Escapism Among Players of MMORPGs—Conceptual Clarification,Its Relation to Mental Health Factors,and Development of a New Measure

Abstract

Previous studies show that the concept of escapism needs to be clarified and that its relation to problematic online gaming and other factors needs further examination. This study uses well-established, basic learning theory to clarify the concept of escapism, and examines its relation to problematic gaming, psychological distress, and satisfaction with life among players of massively multiplayer online role-playing games (MMORPGs). MMORPG players (n=201) answered an online questionnaire where these factors were measured and correlated with a previously developed scale on motivation to play (MTPI), including extra items to cover positive and negative aspects of escapism. Factor analysis and construct validation show that positive aspects of escapism are theoretically and empirically unstable and that escapism is best clarified as purely “negative escapism,” corresponding to playing being negatively reinforced as a way of avoiding everyday hassles and distress. Negative escapism had a stronger relationship to symptoms of Internet addiction, psychological distress, and life satisfaction than other variables and other more positive motivations to play. Future studies should use the revised subscale for escapism (in the MTPI-R) presented in the present study, for example when screening for Internet addiction.

Introduction

General background

Ever since computer games became common popular entertainment in the 70s and 80s, the effect of playing games has been debated. Research on computer games has hence often focused on negative effects such as aggression and addiction.^1–3 In the last 10 years, a new computer game genre has emerged—massively multiplayer online role-playing games (MMORPGs)—where thousands of players can play at the same time. MMORPGs have roots in the MUD (Multi User Dungeon) games that first appeared in the 1970s. MUDs were text-based multiplayer games, often with a fantasy setting. The term MMORPG was coined by the creator of Ultima Online (1997), a game that is widely considered to be the first of the genre. MMORPG players play about 20 hours a week on average, and the average player is around 30 years old.^4–6 The expanding usage makes it important to explore how online gaming relates to a range of factors, such as quality of life and mental health.

Previous research

Compared to other types of games, players of MMORPGs seem to be more at risk for problematic gaming behavior, Internet addiction, and psychological distress such as sleep problems and depressive symptoms.^7,8 The amount of time playing seems to be one factor that can predict problematic usage,^7,9 but results are mixed. For some individuals, playing the game might be a way to avoid face-to-face social situations.⁷ Individuals who perceived the virtual game world as superior and more striking than real life were especially likely to experience psychological dependency on MMORPG playing.¹⁰ However, it was unclear whether playing was driven by avoidance of the real world or a fascination with a fantastic, virtual world.

Motivation to play and the role of escapism

Previous research indicates that escapism, broadly meaning “escaping the real world,” may be an important part in explaining why people play MMORPGs.^11,12 In an online study with 3,000 participants, Yee used factor analysis in order to create an instrument to measure what motivates MMORPG players to play.¹¹ This instrument is referred to in the present study as the Motivation To Play Inventory (MTPI) scale. Yee's study yielded three main components: achievement, social, and immersion. The immersion component, of which the subscale escapism is an important part, has been a strong predictor of Internet addiction¹³ and problematic Internet use (PIU), twice as strong as the other motivational factors.¹⁴ Escapism emerged in Yee's study as the single best predictor for Internet addiction.¹¹

However, the concept of escapism is not easily defined and operationalized. In a study by Warmelink et al.,¹² the term “cause-based” was used to describe escapism that serves the purpose of negating or fleeing from an element in real life (to break the mundane or to relieve stress). When escapism allows people to transcend reality by pursuing an activity or fantasy, it is called “effect-based” (to seek pleasure or conjure imagination). When the researchers tried to define escapism theoretically and with the use of focus groups, they found that it could mean a number of different things, and it was sometimes so broadly defined that it became equivalent to “playing computer games.” In the three items of the escapism scale in the MTPI, one item is neutral or slightly leaning to the negative or avoidance (“How important is it to you that the game allows you to escape from the real world?”), one is positive (“How often do you play to relax from the day's work?”), and one is clearly negative (“How often do you play so you can avoid thinking about some of your real-life problems or worries?”). Although this ambiguity might reflect what is generally meant by the term, it could be problematic when it comes to operationalize a psychological concept and is probably the reason for the rather low internal consistency of the escapism scale (α=0.65) found by Yee.¹¹

