Generalised Versus Specific Internet Use-Related Addiction Problems: A Mixed Methods Study on Internet, Gaming, and Social Networking Behaviours

The field of behavioural addictions related to technological uses (i.e., technological behavioural addictions) has been growing exponentially since 1995 [1,2,3,4] and not without scientific, clinical, and social debates. In mid-nineties, the phenomenon was recognised by the umbrella term of ‘Internet addiction’, a generalised addiction problem covering all online activities together. Almost automatically, this was conceptualised as a clinical disorder [5], initially closely aligned with ‘impulse control disorder’. In 2013, it was proposed as a future ‘addictive disorder’ in the third appendix of the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (APA) [6], and at present it has been recognised as a health disease in the eleventh revision of the International Classification of Diseases (ICD-11) by the World Health Organization (WHO) [7]. However, this international recognition has come about solely for a specific technological addictive problem—problematic gaming—even though other technological use-related addiction problems coexist (e.g., cybersex addiction).

The terminology requires an update, as it covers the emergent health issues related to excessive online uses, which emerged together with the development of technologies at the end of last century, and it has been consolidated in the 21st Century. Thus, although it seems Internet use-related addiction problems were initially mainly studied as a generalised problem [8], there is a scientific and clinical production of other specific problems simultaneously studied, such as problematic video gaming [9] or social networking [10]. Both generalised and specific Internet use-related addiction problems seem to produce addictive symptomatology (i.e., the classic symptoms for substance use or gambling disorders) in a few users, together with functional physical or psychological impairments (i.e., when the online activity(-ies) negatively affects other areas of a user’s organism or lives; e.g., sight or academic/work facets), and distress (i.e., when the online activity(-ies) may reflect a maladaptive behaviour, failure in coping or adaptation processes).

Concerning statistics records, the International Telecommunication Union (ITU) has published its Information and Communication Technologies (ICT) Facts and Figures 2017 [11], showing the continuous worldwide expansion of Internet use through fixed or mobile subscriptions. For instance, in 2017, 3578 million individuals were using the Internet (compared to 495 million in 2001), 830 million being young people (i.e., 15–24-year-olds), which represents 80 per cent of the youth population in the 104 countries studied (see Figure 1).

Similarly, bibliometric evidence extracted from three ProQuest Central scientific databases (i.e., Health and Medical Collection, Psychology Database, and Public Health Database [12]) shows this impactful increase in research on Internet use-related addiction problems during the last two decades (1995–2017), which have especially risen from the beginning of the 21st century [13].

Indeed, an advanced search was conducted to observe the increase of production on these addiction problems. The procedure for the search of Internet addiction production was: It was introduced the terms ‘Internet addiction’ OR ‘problem* Internet use’ OR ‘pathological Internet use’ OR ‘excessive Internet use’ (to cover the main terminology used in Internet addiction). Simultaneously, the options to refine the search were: ‘Peer reviewed’ (i.e., to ensure the outputs were articles from official editorial processes), ‘Exclude duplicate documents’ (i.e., to avoid any article is detected more than once through the databases selected), ‘Show additional terms included in the search’ (to suggest and add alternative terminology used in relation to the terms selected), and a period from 1 January 1995 to 31 December 2017. A total of 116,455 outputs were obtained, showing a growing tendency in its bibliometric production, where each bar corresponded to the number of articles published in a year, going from 146 records in 1995 to 11,630 in 2017 (see Figure 2, first plot). The same procedure was used with the other two specific online behavioural addiction problems studied. Concerning problematic gaming (i.e., ‘gaming addiction’ OR ‘problem* gaming use’ OR ‘pathological gaming use’ OR ‘excessive gaming use’ OR ‘gaming disorder’ OR ‘internet gaming disorder’), 7246 outputs were addressing problems within video gaming (e.g., computer gaming, digital or electronic game addiction). These ranged from 35 records in 1995 to 839 in 2017, with a progressive increment from 2010 and especially from 2014 (after the inclusion of ‘Internet gaming disorder’ (IGD) in the appendix of the DSM-5 by the APA [6]; see Figure 2, second plot). Similarly, problematic social networking obtained the most outputs in the search: A total of 202,045 (using as keywords: ‘social network* addiction’ OR ‘problem* social network* use’ OR ‘pathological social network* use’ OR ‘excessive social network* use’ OR ‘social network* disorder’); from 1474 in 1995 to 18,595 in 2017; with a continuous growth accelerating since 2008 (i.e., the year that Facebook started to be internationally used with the design and functionalities most known; see Figure 2, third plot).

