Gaming Disorder in Adults with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is characterised by persistent impairments in social interaction and communication in addition to restrictive, fixated and repetitive patterns of thought, behavior and interests (American Psychiatric Association, 2013). The American Center for Disease Control and Prevention (CDC) evaluated prevalence rates for ASD and found that approximately one in 54 children were diagnosed with ASD (Maenner et al., 2020) Autism spectrum disorder symptoms present on a wide spectrum and ASD can be diagnosed at three levels. Level 1 diagnoses indicate that an individual requires support, level 2 diagnoses imply that an individual requires substantial support, and level 3 diagnoses are characterised by individuals who require very substantial support (American Psychiatric Association, 2013).

Individuals with ASD are more likely than TD individuals to be diagnosed with other medical conditions such as behavioral problems, feeding problems, toileting issues, gastrointestinal symptoms, epilepsy, sleep problems and attention-deficit/hyperactivity disorder (Devlin et al., 2008; Leader & Mannion, 2016a, 2016b; Leader et al., 2020, 2018b; Mannion & Leader, 2013, 2014a, 2014b, 2016 ) as well as numerous psychiatric conditions. Recently, a meta-analysis was conducted to evaluate ASD and psychiatric conditions and it was found that 54.8% of individuals with ASD presented with a psychiatric disorder of some form (Lugo-Marín et al., 2019).

Addiction has traditionally been related to psychoactive substances (e.g. alcohol, heroin) where there is physical dependence on the substance (Chamberlain et al., 2016). However, in recent years, experts have debated that at excessive levels, many behaviors can be considered compulsive and addictive. These behaviors include gambling, shopping, internet use, videogame play and sexual behaviors (Leeman & Potenza, 2013). Gaming disorder (GD), an addiction to games, is a behavioral addiction which can be more prevalent in individuals with ASD compared to TD individuals (Murray et al., 2021). GD was listed in the DSM-5 under the emerging measures section where it needs further research. Under the proposed criteria, there are nine symptoms of GD, five of which must be present over a 12-month period to warrant a diagnosis: preoccupation with videogames, withdrawal symptoms, tolerance build-up, a need to game at increasing levels to feel satisfied, unsuccessful attempts to quit or control gaming, loss of interest in hobbies as a result of gaming, continued intensive use of internet games despite problems, deceiving others regarding the amount of time spent gaming, use of games to escape negative moods and jeopardising or losing a job, relationship or other important opportunity because of gaming (American Psychiatric Association, 2013).

Since the release of the DSM-5 (American Psychiatric Association, 2013), the World Health Organization has defined gaming disorder as a clinical behavioral addiction in the International Classification of Disease, Eleventh Revision (ICD-11) which will come into effect in 2022 (World Health Organization, 2018). The criteria for a diagnosis overlap with the DSM-5 and must be present for 12 months: reduced control over gaming, increase in priority given to games to the extent that it negatively effects hobbies and the escalation and continuation of gaming regardless of negative consequences in one’s personal life (World Health Organization, 2018).

It is hypothesised that individuals with ASD may be more susceptible to developing GD, both due to the fact that gaming can be a restricted interest (Mazurek & Engelhardt, 2013), and due to internet gaming being a safer space where an individual with ASD may feel less social pressure (Benford & Standen, 2009). Research investigating GD in adults with ASD is sparse (Craig et al., 2021; Murray et al., 2021), with most studies examining samples of children and adolescents (e.g. Mazurek & Engelhardt, 2013; Mazurek & Wenstrup, 2013). The research in young samples has found that individuals with ASD show higher rates of GD symptomology in comparison to typically developing (TD) controls with medium and large effect sizes (MacMullin et al., 2016; Mazurek & Engelhardt, 2013; Mazurek & Wenstrup, 2013; Paulus et al., 2019). Only one study has investigated the relationship between ASD and GD in an adult sample, which found similar results to the studies above looking at youth with ASD. The study revealed a strong significant relationship between ASD and GD when controlling for daily gaming hours and proportion of free time spent gaming (Engelhardt et al., 2017). There are some gaps in the literature on GD and ASD; in these studies, no participant was over the age of 25, there were significantly more males than females, and no studies have investigated correlators or predictors of GD in samples with ASD other than daily gaming hours and proportion of free time spend gaming.

