Problematic Gaming among Adolescents and Youth: The Role of Alexithymia, Emotion Regulation, and Attachment Based on Sex

Introduction

The use of video games among adolescents and young adults has experienced a significant increase in recent decades, becoming a popular form of entertainment and recreation (Sixto-Costoya et al., 2021). Gaming presents some positive aspects, both in terms of academic and learning outcomes, such as enhancing problem-solving skills, quick decision-making, and coordination (López-Gómez et al., 2022; Przybylski, 2014). However, the potential adverse effects of video games have recently been emphasized, with a significant impact on physical (e.g., obesity) and mental health (e.g., depression) (Alanko, 2023; Macur & Pontes, 2021; von der Heiden et al., 2019), including gaming disorder.

The gaming disorder is characterized by maladaptive videogame playing behavior (Wang et al., 2019). It has been classified in the International Classification of Diseases (ICD-11; World Health Organization [WHO, 2018]), and in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; American Psychiatry Association [APA, 2023]). According to the ICD-11, there should be a lack of control over gaming behavior, gaming should be the focal point of one’s activities, and there should be a progression of these behaviors for at least one year. Similarly, in addition to these criteria, the DSM-5-TR emphasizes the presence of emotional traits such as concern, irritability, and unsuccessful attempts at emotional relief.

Although the prevalence of gaming disorder varies considerably, meta-analytical studies conclude that its prevalence among children, adolescents, and young adults ranges from 3.3% to 8.8% and it is higher than in adults, and more common in males than in females (Fam, 2018; Gao et al., 2022; H. S. Kim et al., 2022; Stevens et al., 2021). One of the most controversial aspects of diagnostic manuals is that they are primarily oriented toward adults, as exemplified by the required duration of time for a diagnosis. Similarly, another criticism related to gaming is that studies have predominantly focused on males, leading to potential oversight or underdiagnosis of females with this disorder (Dong et al., 2018; Kuss & Griffiths, 2014; Lopez-Fernandez, Williams, & Kuss, 2019). This is attributed to women’s and men’s different reasons for engaging in gaming (Infanti et al., 2024). For instance, in the case of women, aspects such as competition, hostility, poor body image, and social phobia are motivating factors. In contrast, for men, gaming is often considered a coping strategy to deal with stress and a means of achieving success by winning in the game. Nevertheless, there are also common factors such as escape and avoidance that have been identified as predictors of problem gaming (Lopez-Fernandez, Williams, Griffiths, et al., 2019).

Regarding risk factors for gaming, it has been observed that alexithymia is a predictor of the severity of gaming issues (Pape et al., 2022). Alexithymia is characterized by difficulties in identifying, analyzing, and verbalizing the emotions of oneself and others (Kandri et al., 2014). That is, alexithymia not only affects one’s own emotional experiences but also interferes with the recognition of others’ emotions, thus affecting interpersonal relationships (Parker et al., 2013; Pisani et al., 2021). Specifically, despite women dealing with greater challenges in identifying and describing emotions, while also externalizing feelings less than men (Germani et al., 2023), men with alexithymia have a higher risk of experiencing gaming disorder (Bonnaire & Baptista, 2019).

Another variable associated with alexithymia and gaming is emotion regulation (Bonnaire et al., 2017; Hollett & Harris, 2020). Emotion regulation refers to the ability to control emotional arousal and to act independently of one’s emotional state (Gratz & Roemer, 2004). Studies have indicated that low levels of emotion regulation can be a risk factor for problematic video gaming (Estévez et al., 2017; Uçur & Dönmez, 2021).

One of the variables that has received the greatest attention in recent years in relation to addictive behaviors is attachment (Estévez et al., 2022). The results in this regard are mixed, with some finding a significant relationship with gaming (Estévez et al., 2019; Teng et al., 2020), while others do not (see e.g., S. Kim & Chun, 2022). According to Estévez et al. (2021), individuals exhibiting addictive behaviors may have an insecure attachment to their parents. Therefore, a secure attachment to parents appears to act as a protective factor against addictive behaviors. It has also been noted that, on one hand, maternal and paternal attachments differ. On the other hand, paternal attachment seems to be only related to the analysis and verbalization of emotions.