In light of the basic aspects of well-established learning theory, as described in Catania,¹⁵ these positive and negative aspects of escapism correspond to positive and negative reinforcement. Positive reinforcement means that you act a certain way (e.g., play MMORPGs), get a positive effect from the behavior (having fun, feeling good, get appreciation from other players, etc.), after which the behavior is strengthened (the probability that you will play MMORPGs in the future increases). With negative reinforcement, some negative stimuli is removed when you start playing (e.g., distancing yourself from everyday problems or anxiety), and this removal of negative emotions increase your tendency to play in the future.¹⁵ In the long run, negative reinforcement shapes an avoidance behavior, a behavior category that is viewed as a major contributor to mental health problems and has been associated with both depression¹⁶ and anxiety disorders.¹⁷ Thus, if avoidance is a part of escapism, it is probably that aspect that is most closely related to PIU and Internet addiction. In line with this, one study found that MMORPGs' players often reported using the game to avoid real-life problems,⁸ and another identified escapism as the strongest predictor of PIU.¹⁴ Taken together, it is possible that the concept of escapism could be more theoretically distinct and operationalizable if the scale was divided in two scales based on the well-known phenomena of positive and negative reinforcement.

This study has two aims. The first aim is to examine whether the escapism scale can be further clarified and divided into negative and positive escapism and to replicate and extend Yee's¹¹ findings. The hypotheses is that the division into negative and positive escapism will result in a more psychometrically sound instrument and that the clearer theoretical conceptualization will be validated by showing that Internet addiction, psychological distress, and satisfaction with life will be more strongly related to negative escapism than to positive escapism. Satisfaction with life is used as a complementary and broadening measure in relation to psychological distress, since the two measures are related but not the exact opposites. These findings will be the base for a recommendation on whether Yee's¹¹ escapism scale in the MTPI should be revised or not.

The second aim is to examine what factors predicts psychological distress and life satisfaction respectively. The hypothesis is that the new scale for negative escapism is, to a larger extent than other factors (including Yee's original escapism scale), related to higher psychological distress.

Method

Participants and recruitment

The participants were gathered from 16 different game forums on the Internet, where the majority was World of Warcraft forums (e.g., mmorpgforum.com, www.onrpg.com, www.guildwarsguru.com/forum). The number of participants or the number of posts in these forums was not measured at the time of the recruitment period.

Four of those were Swedish; the rest were mostly English-speaking forums. Individuals following the link to the study received information and were asked to fill out a consent form to participate. Of the 201 participants, 184 (91.5%) were male and 17 (8.5%) female. The average age was 22.6 years (SD=7.99).

Procedure

The online questionnaire was posted on the Internet for 12 days, and a reminder was posted on the forums when 5 days remained. The online questionnaire was designed and put together using Adobe Dreamweaver with HTML and CSS, and programmed in PHP and MySQL. It consisted of eight pages and took 10–15 minutes to complete. The participants were anonymous. Web browser cookie checks made it difficult for participants to fill out the online questionnaire more than one time per web browser. They could, however, do so if they switched web browser (i.e., first filled it out in Internet Explorer, then Mozilla Firefox) or if they deleted their cookie history within the browser.

Measurements

Background variables were age, gender, average playing time for weekdays, average playing time for weekends, what kinds of MMORPGs the participants were playing, and for how many years and months they had played MMORPGs.

