All the most frequently visited Hungarian online gaming websites having more than 100 registered users were identified (N=18). The majority of the sites (n=11) were game-specific: (massively) multiplayer online role playing games ([M]MORPGs) (eg, Lineage II, World of Warcraft, Guild Wars, Diablo II, Lord of the Rings; Thrillion kincsei [The Treasures of Thrillion]); (massively) multiplayer online real-time strategy ([M]MORTS) games (eg, Age of Empires 3, Travian, Klánháború [TribalWars], and Red Alert 3); multiplayer online first-person shooter (MOFPS) games (eg, Call of Duty), 1 site was genre-specific (ie, role-playing games), and 6 sites were general video gaming sites. The search was carried out by 4 experts using online search engines (ie, Google) and additionally obtaining information from gamers from their circle of acquaintances. Subsequently, the 18 websites were invited to advertise for participants in the present study. All administrators agreed to cooperate and advertised the call for participation on their websites or included it in their online newsletter to gamers. In the call for participation in the study, gamers were asked to visit a password-protected website and complete the questionnaire.

Before filling out the questionnaire, all participants were informed about the general goals of the study (ie, to obtain an objective and real picture of online games and the online gamer community in contrast with the simplified and rather negative picture the media disseminates) and the time needed to complete it. They were assured about confidentiality and anonymity, and their informed consent was obtained by ticking a box if they agreed to continue and participate in the study. No personal information was collected or stored and no incentives were offered. Data collection took place between April and July 2009. The advertisements were displayed for approximately 3 months, whereas the newsletters including the call for participation were sent twice. According to the voluntary nature of participation, answering all the questions was not mandatory. The number of unique website visitors was not assessed at the time of the recruitment period, and the number of overlapping visitors between the 18 websites was also unknown; therefore, the view rate could not be calculated. In total, 7520 gamers visited the first page of the questionnaire and 4374 completed at least some of it. Consequently, the participation rate was 58.16%. Of these 4374 gamers, 3186 completed the entire survey including psychiatric symptoms, online gaming motives, and problematic online game use resulting in a completion rate of 72.84%. Consequently, all analyses were carried out on this latter subsample. Only completed questionnaires were analyzed. However, skipping answers was allowed; therefore, missing data were treated with full information maximum likelihood (FIML) method with MPlus 6.0.

Structural regression analyses within structural equation modeling (SEM) were used to test the proposed mediation models. Because the scales were not normally distributed, maximum likelihood estimation robust to nonnormality (MLR) was used in all SEM analyses [48]. Multigroup analyses were used to test gender and game type differences. To evaluate goodness of fit of the overall models, the chi-square goodness-of-fit statistic (with a P value <.05), the comparative fit index (CFI), the Tucker-Lewis fit index or nonnormed fit index (TLI or NNFI), root mean square error approximation (RMSEA) and its 90% confidence interval (90% CI), and the standardized root mean square residuals (SRMR) were used. For both CFI and TLI, values greater than 0.9 were considered a good fit, whereas both the values of RMSEA and SRMR should be less than 0.08 for an acceptable degree of fit [49,50]. Descriptive analyses were performed with the SPSS 20.0 statistical software package and all SEM analyses were performed with MPlus 6.0.

The mean age of the sample (N=3186) was 21.1 years (SD 5.9 years, range 14-54 years), and the majority of the sample (2859/3186, 89.74%) were male. As previously mentioned, 1466 of 3186 gamers (46.01%) had a clear preference for MMORPGs and 872 of 3186 (27.37%) for MOFPSs. Among the MMORPG players, 240 gamers (16.37%) were female, whereas among MOFPS players only 20 gamers (2.29%) were female. Information regarding weekly game time and the proportion of gamers at high risk of problematic use is presented in Table 1.

It was assumed that the parameters of the proposed model might be moderated by players’ game type preference and gender. Therefore, descriptive statistics and group differences regarding the variables included in the model are presented in Tables 2 and 3.

Results demonstrated that MOFPS players reported significantly higher scores on competition, skill development, and coping motives, whereas MMORPG players scored significantly higher on fantasy, escape, POG, the GSI, and recreation.

Results also demonstrated that female gamers scored significantly higher on fantasy, escape, social, and recreation motives as well as on the GSI of psychiatric symptoms, whereas male gamers reported significantly higher scores only on competition motive. The zero-order correlations between the components of the mediation model along with internal consistencies (Cronbach alpha) for all scales and subscales are presented in Table 4.

All correlation coefficients were significant at least P<.001 according to Bonferroni correction except for GSI-MOGQ recreation (P=.61).

Because both the BSI and the POGQ are multidimensional scales, a comprehensive correlation matrix is also provided as a multimedia appendix containing all subscales of the BSI, the MOGQ, and the POGQ (see Multimedia Appendix 1).

The results of the present study suggest that psychiatric symptoms are both directly and indirectly (via escape and competition motives) negatively associated with POG. The mediator effect of gaming motives amounts to approximately 35% of the total effect. To the authors’ knowledge, this is the first study to statistically unravel the complex association between psychiatric symptoms, online gaming motivations, and problematic use using a SEM framework. The results relating to the associations between motives and problematic use are similar to previous findings in the psychological gaming literature. For instance, Yee [11] and Billieux and colleagues [9] found that escapism was the best predictor of problematic use in the case of MMORPG players followed by advancement motivation (ie, the desire to progress rapidly in the game—“level up”—and become powerful).