Moreover, it has been observed that alexithymia is related to attachment because identifying and describing feelings is learned during childhood through the relationship with caregivers or parents (Luminet et al., 2018). This relationship has been previously noted in studies on other types of addictions (Andres et al., 2014; Ding et al., 2022; Estévez et al., 2021; Zakhour et al., 2020; Zdankiewicz-Ścigała & Ścigała., 2018). Previous studies have noted the mediating role of alexithymia between attachment and gaming (Estévez et al., 2021; Jauregui et al., 2023). However, Macía et al. (2023) found that insecure attachment to the mother’s figure predicted problematic video gaming in a sample of young women and adolescents. Therefore, previous research shows mixed results regarding the influence of attachment figures in gaming development. Further studies are needed to explore this issue.

Consequently, the current study aimed to analyze problematic video gaming in adolescents and young adults to gain a better understanding of this addictive behavior. Specifically, the study aimed to examine the differences in attachment, alexithymia, and emotion regulation between individuals with and without problematic gaming, as well as based on sex. Additionally, the study aimed to investigate the predictive role of attachment, alexithymia, and emotion regulation on gaming severity.

Method

Participants

The sample consists of 933 individuals, of whom 50.6% were male (n = 469), with ages ranging from 12 to 18 years (M = 15.24, SD = 1.44). Among the male participants, 34.97% (n = 164) exhibit problematic video gaming, while in the female group, the percentage is 19.69% (n = 90).

Regarding the educational level, 8.4% (n = 78) had completed high school, 6.3% (n = 59) had completed vocational training, 42.2% (n = 393) had completed secondary school, 42.1% (n = 392) had completed primary school, and 1% (n = 9) had no studies. Regarding occupational status, 98.3% (n = 912) were studying, 0.6% (n = 6) were working, 0.1% (n = 1) were unemployed, and 1.0% (n = 9) were working and studying. Finally, 97.6% of the participants were single (n = 878).

Instruments

Sociodemographic data, such as age, sex, educational level, occupational status, and marital status, were collected.

The MULTICAGE CAD-4 instrument (Pedrero-Pérez et al., 2007) was used to assess problematic gaming. The instrument comprises 32 dichotomous items assessing eight subscales (4 items each): alcohol, drugs, gambling, Internet, gaming, compulsive buying, eating disorders, and sexual behavior. The reliability of the test is adequate, as Cronbach’s alpha coefficient exceeds .70 for all subscales. Although this instrument has eight subscales, only the video gaming subscale was used in this study. To classify the sample based on the absence or presence of problematic gaming and dichotomize the variable, the presence of gaming was considered for scores equal to or greater than 2 (Pedrero-Pérez et al., 2007). In the present study, Cronbach’s α was .76 for the gaming subscale.

The Toronto Alexithymia Scale (TAS-20; Bagby et al., 1994; adapted by Sánchez, 1996) was employed to measure alexithymia. The questionnaire comprises 20 items measuring three subscales: difficulties in identifying feelings, difficulties in describing feelings, and externally oriented thinking. Response options range across 6 Likert-type scale choices (0 = strongly disagree, 5 = strongly agree). This instrument has good internal consistency with a Cronbach’s alpha value of .81. In this study, Cronbach’s alpha was .87 for the entire questionnaire and ranged from .71 to .84 for the subscales.