Research into these generalised and specific potential behavioural addictions has provided fundamental advances in clarifying conceptualisation and operationalisation within the spectrum of these problems.

Firstly, Davis in 2001 [14] introduced one of the few existing theoretical models on Internet addiction. His cognitive–behavioural model of pathological Internet use (PIU) proposed dividing the problem into two types: Specific Internet use-related addiction problems (SPIU, referring to the condition in which an individual pathologically uses the Internet for a purpose; e.g., online gaming) and generalised PIU (GPIU, referring to the global set of online behaviours). The basic idea was that cognitive distortions (e.g., thoughts such as ‘the Internet is the only place where I am respected’) were automatically and unintentionally enacted whenever a stimulus associated with the Internet was available, resulting in emotional or behavioural outputs (i.e., GPIU or SPIU symptoms). Thus, maladaptive cognitions impact SPIU or GPIU, but the latter type was found to be more complicated, as several external factors could be the cause (e.g., social isolation, lack of social support), with negative consequences, such as procrastination and other daily functioning problems (e.g., putting off responsibilities to be online without a directive purpose). To the authors’ knowledge, no previous author has asked yet why the same external problems would not be present in generalised and specific Internet-use addition problems. This is a central question, as few works have addressed these factors in SPIUs, which are precisely the ones being treated, studied, and even recognised internationally in the case of gaming disorder.

Between 2002 and 2010, Caplan [15,16] tested and updated this model for GPIU, indicating some users had a preference for online social interactions and used the Internet for mood regulation, which predicted deficient online self-regulation (i.e., compulsive Internet use and a cognitive preoccupation regarding the Internet). Subsequently, Haagsma and colleagues in 2013 [17] tested the model for a SPIU (i.e., online gaming) into an adolescent population and obtained similar findings. However, although these studies showed a few readjustments in Davis’ model (e.g., internal factors, such as a preference for online interaction, online mood regulation, and online deficient self-regulation could predict both GPIU or SPIU), there is still a need for more theoretical development on generalised and specific online problems, especially addressing external (i.e., environmental) factors and structural (i.e., video games) factors.

Secondly, Griffiths in 2005 [18] adapted Brown’s [19] proposal for gambling and developed the component model of addiction to operationalise the common features among substance and behavioural addictions. The addictive problem is formed in a biopsychosocial framework (i.e., as a consequence of individual, situational, and structural factors) and could be defined by six components (i.e., symptoms; see Table 1). Recently, Griffiths [20] has clarified common components are essential keys to delineate behavioural and substance addictions, as although different addictions have idiosyncrasies, these also have similarities (i.e., components), which are critical to the behaviour being labelled as an addiction. Thus, the six components need to be endorsed to operationally define an addiction (e.g., independently if generalised or specific problems). However, in public and mental health organisations (e.g., APA), and in their respective health manuals (e.g., the DSM), the components are usually articulated as criteria. Thus, to diagnose a disease or a mental health illness, the patient has to endorse a number of criteria (e.g., in the IGD proposed by the DSM-5, it is five out of nine). This quantitative approach has generated concern to estimate the prevalence of potential problematic users, as it has been dependent on several factors (e.g., the criteria, psychometric tools). Moreover, some criteria are more prominent and relevant than others, which have been tackled by few authors.

Thirdly, concerning Internet addiction, Tao and colleagues [21] proposed renowned diagnostic criteria for Internet addiction (see Table 1). This had an operationalisation which introduced specifications: First, the relevance of symptoms (i.e., some being more important than others); second, the timing for the problem course (i.e., the addictive problem requires a period over which to be developed); third, exclusion tactics to diagnose the problem (i.e., the addictive problem should be differentiated from other disorders); fourth, the importance of the functional impairment (i.e., the addictive problem affects users’ real-life, impeding at least a facet of a user’s functioning). In concrete terms, they stated preoccupation and withdrawal should always be present, as these are the most important symptoms. Subsequently, at least one of the other symptoms should also be present (i.e., tolerance, persistent desire and difficulty to control it, continued use disregarding harmful consequences, loss of interests, or alleviation of negative emotions). The exclusion criteria were psychotic or bipolar I disorders, together with the need for a clinical impairment criterion (in other duties or relationships), and course the criterion of using the Internet excessively for at least three months for six hours per day as entertainment. Tao and colleagues’ proposal [21] together with substance use disorder (SUD) and gambling disorder criteria were taken as a source by the APA to propose the IGD criteria [22], which slightly differ in the symptoms, time of development (i.e., a year), and exclusion criteria (other excessive Internet uses). The IGD criteria are: (1) Preoccupation, (2) withdrawal, (3) tolerance, (4) reduction/stop, (5) giving up other activities, (6) continuing despite problems, (7) deceit/cover-up, (8) escaping adverse moods, (9) risk/loss of relationships/opportunities (the wording proposed for these criteria has been introduced in Table 1). Nevertheless, the field has recently been characterised by intense debate on whether and how IGD or Internet addiction (among other addiction problems) should become official disorders. These debates are central to the question of how general versus specific behavioural addiction forms.

