The International Classification of Diseases (ICD)-11 recognizes two behavioral addictions [1]: gaming and gambling disorders. The clinical descriptions of these disorders comprise three main dimensions: impaired control, increasing priority given to gambling/gaming, and continuation despite the occurrence of negative consequence. This classification implies common processes between different types of addiction in the development and maintenance of addiction. This commonality is proposed by models of behavioral addictions, such as the Interaction of Person-Affect-Cognition-Execution model [2], which presents addictive behaviors as consequences of the interactions between individual vulnerability factors, affective and cognitive responses to specific behavior, and executive functions. This model includes specificities related to the behavior itself that render them more attractive to individuals with certain psychological profiles. However, it does not include the social dimension of behaviors accounting for a social group’s greater propensity to use the same behavior as a commodity associated with the group’s identity, in contrast with other sociological approaches [3]. Models based on the uniqueness of addiction processes between behavioral addictions are highly contentious, and the inclusion of gaming disorder in the addiction nosography remains controversial [4]. Diagnosis criteria are debated [5], and some authors still consider problem gaming as a symptom of another mental disorder [6].

Beyond these models based on the uniqueness of addictive disorders, comparisons between addictive behaviors in the same study are scarce. Furthermore, the literature lacks a clear picture of the differences between potential addictive behaviors, particularly in the representation of the behavior itself, the associated disorder, and the inner experience and perception of the disorder by users and their relatives. Few studies have made comparisons between gaming and gambling. A previous qualitative study found significant overlap in the experience of people living with a substance use problem and a behavioral addiction/problem [7]. However, gaming and gambling differ at various levels: at the clinical level, assessing the importance of depression as a risk factor in gaming [8]; at the neuropsychological level, in terms of delay discounting and decision making [9]; at the neural level; and in the pharmacodynamic response to certain treatments [10]. However, there are also specificities linked to different profiles of users between the behaviors as commodities. Gaming is more widespread in adolescents and young adults, and the age of onset is earlier than that in gambling, where the average age of onset is around 34 years and the practice is prohibited among minors in most countries [11]. For instance, in a study among 824 adolescents, a prevalence of 3% was obtained of at-risk gaming, with a mean age of 14.5 years, and the majority reported a symptom course greater than 12 months [12]. This younger age range leads to specific cognitions in problem gamers [12].

These differences in profiles support the biopsychosocial model in addictions [13], where addictive behavior as a commodity is consumed by different populations and related disorders have a different representation in the general population [14] with different degrees of stigma, leading to specific clinical pictures and specific complaints from the addict population and relatives. However, these elements are surprisingly absent from the classifications, as illustrated by the absence of age specification in the clinical description of the ICD-11 for gaming disorder [15]. It is therefore important to focus on the difficulties experienced and described by the users themselves and their relatives [16]. The importance of exploratory approaches and qualitative research has also been emphasized by several authors [17,18].

The treatment gap is considerable in behavioral addictions, with fewer than 12% of pathological gamblers seeking help from a health professional [19]. The epidemiological data on gaming disorder are weak, but the prevalence is estimated to range from 0.5% to 10%. The care network and pathways are still being structured. No quantified data exist on the treatment gap in gaming disorder, but it is assumed to be even wider [20]. Nonface-to-face, telephone, and online support devices could help reduce this treatment gap [21], and could further help to collect information to describe a population to which clinicians and researchers have no other access. The debate over the criteria for gaming disorder could be redressed by the description of gaming difficulties by self-diagnosed problem gamers seeking help. There are also minimal data on nonface-to-face help-seekers in gambling and particularly in gaming. The current knowledge on gambling shows the preference of young gamblers for online devices [22], along with the greater reluctance among women to request help and their more difficult access to treatment [22-24]. A study of 168 gamers voluntarily contacting a help service [25] demonstrated the association of mood symptoms and severity of gaming disorder. However, no study has yet explored gaming- and gambling-related burdens collected through the same approach. An exploratory approach could clarify a hypothesized common and subjectively identifiable process in addictive behaviors and the necessarily different expressions of the disorder due to behavior specificities, in particular the sociocultural characteristics and profile of users (eg, age, sex).

We performed a quantitative-qualitative analysis of all contacts to a nonface-to-face help service over 7 years. All contactors voluntarily called or wrote to the help service asking for help or counseling regarding gaming or gambling. No diagnostic or screening assessment was performed or required to access the help service. Our aim was to explore, without a priori assumptions, the burden of gaming and gambling cited by contacts to a help service by phone and internet. Our hypothesis was that we would find both commonalities and specificities in the burden linked to gaming and gambling problems from the perspectives of users and their relatives.