Gelotophobia is defined as a fear of being laughed at, made fun of or ridiculed (Titze, 2009). “Gelos” is the Greek word for laughter (Ruch & Proyer, 2008a) and “phobia” means fear. Gelotophobia can be mild, moderate or severe, although severe gelotophobia is somewhat rare, particularly in TD samples (Ruch & Proyer, 2008b). When a person is mocked, they can experience negative feelings such as embarrassment, shame, anger and disgust (Platt, 2008). However, most people adapt quickly and modify their behavior to act accordingly to the situation (Tsai et al., 2018). There is a subgroup of people who do not adapt to these situations and believe that others mock them due to their own social inadequacy. Gelotophobes believe something is entirely wrong with them and that they are “intolerably ridiculous” (Titze, 2009, p. 30). Gelotophobia is particularly prevalent in individuals with social anxiety (Edwards et al., 2010), those with deficits in understanding and describing emotions (Boda-Ujlaky & Séra, 2013), and in those who don’t understand or appreciate humour as well as others (Chan, 2016; Hiranandani & Yue, 2014). Furthermore, these factors themselves are strongly linked with ASD, which is indicative that those with ASD may be predisposed to gelotophobia. Indeed, previous research has demonstrated significantly higher rates of gelotophobia in participants with a diagnosis of ASD (Grennan et al., 2018; Leader & Mannion, 2020; Leader et al., 2018a).

No studies to date have investigated the link between gelotophobia and GD. However, gelotophobia and GD are both particularly prevalent in individuals with social anxiety (Edwards et al., 2010; Sioni, et al., 2017), individuals with deficits in understanding and describing emotions (Boda-Ujlaky & Séra, 2013; Bonnaire & Baptista, 2019), individuals with lower self-esteem (Hiranandani & Yue, 2014; Van Rooij et al., 2014) and individuals with insecure attachment styles (Miczo, 2017; Schimmenti, et al., 2014). Hence, it is plausible that GD and gelotophobia themselves may be related.

The first aim of the present study was to examine the relationship between ASD and GD, the hypothesis is that adults with ASD will present with increased gaming disorder symptoms in comparison to the TD control group. The second aim was to investigate the predictors of GD in participants with and without ASD, including social functioning, extraversion, emotional regulation, and peer attachment. It is hypothesised that these variables will predict GD symptoms in adult participants with and without ASD. The final aim of the study was to evaluate if GD and gelotophobia are related to each other. It is hypothesised that individuals who demonstrate heightened symptoms of gelotophobia will also show more symptoms of GD.

The present study investigated the link between ASD and GD, the predictors of GD and the relationship between gelotophobia and GD in adults with and without ASD. As hypothesised, gaming disorder symptoms were significantly higher in participants with ASD compared with the control group with 9.1% of the ASD group and 2.9% of the TD group classified as having GD. No research to date has reported the prevalence of GD in an ASD sample, but the prevalence in the TD group is in line with a previous study which found just below 2% of adults were classified as gaming addicts using the same scale and similar recruitment procedures to our study (Laconi et al., 2017). Our results corroborate findings by Engelhardt et al. (2017) who reported adults with ASD were significantly more likely to develop GD. However, our findings showed a small effect size, whereas Engelhardt et al. (2017) and all previous studies on adolescents reported medium and large effect sizes (MacMullin et al., 2016; Mazurek & Engelhardt, 2013; Mazurek & Wenstrup, 2013; Paulus et al., 2019).

One strength of our study was that we included more female participants in comparison to male participants, whereas previous research has been predominantly male-focused. This may have affected the power of our findings as females have demonstrated less GD symptomology across the literature (Fam, 2018). Furthermore, this is the first study to our knowledge that has inspected GD in an ASD sample which includes participants over 25 years old. Younger individuals may be prone to game more excessively (Mihara & Higuchi, 2017) and hence our inclusion of older participants may be a reason why we found only a small effect size.