Thus, critiques of the component model, Internet addiction (i.e., as GPIU), or IGD (i.e., as SPIU) have emerged [23,24]. For instance, Griffiths’ and Tao’s proposals were criticised by Van Rooij and Prause [23], as they considered that the evidence base was not enough to support the diagnostic of the generalised Internet addiction as a behavioural addiction. They suggested studying common unpaired dimensions with the support of neuroimaging proofs, and identifying the changes in the rewarding element of using the Internet (e.g., if users are responding to the hedonic reward indistinctly if it is sex, drugs, or online behaviours, and how this response changes their usage pattern) [23]. Similarly, Kardefelt-Winther [24] criticised the IGD criteria for being too adhered to other previous addictive disorders included in the fourth DSM (DSM-IV), rather than capturing the phenomenology of online gaming; he argued some criteria were weak to diagnose SPIU (e.g., preoccupation, withdrawal, loss of interests, and tolerance; especially the later one, which belongs to SUDs). Moreover, it is worth noting how a relevant component, such as salience, which originally covered person’s thinking, feelings, and behaviours [18,19] has been reduced to a sole cognitive facet in this century’s research and clinical works; even the Davis model was only based on the cognitive approach of the maladaptive behaviour of Internet addiction.

Fourthly, Charlton and Danforth in 2007 [25] stated the distinction between Internet use-related addiction problems and high online engagements through specific components (i.e., criteria). They established the difference between core and peripheral criteria for behavioural addictions, initially performed for the GPIU, and subsequently applied to an SPIU: Online gaming (i.e., massively multiplayer online game playing [MMORPG]; e.g., Asheron’s call; see Table 1). The core criteria which defined an addictive problem were: Conflict (with other personal activities or other persons), withdrawal, relapse and reinstatement, and behavioural salience; while peripheral criteria were present in nonproblem online users (i.e., high-engagement users): Cognitive salience (e.g., preoccupation), tolerance, and euphoria. Moreover, time spent on online gaming was positively associated with those who highly scored on the core criteria. A study recently carried out by Lehenbauer and Fohringer [26] has found similar results regarding online gaming. They adapted the version of a previous MMORPG (i.e., World of Warcraft), and found differences between highly-engaged and addicted gamers to the same core versus peripheral criteria, together with more time spent on the core criteria (i.e., addicted gamers were gaming 30 h per week, while highly-engaged players played around 20 h). Furthermore, this study also showed the quality of life for addict gamers was significantly lower than highly-engaged players, especially in physical and psychological health indicators.

For problem Internet and gaming addictions, other research has been undertaken this decade and provided evidence about other potential behavioural addictions which could be classed into this spectrum of online addiction problems [27]. However, the existing theoretical studies (e.g., critiques, reviews) have scarce theoretical development, and only a few of the classic studies have developed attempts of theoretical models (e.g., Davis’ model [14]). Studies are usually empirical and use a quantitative approach (e.g., surveys), while qualitative or mixed methods approaches are still scarce, as in other complementary fields, such as behavioural or educational sciences [28,29]. At present, there is a need for knowledge on the phenomenology (i.e., nature) of these problems and more theoretical development. Young developed the latest published study addressing the phenomenon of Internet addiction in 2004 [30], eight years after she coined the term [2,5]. She provided awareness about the nature of Internet use and its potential abuse, as a decade ago this phenomenon had not been identified and defined yet [31,32]. Similarly, recent research has been published, tackling the phenomenology of traditional gaming versus gaming addiction through insights from the gamers’ perspective [33], especially in younger generations. Thus, GPIU and SPIU (gaming) might become emerging public health problems as, according to Grant, Schreiber, and Odlaug [34], behavioural addictions are characterised by the inability to resist a drive, resulting in actions that are harmful to oneself and others.

