and clinical populations [25,87], indicating that the GD literature
should also mimic this global approach. In addition, individuals
with co-occurring behavioral or substance use disorders (or prob-
lematicuse)tendtohavepoorerfunctioning and treatment out-
comes, much like individuals with disordered gaming
[156–158]. These findings within the substance use literature
are in part facilitated by the longitudinal research investigating
the development, maintenance, and remission of each disorder,
which the present field of co-occurrence in disordered gaming
While research on GD focuses on the prevalence and co-
occurrence of psychiatric disorders , the substance use lit-
erature has gone much further by investigating and identifying
the epidemiological factors of co-occurrence and the impact co-
occurring disorders can have. For example, there have been a
number of studies that have investigated a wide range of under-
lying mechanisms between co-occurring substance use and oth-
er disorders such as neurobiological commonalities, genetic
markers, temporal changes, and qualitative research focusing
on behavioral changes [159,160]. Furthermore, the substance
use literature has also investigated whether treating one disorder
causes the accompanying co-occurring disorder to go into re-
mission, concluding that it can vary depending upon the disor-
ders and individual presentation [25,161]. However, when
looking to research concerning disordered gaming, this addi-
tional step has not yet been made, and the effects of co-
occurrence and its impact on course of illness and by type of
disorder are not yet known. Additionally, the substance abuse
literature has also closely examined the exacerbating effects of
multiple co-occurring disorders [158,162]. While the research
Curr Addict Rep (2019) 6:383–401 395
on disordered gaming has begun to move in this direction,
research on substance use has attempted to separate various
dimensions of co-occurrence (e.g., psychiatric disorders, mental
health, and social functioning) by controlling for their effects on
the primary disorder in question .
Finally, when considering treatments, the substance use lit-
erature has paved the way for behavioral disorders. There is a
general agreement that co-occurring disorders may require an
integrated approach [164,165] which consider not just the pri-
mary disorder, but also the co-occurring disorder. For example,
in a systematic review on people who experiences severe men-
tal illness and co-occurring substance use suggested that moti-
vational interviewing in conjunction with cognitive behavior
therapy (CBT; targeting both substance use, and mental health
respectively) showed “quality”evidence for reducing substance
use and improving mental health than just CBT alone.
However, this type of approach is not near the level of accep-
tance as more traditional treatments (such as CBT), although
there are considerable efforts to evaluate its efficacy in the sub-
stance use field [24,162]. In contrast, the research into integra-
tive treatments that targets both disordered gaming and co-
occurring addictive disorders is, to the best of authors’knowl-
edge, notably absent from the literature.
A majority of the surveyed literature does not go beyond mea-
sures of association and with measures of prevalence being ques-
tionable due to overwhelming lack of representativeness of sam-
ples. The published literature suggests that there are various be-
havioral and substance-related addiction disorders that have the
potential to co-occur with GD. However, there is very little ad-
ditional literature that continues to investigate this further.
Regarding the co-occurrence of disordered gaming with other
behavioral addictions, only a few studies exist, suggesting a co-
occurrence with problematic gambling, shopping, and social me-
dia use. While there has not been an extensive amount of litera-
ture on the co-occurrence prevalence rates of disordered gaming
with other addictive behaviors, it has been explored across sev-
eral geographical locations and cultures, indicating that it is mov-
ing in a similar direction of other addiction-related literature (e.g.,
gambling ). However, while it is important that this line of
enquiry is followed, it is also important to investigate the etio-
logical aspects of co-occurrence within GD because it is experi-
enced differently across culturally diverse groups of people.