Although advancement and competition motives are not the same, they are related to each other via a common connection to achievement and performance. Progressing rapidly and gaining power eventually become a way to be competitive, a way to complete goals successfully, and a way to defeat others. However, the advancement motive was developed in studies focusing on MMORPGs where “leveling up” is of a particular importance due to the persistence of the virtual world. On the other hand, the competition motive used in the present study is related to online games in general including games such as multiplayer online first-person shooter games or strategy games, in addition to MMORPGs. Other studies [12,13] have also reported a strong association between escapism and problematic gaming as well as achievement and problematic use. Achievement is the higher order factor in Yee’s [11] motivational model comprising 3 subdimensions (ie, advancement, mechanics, and competition), whereas in the study by Zanetta Dauriat [13], the motive with the same name refers to the need for being competitive, to obtain fame and recognition, and to be member of a top guild. Furthermore, our results relating to the association between psychiatric symptoms and motives are also in-line with previous findings. For instance, Hagström and Kaldo [51] reported that among all online gaming motives, escapism showed the strongest relationship with psychological distress.

In addition to confirming previous findings in the gaming literature, as predicted the present study showed that the same 2 motives (escape and competition) mediated between psychiatric symptoms and problematic gaming. Playing games to escape everyday difficulties appears to be a motivating behavior that can ease psychiatric distress, and thus extends self-medication theory [52] to online gaming. This theory states that substance use is a coping strategy through which users try to compensate their psychiatric distress and attain emotional stability. This compensatory behavior then contributes to the development and maintenance of the problem behavior. The findings outlined in the present study also strengthen the inclusion of escapism as an individual criterion for Internet Gaming Disorder in DSM-5 [6].

The second mediator variable in the present study was competition. Despite the fact that competition is usually considered a healthy and adaptive behavior, our findings suggest that in some cases it can also be a pathological factor. This has also been reported in the literature on problem gambling in which problem gamblers have been shown to be more competitive than nonproblem gamblers [53]. Gamers whose psychiatric distress level is high might use online gaming as a source for achievement through defeating other players and winning in general. If games are the only sources that maintain and boost their self-confidence and self-efficacy, and thus become a replacement for real life competition and achievement, the activity appears to increase the risk of developing a problematic behavior. However, this reasoning needs further confirmation.

In contrast to prestudy expectations, coping did not mediate between psychiatric distress and problematic gaming. Earlier motivational research yielded the surprising finding that although highly correlated (.60), coping and escape are distinct motives [8], and the present study strengthened the argument that these 2 motives have different mechanisms of action. The results of the present study suggest that in contrast to playing to escape everyday problems, gaming can also be used as an adaptive coping strategy for stress release or tension reduction without necessarily leading to problematic use. A possible explanation might be that different underlying mechanisms lie behind the 2 strategies. Avoiding real life problems (ie, escape) only alleviates the perceived stress for a short time, retaining or further multiplying the original problem (ie, stress source). On the other hand, channeling everyday stress, tension, or aggression into gaming (ie, coping) can be an active coping mechanism where at least some extent of the perceived stress is dissipated while playing. However, this is speculative and requires further research.

The recreational use of online games was related neither to psychiatric symptoms nor to problematic use of games. This suggests that playing online games can be a healthy form of entertainment if it is used moderately and balanced with other leisure time activities (ie, sports). This result also serves as counterweight for media scaremongering that often exaggerates the potential dangers of video games [54].

This model in the present study was found to be invariant across game type preference (ie, MOFPS or MMORPG), but varied significantly between males and females in the case of MMORPG players. As expected, females were characterized by a stronger link between escape and POG, and also had higher escape scores than males. This latter result is in-line with Yee’s findings [55] that examined the motivational background of MMORPG players and also found that female players scored higher on the escape motive than male players. However, the present study suggests that this higher inclination for escape motivation among females is linked to a higher risk of problematic use. In contrast to the other prestudy assumptions, no gender differences were found regarding competition and social motives.

In addition, it is important to point out that the proportion of female players in the present sample is much lower than the proportion of women that play video games in the general population (ie, approximately 40% [4,18]). This is most likely due to the online data collection method in which participation is voluntary. In online gamer samples, the proportion of female players is usually quite low (approximately 10%-20% [55,56]). The reason might be that the so-called “hard-core” gamers are more interested in participating in such research studies and that the proportion of hard-core female players is lower than the proportion of hard-core male players. Therefore, it is important to acknowledge that these findings apply more to those female gamers who play seriously (in a hard-core or “masculine” gamer manner) than to the average female (casual) gamers in the general population [57,58].

Despite the advantage of a large sample size, the self-selected and self-reported nature of the Hungarian-only data need to be taken into consideration when generalizing the results (especially because recent research has shown that self-selection of MMORPG players affects the sample’s representativeness [59]). Consequently, there is a clear need for future observational and clinical studies to confirm the findings of the present study in other nationalities of gamers. The cross-sectional study design should be also borne in mind when applying the findings because causation and directionality of findings cannot be confirmed. Consequently, future studies should also use longitudinal or experimental design to establish causal relations regarding the proposed model. Furthermore, it is theoretically feasible to construct alternative models that act in the opposite direction (ie, POG leading to psychiatric distress) and/or that both models may not be mutually exclusive (that for some people psychiatric distress leads to POG and vice versa for others). Such possibilities should also be empirically tested in future studies.

The present study has some direct implications for prevention and treatment. There is little reason for parents, educators, and health professionals to be concerned or worried about the recreational use of online games. Neither should they necessarily be concerned about playing as a way to cope with day-to-day stress or tension. However, playing excessively as a way to avoid real-life problems or to defeat other players should receive attention because such motivations may lead to negative (addiction-like) real-life consequences. Therefore, exploring gaming motivations both on the individual and group level are likely to be helpful in the preparation of prevention and treatment programs concerning problematic gaming.