There is a need to cover the gap to start ascertaining the addictive nature of these Internet use-related addiction problems; especially when a public health organisation, such as the WHO, has included ‘gaming disorder’ as a behavioural addiction into the category for ‘Disorders due to substance use or addictive behaviours’, subcategory ‘Disorders due to addictive behaviours’, together with gambling (WHO, 2018 [7]). Furthermore, it seems that while other potential addictive problems connected to technological uses are still under investigation by academic and clinical professionals, there is limited evidence to consider their official recognition yet. This is the case of social media or social networking addiction, where a small number of controversial studies have reported these problems related to the maladaptive use of these media as entertainment and communication tools [35,36]. However, although a few psychometric instruments have been developed to measure this new phenomenon (based on previous addictive criteria, such as SUDs or IGD [37,38]), the evidence is limited and concentrated on adolescents and young adults.

On the other hand, it seems to be established that the existing scales which have been developed in the field of technological (behavioural) addictions have usually been developed through other current addiction criteria and validated using student community samples. An outstanding scale is the compulsive Internet use scale (CIUS [39]), which has been recognised as one of the most psychometrically stable tools (e.g., similar factorial structure among several language adaptations) to measure both generalised and specific (i.e., cybersex) use-related addiction problems. In this study, this scale has been selected to quantitatively measure the phenomena of GPIU (i.e., Internet) and SPIUs (i.e., gaming and social networking), respectively (see Table 1). Indeed, psychometrically, the CIUS has excellent reliability, a unique factor structure demonstrated by exploratory and confirmatory approaches, and has shown measurement invariance [39]. However, as the purpose of this paper is to go further in depth and observe the commonalities and differences among GPIU versus SPIUs, a qualitative measure was performed by interviewing participants potentially classed as problem Internet, gaming, and/or social network users. This strategy required a mixed methods approach of a community sample, accomplishing the following methodological requirements provided below.

Thus, the principal aim is to understand adults’ online uses in their personal sphere (i.e., non-academic or professional) to ascertain if these behaviours could be classed as GPIU and/or SPIU and to know about the problems from those who could be categorised as potential problem users. This is articulated in a four-fold specific aim: (i) To validate the CIUS adapted to these three Internet use-related addiction problems (i.e., Internet, gaming, and social networking) to compare them; (ii) to estimate the prevalence of potential problem Internet, gaming, and social networkers users to explore them by sociodemographic variables and addictive symptomatology; (iii) to examine potential problem users’ knowledge, experiences, and perceptions with regard to the nature and development of these problems; and (iv) to know their opinion on IGD criteria adapted to the GPIU and SPIUs studied.

Permission to conduct this study was obtained from the ethics committee of the Psychological Science Research Institute (IPSY) at the Catholic University of Louvain (UcL; Belgium) in 2014. Respondents participated in leading research, which builds upon the Tech Use Disorders (TUD; [40]) project, carried out between 2014 and 2016. The qualitative part was undertaken at UcL, which is the main reason only Belgian results have been included in this paper. None of the data analysed in this paper have been used in any other article from this Marie Curie Intra-European Fellowship (FP7-PEOPLE-2013-IEF; ID 627999 [40,41,42,43,44]).

This mixed methods study had as a primary aim to understand potential technological behavioural addictions in young adults based on their self-reported online uses (i.e., Internet, gaming, and social networking) to compare generalised versus specific addiction problems and verify if these could be classed as public health outcomes. This approach has added an innovative research study type into the literature of this field, as the individuals were targeted based on unique trends of Internet use, gaming, and social networking simultaneously in a mixed methods study. The specific aims were: To validate the generalised and specific CIUS to compare these problems, to estimate their prevalence, and to examine problem users’ perceptions regarding the phenomenology of these problems, and their opinion about the IGD criteria for the GPIU and SPIUs studied.

Concerning the first specific aim, the main psychometric properties were outstanding, showing the commonalities of the three CIUS adaptations tested. Findings showed excellent reliability in all versions (Cronbach alpha coefficients: From α_CIUS = 0.90 to α_CIUS–G = 0.95), which were even higher than the previous French version [52]. The scales’ factor validity was consistent with its unidimensional model [39], achieving greater explained variance than the original version (from CIUS: 49% to CIUS–G: 60%), and with factor loadings being high enough (from CIUS with a minimum of 0.53 to CIUS–SNS with 0.58).