Life satisfaction was measured with the Satisfaction With Life Scale (SWLS), a 7-item scale (1=“strongly disagree,” 2=“disagree,” 3=“slightly disagree,” 4=“neither agree nor disagree,” 5=“slightly agree,” 6=“agree,” 7=“strongly agree”) with high result of SWLS indicated high satisfaction with life.¹⁸ High test–retest reliability (0.82) and internal reliability (Cronbach's α=0.87) have been found,¹⁸ and in this study a Cronbach's alpha of 0.88 was found.

A short version of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was used to measure mental health. This is called the GP-CORE and consists of 14 items scored from 0–4 with the response categories “never,” “seldom,” “sometimes,” “often,” and “always.” High scores on GP-CORE indicate high levels of psychological distress and lower levels of functionality and global well-being. Its test–retest reliability had previously been found to be 0.91, and the internal reliability 0.84–0.87.¹⁹ In this study, the internal reliability was 0.89.

Eight items were used to measure the level of Internet addiction on a continuous scale, from now on referred to as “symptoms of Internet addiction” to separate it from “Internet addiction,” which refers to fulfilling the diagnostic criteria (or not). These items were built on modified criteria from pathological hazard game playing, and each item was answered with a Yes (1) or No (0), summed up to a total between 0 and 8.¹³ This sum was used in the analyses to capture the whole range of addictive behavior, also at a subclinical level. The Cronbach's alpha for this scale, based on the current data, was 0.75. Young's criteria, where five or more “Yes” answers are an indication of Internet addiction, was used as a sample characteristic presented in Table 1.

Table 1.

Background Data for All Participants (N=201)

Gender n (%):
Women	17 (8.5%)
Men	184 (91.5%)
Age: M (SD) (min–max)	22.6 (7.99) (11–55)
MMORPGs played:
World of Warcraft	29%
Guild Wars	20.4%
Eve Online	7.3%
Age of Conan	6.7%
Lord of the Rings Online	3.5%
Everquest II	2.9%
Star Wars Galaxies	1.6%
Other	24.2%
Average playing time (hours/day, M(SD)):
Total	4.15 (1.84)
Weekdays	3.48 (2.05)
Weekends	6.32 (3.16)
Years playing MMORPGs: M (SD)	4.23 (3.24)
GP-CORE M (SD)	2.48 (0.63)
SWLS M (SD)	4.04 (1.49)
Indication of Internet addiction, n (%)	11 of 141^* (7.8%)

Note. n=141 for the questions on Internet addiction, since they occurred in the later part of the questionnaire.

The Motivations To Play Inventory scale (MTPI) consists of 39 five-point Likert scale items. The response sets varied depending on the type of question, for example from “not important at all” to “tremendously important” and from “never” to “always” (see Yee¹¹ for a complete description of questions and their respective response items). The MTPI measures different motivations to play in three main components and 10 subcomponents, calculated as means of each components' or subscales' items. These components were achievement (with the subcomponents advancement, mechanics, and competition), social (including socializing, relationship, and teamwork), and immersion (including discovery, role playing, customization, and escapism). The immersion component included things like finding out things about the world other players did not know (discovery), getting involved in your character (role playing), customizing the appearance of the character (customization), and escapism (see above for further definition).¹¹ Twelve items were added to the MTPI scale (labeled as “new” in Table 2) in order to explore and strengthen the subcomponent escapism further, where seven questions were developed to measure negative escapism and five to measure positive escapism. The negative items were based on the concept of negative reinforcement. The positive items were formulated to capture aspects of positive reinforcement, with a rather broad focus on positive states and moods rather than on specific descriptions on what exactly causes the positive emotion. This was done in an attempt to separate positive escapism from all other subscales in MTPI that in fact also represents aspects of positive reinforcement, however more specifically and less emotionally and generally defined.

Table 2.