Our quantitative-qualitative explorative study allowed for exploration without any a priori burdens linked to gaming and gambling in a large and exhaustive sample of contacts to a help service by phone or online. As hypothesized, some classes grouped both gaming and gambling, but others illustrated their specificities, both for the profiles of users and for core clinical symptoms.

Negative emotions described in class 2 regarded gaming and gambling for users and relatives. This class highlights that users or relatives of gamers and gamblers can experience psychological distress related to these behaviors. Current American Psychiatric Association and World Health Organization classifications mention as a prerequisite for gambling and gaming disorder that these behaviors lead “to clinically significant impairment or distress” [1,29], and align with expert consensus that these behaviors produce psychological distress in some people [30]. Our findings support this scientific consensus and the relevance of structuring care and facilitating access to care for these populations, while countering the assumptions of moral panic on gambling and gaming particularly. These negative emotions (especially guilt and loneliness) have been consistently described in addictions, particularly with regard to gambling disorder [31]. The feeling of incomprehension of the user’s own behavior and mental state, and of the user’s behavior regarding relatives had also been previously described in the context of gambling [31]. Our study illustrates that this feeling is shared in gamers and relatives, and is similar to the powerlessness to change or help. Interestingly, “loss of control,” as an escalation of behavior and failure of inhibition, was present in another class specific to gamblers, but was not associated to gaming. Thus, the specificities of gambling go beyond the practical aspect of games as a consumer product, touching on the addictive symptomatology. Loss of control, the core symptom of addiction, was not found to be associated with gaming in this study. This finding questions the recent assertion that gaming disorder is part of the addictive disorder framework in the ICD-11. Although loss of control had been previously described as part of the disease in gaming disorder in qualitative research with a very small sample of nine gamblers using the grounded theory approach [32], our computerized analysis on a very large sample allowed us to move away from a priori models of addiction for understanding gaming and gambling disorders.

The difference in the onset of suicidal thoughts also puts into question the commonality between gaming and gambling disorder. In gambling, suicidal thoughts seemed to occur concomitantly to psychological exhaustion and the feeling of being pushed to the wall due to financial damage. These feelings have been consistently described in the literature [23,33]. In gaming, the suicide theme appeared indirectly during conflicts with parents. This finding supports previous studies suggesting predominant roles in gaming disorder development and maintenance of parental rejection, poor attachment modalities, and resulting poor self-esteem [34]. Moreover, childhood adverse events and a difficult family climate were broadly reported in class 1, which reflects gaming specificities, namely in younger users. Emotional trauma was recently described as an indirect path to gaming disorder through depressive symptoms [35]. The hypothesis of high involvement in gaming as an effort to cope has also been previously debated [36]. No causal inference can be drawn from this cross-sectional study; however, relatives repeatedly described a chronological link between an adverse event and the onset of gaming disorder. This could also reflect a reporting bias in that relatives, and particularly parents who comprised the majority of the gaming specificities class, are more prone to share family history, or that the helpline operatives asked more often about the familial context when the user was a gamer. Communication difficulties with parents were also widely reported. Parents’ anxiety and own depression, previously reported to be highly correlated to gaming disorder in children [37], could contribute to these particularities and especially to communication difficulties.

Relatives of gambling users frequently complained about financial difficulties, grouped in class 6, that often become their shared burden. This result supports previous findings that financial difficulties and familial conflicts were key help-seeking precipitators among gamblers [38]. In contrast, specific help-seeking precipitators in gamers were externalized behavior problems and drop in grades, reported in class 1. Externalized behavior problems have been previously linked to cumulative childhood trauma [39]. A future exploration of this link in gaming disorder could reinforce therapeutic strategies and highlight prevention.

Our study has several limitations. The imbalance between gaming and gambling and the proportion of relatives in the respective subsamples could have influenced the hierarchical classification; however, both gaming and gambling samples were very large compared with those reported in classical qualitative studies. Some contactors could have contacted the help service several times, although the anonymity of the facility prevented documentation of repeat contacts. Moreover, no structured diagnostic or clinical assessments were collected during the calls, and we cannot assume that all contacts regarded people with a clinical addictive disorder. We can only assume that the contactors felt the need to seek help regarding gambling or gaming.

In conclusion, negative emotions and shared distress linked to gambling and gaming support their classification as mental disorders in se, but meaningful differences were observed in core symptoms of addiction between gamers and gamblers, beyond specificities related to the behavior itself. Our findings support differences in the development and maintenance of gaming and gambling disorder and should been further explored in a process-oriented approach.