Regarding the construct validity, positive associations between the overall scores of each problem and time variables supported the degree to which the adaptations measure what they claim. Nevertheless, differences among the three problems started to appear. For instance, a device profile emerged for the different problems: The GPIU is mainly associated with computer use, although it was also moderately related to time spent per day with other devices (e.g., tablets and smartphones). Gaming only was modestly associated with daily time in computers and tablets, and social networks above all in smartphones (a part of computers on a weak basis). Thus, gaming is not a usual problem when playing on the mobile phone [44,59], as probably modern smartphones and mobile game apps are not yet developed enough for gamers, at least in Europe. However, computers seem to act as an object of these addiction problems and the Internet can provide a vehicle for facilitating some of the addictive symptomatology, as reported in other behavioural addictions (e.g., gambling [60]).

Concerning content validity, the three forms measured different facets of the ‘Internet addiction’ umbrella construct. For instance, general use was weakly associated with a set of common online behaviours, with messaging, viewing, social networking, and sex consumption standing out. An issue which emerged is the taste for online TV shows/series and film consumption, a recent research line developed in the field [61,62,63], which is usually linked to Internet addiction and gaming as a sedentary behaviour affecting mental health [64,65]. Regarding gaming, game genres with a strong association to this problematic use included by order: MOBA [66,67], MMORPG [50,68,69,70,71], FPS [70,72,73], and solo games [71] (i.e., almost all big games). It is unusual that MOBA and especially ‘solo games’ have emerged, as the literature around problem gaming tends to include only role-playing games. The ‘solo games’ genre makes sense based on the qualitative findings associated with the aetiology about excessively play to avoid or prevent loneliness and boredom, reported in problematic gaming research [71,74,75,76,77]. On the other hand, regarding problem SNS usage, only Facebook emerged as the leading network with which users present addiction symptoms similar to Internet addiction, as previous studies reported [10,78]. As far as the author knows, it has scarcely been clarified what activities are really under the labels of GPIU and these SPIUs, such as gaming [79,80].

Interestingly, another set of differences was found between the three problems at a psychometric level. The general Internet and social networking overall scores were strongly positively correlated, which probably means that their constructs are very close, as current SNS have plenty of resources (e.g., Facebook have options to communicate, to share files, to play games, to consume information, even online gambling) that are starting to emulate a generalised online use [10,78,81]. Moreover, the findings of the content validity supported why the general purpose of the Internet and the specific use of social networks were so close in their interpretation. This could explain why when analysing the scales by items, the CIUS and CIUS–SNS have a similar pattern with moderate scores (i.e., CIUS: a M from 0.78 in item 9 to 2.05 in item 12 out of 4; CIUS–SNS: An M from 0.63 in item 4 to 1.84 in item 1) compared to the CIUS–G (i.e., an M from 0.22 in item 9 to 0.66 in item 1). However, the association between general Internet use and gaming was weak, and it did not exist between gaming and social networking, meaning both SPIUs were independent between them. Moreover, qualitative findings support this different phenomenology of both constructs, as users state many differences between problem gaming and problem networking (e.g., the first being detached from real life, while the second overly attached to real life). This independence observed could be interpreted as those who mainly use SNS are not heavy gamers, and inversely [82]. This is a crucial finding as, from a phenomenological perspective, this indicates gaming could not be classed as a social networking problem and vice versa. These findings also suggest that while from an adult’s perspective, their potential addictive symptomatology is higher when using the Internet in general or when networking, only a few users play games in an excessive and problematic form, and these are all types of adults (i.e., males and females, young and middle-aged ones). In a recent study testing the spectrum hypothesis using the network approach, the umbrella construct of Internet addiction was also highlighted; this study recommended the focus on the specific Internet- and technology-mediated addictive behaviours: Gaming, smartphone, and cybersex [83]. Present quantitative and qualitative findings support the specificity of the SPIU of gaming. Regarding gender issues, the differences were detected on SPIUs at a descriptive level, as while descriptively males tend to be gamers and view online porn, females tend to use social networks, as Andreassen and colleagues also reported [82]. However, when analysing only those classed as problem users, findings change.