Principal Component Analysis of Escapism (with Varimax Rotation)

	Factor and loadings in final solution
Item	1	2	Origin and theoretical scale	M (SD)
Positive escapism (α=0.57)
How often do you play to relax from the day's work?		0.71	Yee	3.39 (1.08)
To what degree do you agree with the following statement: I consider my playing an extra spice or a bonus in my life?		0.64	New, positive	3.00 (1.15)
How often do you start to play when you are in a good mood?		0.62	New, positive	3.70 (0.82)
When you are in a good mood, which is more likely—that you choose to play or to do something else?		0.58	New, positive	3.31 (1.01)
Negative escapism (α=0.82)
How often do you play so you can avoid thinking about some of your real-life problems or worries?	0.85		Yee	2.28 (1.17)
How often do you play in order to avoid real-life social encounters or situations?	0.84		New, negative	1.76 (1.07)
How often do you continue to play so that you won't have to deal with everyday problems and issues?	0.80		New, negative	2.36 (1.26)
Excluded from negative escapism to reduce number of items
If you are annoyed, worried, or low-spirited, how often do you play to distract yourself from these negative emotions?	0.74	0.29	New, negative	2.67 (1.23)
To what degree do you agree with the following statement: If I feel bad, I play for a while and then it feels better?	0.72	0.36	New, negative	2.26 (1.11)
How often do family and/or friends tell you that you play instead of dealing with everyday problems and issues?	0.70		New, negative	1.93 (1.15)
To what degree do you agree with the following statement: I usually feel better when playing than when I'm not playing?	0.68	0.28	New, negative	2.23 (1.26)
How often do you start to play when you are in a bad mood?	0.56		New, negative	2.55 (0.99)

Note. n=148 with listwise exclusion of missing data. Loadings below 0.25 are not shown.

Statistical analysis

The statistics program SPSS (SPSS v15; SPSS Inc., Chicago, IL) was used to realize the statistical analysis. Principal component analysis with varimax rotation was used to analyze factor structure of the old and new questions in the escapism scale. Furthermore, Cronbach's alpha, correlation analysis (Pearson's), multiple regression analysis, and t test for independent groups were used.

Attrition

Nine participants were completely excluded due to low quality of data and a risk of not having been answered truthfully and seriously (e.g., indicated an age of 127). Out of a total of 192 participants, 141 completed the whole survey and 145 the whole MTPI. Some specific answers were excluded, as they were deemed extreme outliers (e.g., a playing time of 80 hours a week). However, the analysis did not yield substantially different results with the extreme results included. Regarding the MMORPG questions, the number of answers varied between 145 and 164, depending on where the participant had ended the survey. A total of 143 participants completed up until the questions on psychological well-being (GP-CORE), and 145 up until the questions on life satisfaction (SWLS).

Results

Participant characteristics

Background variables can be seen in Table 1.

Factor structure of positive and negative escapism

After an initial factor analysis where some statistically inappropriate items were removed (including Yee's original and somewhat neutral item “How important is it to you that the game allows you to escape from the real world?”), the factor solution shown in Table 2 was found. It revealed one robust component for negative escapism (eigenvalue of 5.16) and one less robust for positive escapism (eigenvalue of 1.39). These two factors explained 54.5% of the total variance. The Kaiser–Meyer–Oklin value was 0.89, which exceeds the recommended value of 0.6, and Bartlett's Test of Sphericity reached statistical significance at a 0.01 level, which supports the two-factor solution.

In order not to lengthen the questionnaire, the number of items for negative escapism was reduced to the three with the strongest loadings, yielding an internal reliability of 0.85 (Cronbach's alpha) as compared to 0.90 for all eight items.

As for positive escapism, four items seemed to be part of the same component. However, the reliability for this component was low (α=0.57). The weak psychometric qualities, its conceptual closeness to other positive aspects of playing, and its non-significant correlation with symptoms of Internet addiction (r=0.11, n=144; p=0.19) made us decide to exclude it from further analysis. Without the positive escapism items and with only the three main items for negative escapism, a secondary factor analysis resulted in a single factor of negative escapism explaining 77.4% of the total variance. The original escapism scale also had somewhat low reliability (α=0.66), quite comparable to the reliability found in Yee's previous study (α=0.65).¹¹ The mean was somewhat lower on the scale of negative escapism (M=2.07, SD=0.95) compared to the original escapism scale (M=2.74, SD=0.95).