The Cognitive Emotion Regulation Questionnaire (CERQ-18; Garnefski et al., 2002; adapted by Domínguez-Lara & Merino-Soto, 2015) assesses the cognitive regulation of emotions in response to stressful events. It is an 18-item self-report instrument rated on a 5-point Likert-type response scale (1 = almost never, 5 = almost always). This questionnaire comprises nine subscales: self-blame, acceptance, rumination, positive refocusing, planning, positive reappraisal, putting into perspective, catastrophizing, and blaming others. It exhibits adequate psychometric properties (α > .70). In this study, Cronbach’s alpha was .90 for the overall scale, and for the subscales, the values were as follows: .91 for self-blame, .64 for acceptance, .75 for rumination, .80 for positive refocusing, .79 for planning, .51 for positive reappraisal, .76 for putting into perspective, .86 for catastrophizing, and .82 for blaming others.

Finally, the Inventory of Parent and Peer Attachment (IPPA; Armsden & Greenberg, 1987; adapted by Gallarín & Alonso-Arbiol, 2013 and by Maya et al., 2023 in the adolescent population) assesses attachment styles toward one’s father, mother, and peers. This questionnaire comprises 48 items rated on a 5-point Likert-type response scale (from 1 = never to 5 = always). These items are divided into three subscales of 16 items each, measuring attachment to the mother, father, or peers. A high score indicates secure attachment, whereas a low score indicates insecure attachment. The Spanish version shows a good level of Cronbach’s alpha in all three subscales (.87 for mother attachment, .88 for father attachment, and .93 for peer attachment). Regarding internal reliability in this study, a value between .90 and .96 was obtained.

Procedure

The sample was obtained through a convenience sampling process, wherein we contacted the managers of educational and vocational training centers, inviting them to participate. Participants were included in the study if they were between 12 and 18 years old from high schools or vocational training centers.

Participants completed the questionnaires in a paper-and-pencil format or, if not feasible, online under a teacher’s supervision. Additionally, participants signed an informed consent form, and for minors parental consent was obtained. Anonymity, confidentiality, and voluntariness were ensured and, in case any participant required additional information, the contact details of the researchers were provided. Participants did not receive any compensation for their participation. This study followed the principles of the Declaration of Helsinki and received approval from the ethics committee of the University of [blinded] [ref. blinded].

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Data Analysis

Firstly, differences based on sex were analyzed in the sample with and without problematic gaming regarding attachment, emotion regulation, and alexithymia using a Student’s t-test. The effect size was calculated by using Cohen’s (1992) d, with index values below 0.20 corresponding to a small effect size, around 0.50 indicating a medium effect size, and values exceeding 0.80 indicating a large effect size.

Furthermore, bivariate correlations between the study variables were calculated using Pearson’s r. Subsequently, hierarchical linear regression analyses were conducted to examine the predictive role of age, emotion regulation, alexithymia, and attachment in gaming severity. In the first step age was introduced, in the second step emotion regulation was added, in the third step alexithymia, and, in the fourth step attachment was included, assessing changes in R² at each step. Given the exploratory nature of the study, all variables of interest were included in the linear regression, regardless of their correlation with the dependent variable.

All analyses were conducted using the statistical software IBM SPSS Statistics 28, with a confidence level of 95%.

Results

Sex Differences in Attachment, Emotion Regulation, and Alexithymia

Firstly, in both participants with and without problematic gaming, females showed higher peer attachment and greater levels of alexithymia in total scores and in the subscales of difficulties identifying and describing emotions, albeit lower scores in the externally oriented thinking subscale. On the other hand, concerning emotion regulation strategies, within the group of participants with non-problematic gaming, women obtained higher scores in acceptance, rumination, and putting into perspective (d ≥ 0.232). Conversely, within the problematic gaming group, women exhibited higher scores in self-blame, rumination, and catastrophizing (d ≥ 0.309) (see Table 1).

Differences in Attachment, Emotion Regulation, and Alexithymia Based on Gaming Status

Secondly, mean differences in attachment, emotion regulation, and alexithymia were analyzed between the sample with and without problematic video gaming, differentiated by sex. In the case of men, those with problematic video gaming showed higher levels of alexithymia, specifically in the difficulty identifying feelings subscale (d = 0.277) and the total score (d = 0.323).