Concerning the second specific aim, the estimated prevalence of potential at-risk addiction problem users, findings were (in descending order): 37.4% Internet addicts (generally women and young adults), 32.5% problematic social networkers (usually women and young adults too), and 10.8% problematic online gamers (both genders equally, as well as all group ages in adulthood). Thus, this suggests women are starting to be problem users, especially in addictive gaming, which traditionally was a problem in males [84]. Moreover, while young adulthood has a higher prevalence in general Internet and social networking uses, in the case of gaming, all adults have a similar level of addiction problems, as previously reported [85]. These findings provide evidence for IGD proposal and gaming disorder [6,7], as the problem is extended to both genders and adult group ages. The prevalence estimated was higher than usual for a European study, as reported previously by Laconi and colleagues [80,86]. This overestimation is probably due to a set of methodological factors, the different scales selected in similar studies (e.g., the Internet addiction test; IAT [5] vs. the CIUS [39]), the different interpretation of the symptoms measured as addiction criteria (e.g., see Table 1), and the cut-off score applied to the CIUS, which could be considered a threshold for risk instead of an addiction problem (i.e., as the theoretical median of the CIUS is 28, and 21 was used based on Guertler and colleagues’ study [47], which it was found in the sole self-reported measures from German problem and pathological gamblers, but without clinical support as it is usual in the field). Furthermore, the cut-off was not performed by gender and by type of problem use, and the present sample was mainly composed of women, as it was based on Belgian academic environments of social sciences in higher education. However, almost no research has provided validated cut-off scores using the CIUS, except for the short CIUS [87], which implies a future research line. For this reason, prevalence should be taken with caution as a proposed proportion of users in risk of potential GPIU or SPIU.

Moreover, as a usual practice in the field, potential problem users were chosen by a psychometric measure, without explicit attention to the symptoms accomplished and their relevance [18,21,22,28] or clinical supervision. Other problems were the results obtained by endorsement per items, as there is no agreement on how to operationalise it (e.g., only extracting those who state ‘often’ and ‘very often’ or only ‘very often’ [88]). Interestingly, a clear difference between core and peripheral symptoms has not clearly emerged by the GPIU and SPIUs studied, contrary to other studies [89], as even the core ones were not related to time spent playing, unlike in previous research [25,26]. It is probably because the quantitative sample contained fewer gamers and problem gamers (the lower prevalence), and usually only players of the ‘big games’ seem to be the ones with more addictive problems [25,26,66,67,68,69,70,72]. Nevertheless, in the qualitative findings, the main addiction problem was gaming through ‘big games’, covering all symptomatology and causing more harm compared to the other two problems studied.

Thus, only half of the sample could be classed as potential or at risk of being a problem user, a quarter as having a potential Internet use-related addiction problem, and another quarter more than one problem (i.e., mixed profile: Usually by problem general Internet and networking uses), such as in another European study [80], which was closer in its phenomenology, as reported. It is worth noting that most prevalent symptoms in the quantitative evidence on GPIU and SPIUs studied were not those classed as core criteria according to Charlton and Danforth [25] (e.g., conflict, withdrawal) and Tao and colleagues [21] (i.e., preoccupation, withdrawal). Indeed, the commonality between the GPIU and SPIUs studied at a symptomatologic level was with items addressing loss of control and mood modification. This could highlight the fact that potential problematic users are being classed by criteria which are not the core ones, at least in problem gaming; in other words, the overestimation of these potential problem users could be due to a proportion of them being high enthusiasts of using the Internet in general, gaming and/or social networking. In this study, quantitative evidence has highlighted the loss of control was the symptom with high scores, and according to Griffiths, this is not central to addiction [90] (i.e., it is not a necessary component or a consequence of addictive behaviour). However, a few studies reported a difference in the conceptual and nosological entities of these problems using quantitative approaches, especially between GPIU versus SPIU (i.e., Internet addiction vs. problem online gaming [80]), although the distinction was mainly based on gender, which it seems to be changing based on present findings. Furthermore, the female gender seems at risk of these potential behavioural addictions, even gaming, which is a novel finding against the current literature [91]; this highlights that more research in female gamer in behavioural addictions is needed.

Regarding the third specific aim, the aetiology observed through the qualitative evidence shows more causes have emerged than in previous qualitative studies (e.g., usually only focused on boredom, mood feeling, stress, and escapism [58]); for instance, being an indoors person, with an introvert personality, real and virtual friendship with the guild, and being tech-savvy, feeling the need to be updated, connected, and obsessively informed by others in the case of social networkers. Curiously, environmental factors, such as weak or perceived difficult interpersonal context, have emerged as facilitating problematic gaming, but not other PIUs. Thus, maybe not all external factors facilitate same GPIU or SPIU. Similarly, Griffiths’ component model was effective only for problem gaming [18], as a phenomenon caused by a biopsychosocial perspective; followed by problematic social networking; and finally, GPIU with less symptoms, which do not facilitate covering the need for more evidence to promote theoretical development on GPIUs [14] (e.g., only relapse was present as a symptom in problematic gaming).