Social functioning, extraversion, emotional regulation, and peer attachment each predicted GD. Only the subscale cognitive reappraisal in the emotional regulation scale and alienation in the peer attachment scale were significant in the prediction model. Extraversion negatively predicted GD, indicating that the more introverted a person is, the more likely they may be to develop GD. Similarly, alienation positively predicted GD, which would suggest being alienated from friends and peers could increase the likelihood of a person developing GD as previously found in TD samples (Tonioni et al., 2014).

Lessened cognitive reappraisal abilities predicted GD in this study, supporting previous findings in TD samples (Yen et al., 2018). This suggests that individuals who are less able to alter their emotions by changing their thoughts may be more at risk of developing GD. Better social functioning predicted higher GD scores, which is contradictory to previous research which found lower levels of social functioning were related to higher GD scores (Mihara & Higuchi, 2017). However, social functioning was a weak predictor only accounting for a small amount of variance in GD scores which may explain the discrepancy. Alternatively, a specific social functioning measure has not been used in previous research, only subcomponents of social functioning have been examined, which may explain the difference. The total regression model only explained a small amount of variance indicating there are likely other variables affecting GD symptomatology.

Our study included a novel finding that GD and gelotophobia were related to one another with a small effect size. The two variables had similar relationships with extraversion, emotional regulation and peer attachment in this study. Social anxiety, deficits in understanding emotions, low self-esteem and insecure attachment styles have been associated with higher levels of both GD and gelotophobia, which further suggests they may be related. However, this is the first study to investigate GD and gelotophobia, hence further research is needed to support the finding that they are associated.

Some limitations to this study include the use of self-report measures, convenience sampling, the inclusion of more female participants in comparison to male participants, and the use of a cross-sectional design. Self-report measures can be unreliable and are prone to the exaggeration of conditions such as GD (Maraz et al., 2015). ASD diagnoses were self-reported and were not verified, however those who indicated they were self-diagnosed were excluded. It is also imperative to note that while we included a prevalence rate of GD, this is strictly for descriptive purposes and is not diagnostic in nature. Convenience sampling is a second limitation as gamers may self-select into the study. However, the study aimed to include non-gamers and it was made apparent to participants that they did not need to game to take part. More females were included in comparison to males, leading to a gender imbalance which means our findings may not extend to a general demographic. However, this the frequency of female participants could also be considered a strength of the study. Lastly, as this study implemented a cross-sectional design, no causation can be inferred.

Numerous scales and measures have been used to evaluate GD in individuals with ASD, impacting the comparability of studies. A screening tool for GD based on ICD-11 criteria is being created by an international working group from the WHO at present (Carragher et al., 2019). Future research would benefit from the implementation of this scale across all studies to increase the generalisability and comparability of studies. Research which involves clinical interviews to validate an autism diagnosis, could also extend the interview to clinically diagnose GD according to the criteria set out in the ICD-11, or to evaluate gelotophobia through an interview format.

Age and gender may be influencing the strength of the relationship between ASD and GD. Future research could aim to discern if older individuals with ASD and females with ASD may be less likely to become addicted to gaming. Gelotophobia and GD were related in this study and this relationship should be investigated in future. Gelotophobia may increase the likelihood of developing GD, or GD may increase the likelihood of developing gelotophobia.

This novel study was the first to investigate ASD and GD which included participants over 25 years old and included a range of predictor variables. Our findings indicated that individuals with ASD may indeed be more likely to develop GD. Extraversion, alienation and cognitive reappraisal emerged as the biggest predictors of GD. Future research should investigate clinically diagnosed GD and ASD, gender and age differences in GD, and further establish prevalence rates and risk factors of GD in both ASD and TD samples. The unique finding that gelotophobia and GD may be related to one another needs to be further examined in future research studies.