There is a significant gap in the literature when it comes to
longitudinal studies that focus on the changes of co-occurring
addictive disorders over time. The current literature estab-
lishes that co-occurrences between disordered gaming and
other addictive-related disorders are common. Furthermore,
no paper to the authors’knowledge has investigated whether
disordered gaming preceded the onset of another co-occurring
addictive disorder or vice versa. It is imperative to understand
how co-occurring disorders interact over time in order to de-
velop appropriate treatment methods. Moreover, models for
hypothesizing potential treatment frameworks and outcomes,
which consider onset or remission of other co-occurring prob-
lematic or disordered behavior, would be instrumental in im-
proving potential effectiveness of treatment methods. For ex-
ample, having confidence that disordered gaming symptoms
typically occur within specific substance abuse disorders (e.g.,
alcohol or cannabis abuse) may allow for a more tailored
approach that targets both disordered gaming and the co-
occurring use of other behaviors or substances. Future studies
should also consider investigating the time of onset in relation
to disordered gaming because this would also provide more
robust data and allow for more significant conclusions to be
Substance Use Literature May Act as a Model to Guide
A finding that was consistent across both adults and adoles-
cents was that those who presented with problematic or disor-
dered gaming and a co-occurring addiction-related condition
consistently reported more severe experiences as assessed
using clinical measures [27,30,31], which is mirrored within
the substance abuse literature [25,166]. Another way in which
the reviewed literature mirrored the substance use literature is
the calls for the early intervention for individuals experiencing
co-occurring disorders , with a number of studies calling
for additional early intervention screening measures , pro-
viding psychoeducation on the co-occurring disorder , or
considering shared clinical features (e.g., personality factors
). These suggestions highlight the need for careful clinical
assessment of co-occurring problematic behaviors that may
have developed on a subclinical level and, thus, might con-
tribute to the primary disorder.
The momentum of research examining GD more generally
has increased and those in the field are engaging in effective
efforts to understand the impact of co-occurring addictive be-
haviors. The substance use literature provides various research
frameworks and designs that could be utilized in the future to
bring gaming research in line with the wider field of addictive
disorders. For example, investigating the nuances between
different co-occurring disordered use in clinical samples
, continuing investigations into prevalence, but expanding
and evaluating the epidemiological data of such impacts as
onset and remission , and establishing clinical trials and
protocols that are tailored toward individuals presenting with
co-occurring disorders [25,160].
Although the present review identified several important
trends within the disordered gaming co-occurrence literature,
Curr Addict Rep (2019) 6:383–401
it is subject to limitations. Firstly, methodology used in the
review was descriptive and does not quantitatively synthesize
data. Although the authors followed a rigorous and transparent
review methodology, it still investigates the breadth of litera-
ture, rather than its depth, and as such, no statistical conclu-
sions can be drawn from the results. Secondly, the study ex-
cluded literature that was not peer-reviewed. Furthermore, the
inclusion criteria meant that only English language papers
were reviewed, limited by a specific set of databases and
search terms. As a result, the authors may have missed rele-
vant studies in other languages or databases. As with any
review, screening and selection is always a subjective process
and is thus prone to biases. Despite capturing a wide range of
research terms in several databases, it is possible that relevant
studies may have been missed due to a lack of fit with the
inclusion criteria. Finally, considering only the use of papers
that were published in the last several years may have also
contributed the small amount of papers on co-occurrence and
The evidence in the present review suggests an increase in
research interest on co-occurrence of other addiction-related
behaviors with disordered gaming. However, currently, most
research investigates the prevalence rates of co-occurring ad-
diction-related disorders with disordered gaming and fre-
quently demonstrated the potential for co-occurrence between
problematic and disordered behaviors and substance use.
Various reviewed papers considered novel ways to investigate
the potential development and maintenance of problematic
and disordered gaming and its co-occurrence, which could
be improved further by considering the frameworks and study
designs used in the substance addiction disorder literature.
Indeed, the research indicates that co-occurrence in problem-
atic and/or disordered gaming is common, and when examin-
ing the substance use field as a guide, outcomes may be im-
proved when separate treatment modalities for these co-
occurring disorders are offered in combination. While it is
not certain how well these treatment models may work
in a diverse population, current research consistently calls
for trials of multimodal treatment (i.e., using tailored
treatments that consider co-occurring behavior or sub-
stance use) to take place.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appro-
priate credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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