For women, those with problematic video game use exhibited lower maternal attachment (d = 0.437) and differences in emotion regulation, particularly higher self-blame (d = 0.413), and catastrophizing (d = 0.367). Regarding alexithymia, women with problematic video gaming obtained higher scores in alexithymia, both in the total score (d = 0.509) and the subscales of difficulty identifying feelings (d = 0.415) and difficulty describing feelings (d = 0.628) (see Table 2).

Relationship between Attachment, Emotion Regulation, and Alexithymia

Thirdly, the correlation between gaming, attachment, emotion regulation, and alexithymia was analyzed separately according to the participants’ sex. Regarding men (see Table 3), a positive correlation was found between gaming and alexithymia (r ≥ .105). However, no significant relationship was found between gaming and emotion regulation (r ≤ .081). On the other hand, maternal and paternal attachment negatively correlated with alexithymia (r ≥ -.113). Additionally, (maternal, paternal, and peer) attachment showed a positive correlation with emotion regulation (r ≥ .104).

In the case of women (see Table 4), problematic gaming correlated negatively with maternal attachment (r = -.195), difficulties in identifying and describing feelings (r ≥ .184) and emotion regulation, specifically with self-blame (r = .150) and catastrophizing (r = .160). Moreover, maternal and paternal attachment correlated negatively with alexithymia (r ≥ -.105) and emotion regulation, specifically self-blame (r ≥ -.104), planning (r = .126), and positive reappraisal (r = .142). Finally, emotion regulation strategies correlated positively with difficulties in identifying and describing feelings (r ≥ .98) and negatively with externally oriented thinking (r ≥ -.209).

Predictors of Gaming Severity

Finally, a hierarchical multiple linear regression analysis was conducted to examine the predictive role of age, emotion regulation, alexithymia, and attachment on gaming differentiated by sex (see Table 5). Regarding the male participants, lower age (β = -.158) and poorer paternal attachment (β = -.189) were related to greater gaming severity. Concerning women, lower age (β = -.129) and maternal attachment (β = -.263) were significant risk factors for increased problematic video gaming.

Discussion

The present study investigated the predictive role of attachment, emotion regulation, and alexithymia in problematic gaming, the differences in these variables, and the sex differences between participants with and without problematic gaming. Age and paternal attachment were identified as risk factors for problematic gaming in male participants, whereas age and maternal attachment were risk factors in female participants.

Results demonstrate that regardless of gaming status, women present greater difficulties in identifying and describing feelings and less externally oriented thinking than men (both in groups with problematic and non-problematic gaming). On the other hand, the findings suggest sex differences depending on gaming status specifically women with problematic gaming tend to employ emotion regulation strategies related to self-blame, rumination, and catastrophizing, whereas women without problematic gaming tend to utilize strategies of acceptance, rumination, and putting into perspective. Except for the rumination strategy, women without problematic gaming tend to employ more adaptive emotion regulation strategies, such as acceptance and putting into perspective (Kökönyei et al., 2019).

Both males and females with problematic gaming obtained higher scores in alexithymia, primarily in the subscale of difficulties in identifying feelings. This finding has been previously reported in gamers undergoing treatment (Pape et al., 2022), children (Ahmed et al., 2022), and young adults (Bonnaire & Baptista, 2019), although most prior studies did not differentiate sex. This result is also found in other behavioral addictions, such as gambling, where problem gamblers present more alexithymia issues than non-problematic gamblers (Estévez et al., 2021) or smartphone addiction (Ding et al., 2022).

Problematic gamers also displayed different emotion regulation strategies. Particularly, women with problematic gaming presented higher self-blame, catastrophizing, and blaming others. Previous studies have pointed out the strong relationship between cognitive emotion regulation strategies, particularly maladaptive strategies (e.g., self-blame) and problematic gaming (Kökönyei et al., 2019; Yen et al., 2018), but, to our knowledge, no studies have analyzed this association based on participants’ sex.