According to addiction symptoms, salience seems not to only be a cognitive component, as its emotional facet has emerged, as it was stated by Griffiths [18], and it appears to include craving; however, it was not involved in other Internet addiction criteria or IGD [21,22]. Moreover, this addictive symptom is usually used to diagnose SUDs and gambling disorder, but not included in, for example, IGD [6,92]). Davis’ model [15] did not cover this affective aspect of the nature of GPIU or SPIUs. Indeed, Caplan statements about the preference for online interaction, mood regulation, and deficient self-regulation [15,16] were supported by all interviewees. However, tolerance is more complicated than stated in the most contemporary proposals to diagnose behavioural addictions [21,22], especially in gaming [33]; as it is the increment of not only time (i.e., intensity, expertise, or advancement in the game), and not only for excitement or desire (wording usually used in IGD [22], which has been highly criticised in the interviews). Concerning deception or cover-up, like tolerance, it is more complicated than initially described in addictive symptomatology [18,19,20,21,28,33], as well as in the existing scales (e.g., the IAT [87]). It seems gamers usually maintain a ‘secret double life’ in the game, as they have explained, and as it has scanty been reported as a shared virtual environment among MMORPG players [93,94]. They have ‘game friends’ (the partner, guild or other teams) and their codes to communicate (own language), dedicating daily time to set goals and enjoy within the virtual world of the games; this essential element of gaming behaviour has not been studied in-depth yet [95]. If quantitative and qualitative findings are observed simultaneously, according to Tao and colleagues [21], preoccupation and withdrawal are weakly and moderately present, respectively, in the main sample. However, they are only present in the problematic gamers subsample, and persistent desire and difficult to control are strongly present in the sample for all (GPIU and SPIUs) studied, as well as in all problem users studied. Thus, based on Tao’s criteria, problems studied could be classed as Internet use-related addiction problems with caution; only gaming seems to fit in their proposal. Nevertheless, for IGD [6,22] criteria, only gaming could also be categorised as SPIU based on all findings. Remarkably, the core components [25] could just be checked on the qualitative findings extracted from potential problem users, which concurrently stated conflict was the main addiction symptom (i.e., the one with a higher frequency of agreement), followed by withdrawal, giving up other activities, and continuing despite problems, as probable indicators of behavioural salience. In other words, matching all Charlton and Danforth core criteria for addictive gaming [25,26], qualitative findings support the health problem, together with IGD opinions, which are considered.

Regarding the consequences of excessive online uses, it should be highlighted not all of them are negative. Almost all of the users agreed they have experienced (or observed in others close to them) the risk of being addicted to the Internet or an online activity (usually gaming). They reported developmental and contextual factors as those supporting how a habit such as gaming could slowly and unconsciously develop into an addictive behaviour. For instance, to be a gamer and play video games during adolescence indoors during a long time, avoiding loneliness, establishing an identity in the game, and virtual social life may relate to real life (e.g., real friends are also gamers of the same role-playing games). The risk factors highlighted compared to the symptomatology reported [18,19,20,21,22,23,24,25], which were connected to both developmental and contextual factors (e.g., adolescent crises, parent styles) were found to be more important than individual factors (e.g., personality traits). This assertion goes against our current research in the field (i.e., focused on personality traits [73,96]), while few contextual or structural risk factors [97] or protective factors have been reported. Nevertheless, it should be argued that maybe these participants are not so aware of their characteristics that may help to develop extreme online behaviours, as in other addictive problems (e.g., SUDs). However, none of the interviewees recognised they might be a problem user at present, which questions the cut-off score selected in the adapted CIUS or supports that they probably had (or have had) an addiction problem (i.e., only one gamer recognised to have had this problem in the past, and another gamer described the game transfer phenomena [98]).

Finally, with respect to the fourth specific aim about IGD criteria opinions for diagnosing these problems, qualitative findings highlighted as the most critical addiction symptoms: Risk or loss of relationships or opportunities (conflict), giving up other activities, withdrawal, and continuing despite problems, which coin the core components previously pointed out [25] and match research findings [33]. Moreover, users clearly state ‘intrapersonal or interpersonal conflict’ [18] is equally important, sometimes associated with a ‘functional impairment’ [21]. The qualitative evidence seems to agree with critiques considering GPIU with not enough entity to be as a behavioural addiction [23,80], as a few subthemes did not provide evidence (e.g., not emerging in all addiction symptomatology analysed). In this sense, other excessive online behaviours, such as watching series online, have emerged and caused public health concerns with sedentary lifestyle and time in front of the screens [61,62,63]. Other criteria, such as escaping adverse moods, deceit or cover-up, preoccupation or not being able to reduce or stop online behaviour, are quite ordinary and excessive users agreed with them, the only criterion where users disagree being tolerance, one of which Kardefelt-Winther [24] criticised in the current IGD [22], and about which other authors have found similar evidence [33]. Tolerance, giving up other activities, or escaping adverse moods require a part of rewording them and covering their complexity, an indicator of frequency, as Ko [99] also stated when IGD was published in the DSM-5 appendix [6], as the need for using the intensity and frequency criteria to distinguish subjects with IGD from casual online gamers.