GP-CORE were significantly correlated with negative escapism (r=0.46; n=143; p<0.001), playing time (r=0.23; n=140; p<0.01), mechanics (−0.22; n=143; p<0.01), and socializing (r=−0.21; n=143; p≤0.05). With SWLS, the following factors were significantly correlated: negative escapism (r=−0.30; n=145; p<0.001), playing time (r=−0.27; n=142; p<0.001), and socializing (r=0.24; n=145; p<0.01). There was also a strong correlation between negative escapism and symptoms of Internet addiction (r=0.54; n=141; p<0.01)(Table 3).

Table 3.

Correlations Between Negative Escapism and Other Factors

	Negative escapism	Escapism (original)	Internet addiction	GP-CORE	SWLS	Social—Socializing	Achievement—Mechanics	Hours played/day interpret
Escapism (original)	0.71^**
Internet addiction	0.54^**	0.35^**
GP-CORE	0.46^**	0.21^*	0.50^**
SWLS	−0.30^**	−0.14	−0.38^**	−0.61^**
Social—Socializing	0.07	0.18^*	−0.00	−0.21^*	−0.24^**
Achievement—Mechanics	0.12	0.21^*	−0.01	−0.22^**	0.15	0.22^**
Hours played/day interpret	0.34^**	0.21^*	0.34^**	0.23^**	−0.27^**	0.01	−0.01
Play time months	−0.02	−0.00	0.04	0.08	−0.12	−0.20^*	−0.22^**	−0.04

Note. GP-CORE, General Population—Clinical Outcomes in Routine Evaluation outcome measure; SWLS, Satisfaction With Life Scale. Ns between 138 and 196.

Correlation is significant at the 0.01 level (2-tailed); ^*correlation is significant at the 0.05 level (2-tailed).

Validation of the new scales for negative escapism and a comparison to Yee's original scale

We considered whether the relation of the new scales to symptoms of Internet addiction, psychological distress, and satisfaction with life differ.

Correlation analysis showed a strong correlation between negative escapism and symptoms of Internet addiction as seen in Table 3 (r=0.54; n=141; p<0.01). This was better than the moderate relationship that was present when applying Yee's original escapism scale to our sample and correlating it with symptoms of Internet addiction (r=0.34; n=141; p<0.01).

Psychological distress (GP-CORE) was also more strongly correlated with negative escapism (r=0.49; n=143; p<0.01) than with Yee's original scale (r=0.21; n=143; p<0.05). The same pattern was found for satisfaction with life (SWLS), which correlated more strongly with negative escapism (r=−0.30; n=145; p<0.01) than to Yee's original scale (r=−0.14; n=145; n.s., p=0.09).

The psychometric properties and validity for the new scale of negative escapism came out favorably compared to Yee's original escapism scale (which included a mix of positive, negative, and neutral escapism items) and was hence used in further analysis.

Does negative escapism predict psychological distress and life satisfaction better than other factors?

Initially, correlations between GP-CORE and SWLS and 20 possible predictors (background variables and scales from MTPI) were made to decide which to include in the regression analysis. If a subscale showed a stronger correlation than the main scale it belonged to, the subscale was chosen for further analysis.

As presented above, GP-CORE was significantly correlated with negative escapism, hours played per weekday, mechanics, and socializing. When used as independent variables in a stepwise regression, playing time was excluded as nonsignificant, and the remaining variables explained 31% (adjusted R²) of the variance in GP-CORE (F(3, 136)=21.5, p<0.01), with negative escapism as the strongest predictor (β=0.50), followed by mechanics (β=−0.24), and socializing (β=0.19). Entering mechanics and socializing in a first step explained 6.3% of the variance. Subsequently adding negative escapism resulted in a significant (p<0.001) addition of 24.4% of explained variance.