Furthermore, our results indicated a strong relationship between gaming and attachment, specifically maternal attachment among women. Recently, attachment has been extensively examined in addictive behaviors, particularly in gaming. Studies in this area yield mixed findings: whereas many studies have found no significant relationship between attachment and gaming (Grajewski & Dragan., 2020; S. Kim & Chun, 2022; Liese et al., 2020; Scalone et al., 2023), other studies have found a significant relationship only with peer attachment (Teng et al., 2020). In line with our findings, many studies report a strong relationship between attachment and gaming (Estévez et al., 2019; Monacis et al., 2017; Warburton et al., 2022), noting that Estévez et al.’s (2019) study found that attachment was more closely related to gaming than other behavioral addictions, such as gambling or problematic Internet use. Notwithstanding, to our knowledge, no studies have analyzed the relationship between gaming and attachment based on sex.

Unlike previous studies that reported a strong association between emotion-regulation strategies and gaming, our study found this relationship only in the female population. Previous evidence has pointed to the role of emotion regulation in gaming, both in adolescents (Kökönyei et al., 2019; Uçur & Dönmez., 2021) and young adults (P. Y. Lin et al., 2020; S. Lin et al., 2023). Other studies have examined the mediating role of emotion regulation between childhood experiences and gaming (H. S. Kim et al., 2023).

The regression results indicate that lower age and poorer paternal attachment were related to gaming severity in men. Conversely, in women, age and maternal attachment played an important predictive role. These results suggest that sex should be taken into account when intervening and preventing the gaming disorder in adolescents and young adults.

Previous studies have shown that the adolescent population has higher rates of problematic video game use compared to young adults and adults (Darvesh et al., 2020; Gao et al., 2022; Gentile et al., 2017). This is particularly important because an earlier age of onset is associated with greater severity of gaming disorder (Beard et al., 2017).

On the other hand, concerning attachment, relationships with primary caregivers play a crucial role in shaping personal development. Individuals with insecure attachment patterns may be more inclined to seek fulfillment of their attachment needs through video games rather than through real-life relationships (Bowditch et al., 2024; Flores, 2004; Suárez et al., 2012). In other words, when someone experiences emotional neglect and develops a negative self-concept due to adverse childhood relationships, they may turn to addictive behaviors as a way to escape feelings of rejection, emotional distance, and abandonment, as well as a lack of trust and intimacy (Estévez et al., 2022).

The results of this study should be interpreted in light of several limitations. Firstly, a convenience sample of the Spanish population was used, so the findings may not be generalizable to the global population due to cultural differences. Additionally, as the data were collected through self-reported questionnaires, a social desirability bias cannot be discarded. On one hand, the MULTICAGE questionnaire is not the most suitable for assessing the severity of gaming, as it has only four items, and future studies should consider other validated instruments for this purpose. On the other hand, the cross-sectional design of the present study precludes establishing interpretations regarding causality and the direction of the effects. Moreover, findings obtained in this study are based on sex differences, so it would be appropriate to carry out studies based on gender differences. Finally, this study includes individuals aged between 12 and 32 years, so age-dependent variables such as emotion regulation may not have been fully accounted for in the results.

Conclusions

Despite the mentioned limitations, this study highlights the differences between young adults with and without problematic gaming, both in men and women, as well as the relationship of alexithymia, emotion regulation, and attachment with gaming. The study suggests that lower age and attachment may play a crucial role in gaming among men and women. Further large-scale research is needed to elucidate the role of these variables in the development, maintenance, and treatment of problematic gaming. This study entails important clinical and research implications, as it underscores the importance of considering alexithymia and attachment in the assessment, prevention, and intervention of gaming disorder in both men and women.