Some limitations of this cross-sectional and self-report study have been already discussed, but it could be added that it was performed with a non-random community and academic sample, with an online survey and interviewing only those who accepted the invitation to participate in the second part of this study (e.g., economic motivation). However, similar quantitative studies have been performed with smaller samples than the quantitative [80] and qualitative [50] parts of the study. The study’s strengths include a survey with psychometric and epidemiological validated techniques, with a considerable and sufficient sample size based on Nunnally’s recommendations for psychometrics [100], and Smith and Osborn’s assertion [101] for the qualitative part of the study. The provision of a Belgian French adaptation of the CIUS and IGD for specific Internet use-related addiction problems was supported by previously validated adaptations [22,52]. The qualitative participants were psychometrically and theoretically selected after validating the CIUS scales to have the potential problem online users from all profiles studied to shed light on the phenomenology of these new addiction problems from adults.

In summary, technology uses are growing within contemporary societies and bibliographic productivity is attending these phenomena quantitatively. However, confirmatory approaches could have been chosen as a method for factor validity, which is a future research study under development. Finally, although this is not the first mixed methods study done in the field [33,92], it is one of the few that have been undertaken covering mixed user profiles of these problems. Therefore, it is an original contribution looking for mixed evidence on what seems to constitute the phenomenology of these problems through potential or at-risk adult problem users, although no functional impairment or other possible mental disorders were measured to disentangle the problem users with a clinical approach.

The present study is one of the first to ascertain what seems to be behind current psychometric measures and to start to disentangle generalised and specific Internet addiction problems, addressing their phenomenology with quantitative and qualitative evidence.

The findings show that around half of Belgian (European) adults seem to present at least a risk of Internet use-related addiction problems. However, a lower proportion could have a mixed profile, covering the risk of more than one problem. The CIUS for generalised problematic internet use and specific problematic gaming and social networking has been validated, and the potential prevalence in at-risk users have been estimated. Young or middle-aged adults in both genders have been shown to be equally vulnerable to problematic gaming. Furthermore, the addiction symptoms are present in the problems studied, but not with the same weight or level of importance. The higher scores are in general Internet addiction and problem social networking, which seem to have a common phenomenology, while problem gaming seems different. However, all of them have loss of control and mood modification as main prevalent symptoms. Nevertheless, when problem gaming is analysed in-depth, it is difficult to confirm all addictive components, symptoms, and criteria, in quantitative and qualitative findings. Furthermore, the classic core components have been tested but were only ratified in the qualitative results, where the relevant symptoms were conflicting, giving up other activities, withdrawal, and continuing despite problems.

An in-depth theoretical and empirical review of the public health approach usually used in behavioural addictions literature applied to generalised and specific addiction problems has been provided. This strategy together with analysing quantitative and qualitative evidence of these problems has shown what seems to be behind each addictive criterion usually used to screen users and classify them as a potential problem user (i.e., through DSM criteria, component addiction symptoms, and core vs. peripheral symptoms). Moreover, it has been documented that at-risk users’ perceptions about the phenomenology of these problems, which start in adolescence and remain during adulthood, with a potential of increased harm. The aetiology is more diverse than previously described, and its development is supported by psychosocial, environmental, and technological factors, leading to a few cases of extreme problems. Potential at-risk problem users’ opinions about IGD criteria have highlighted that some criteria (e.g., risk or loss of relationships or opportunities) are more important and better developed than others (e.g., tolerance), but the need to apply them with clinical resources is essential in the evaluation and diagnosis of these mental health problems. Nevertheless, natural recovery has emerged as a finding for some potential problem users, although mental health systems to support those users who have developed the problem(s) and cannot naturally recover are required. Other preventive actions in education, social, and family relationships could promote the maintenance of users’ health and wellbeing.

Thus, it seems these problems exist, but probably in a lower proportion than reported. However, when they do appear they present addictive symptomatology, especially in problem online gaming. These findings seem to provide evidence for the IGD proposed by the APA (with the restrictions and improvements suggested) and the recent recognition of gaming disorder by the WHO (especially for specific online gaming behaviours).