With SWLS, the following factors were significantly correlated (see above for coefficients): negative escapism, hours played per weekday, and socializing (r=0.24). In the stepwise regression, these factors explained 17% of SWLS (F(3, 137)=10.5, p<0.01). Socializing was the strongest predictor (β=0.26), followed by negative escapism (β=−0.25), and playing time (β=0.18). Entering socializing and playing time in a first step explained 13.3%. Subsequently adding negative escapism resulted in a significant (p<0.01) addition of 5.8% of explained variance.

Discussion

The results from the present study indicate a weakness in both the concept of escapism and the MTPI scale developed by Yee.¹¹ The escapism scale that was developed in Yee's¹¹ study mixed negative, neutral, and positive meanings of escapism, with low internal consistency as a result in this study. The MTPI scale could be refined by instead using the three items for negative escapism provided in this study to make the scale more robust and conceptually clearer. The subscale for negative escapism had better psychometric qualities and is in line with the broadly established psychological concept of negative reinforcement. Its theoretical clarity and empirical usefulness is clearly shown by strong associations with symptoms of Internet addiction, psychological distress, and life satisfaction, replicating and further strengthening Yee's finding.¹¹

The strength of conceptualizing escapism more clearly as negative escapism (avoidance of negative aspects of real life) becomes even more obvious when taking into account the difficulties of conceptualizing positive aspects of escapism. Trying to conceptualize playing for recreational purposes or for the pure fun of it as “escaping reality” does not seem to be a theoretically or empirically fertile way to move forward. When these aspects are instead removed from the concept of escapism and the focus is only on the avoidance of thoughts, feelings, or social situations, a much clearer picture appears.

Hence, we recommend that the concept of escapism should either be clarified as negative escapism (avoidance) or dropped completely, unless further studies can present a theoretically and psychometrically sound version of the more broad and ambiguous original concept. In line with this, we also recommend that the revised version of the MTPI—the MTPI-revised (MTPI-R)—is used in future studies, using the three items for negative escapism presented here instead of Yee's original escapism items.

The results of this study are important in order to understand the relationship between MMORPG playing and mental health. Negative escapism showed the strongest relationship with both psychological distress and life satisfaction, making it the single most important predictor when considering the overall psychological well-being of players. This is an important addition to previous studies. Yee¹¹ and Caplan et al.¹⁴ found immersion, and its subcomponent escapism, to be an important predictor of problematic Internet use. Our clarified concept of negative escapism in the MTPI-R shows even stronger predictions of psychological well-being and symptoms of Internet addiction. This suggests that it better captures the essence of why immersion and related concepts might cause problems because they are reflecting avoidance behavior and negative reinforcement. A more direct focus on those players using their game as an avoidance of real-world problems would most probably be beneficial to the research field as a whole.

Socializing and showing an interest in the underlying mechanics of the game were found to be protective factors. In the case of socializing, it seems quite obvious that having fun with friends and making new ones would be a strong positive reinforcer and a protective rather than destructive reason to play. Previous findings are, however, mixed. Caplan et al.¹⁴ found that, in general, social usage of the Internet predicted problematic Internet usage but that social motivation to play MMORPGs where not related to problematic Internet usage.

This study has some limitations. The response rate of all those in the Internet forums who were invited to fill out the questionnaire is unknown, and the representativeness of our sample is unknown and suffers the risk of being biased. For example, there could be a selection effect in that players who choose to participate in a survey like this generally are more outgoing than those who choose not to take part. This may imply an uneven distribution with many players who primarily indulge in the social aspects of MMORPGs. Also, the choice of forums could have been biased, for example toward more novice players and fewer hardcore players. These hardcore players may be an important group to consider in future studies.

The partial attrition was relatively high; 27% (141 out of 192 participants) did not complete the whole survey, and 24% did not complete the MTPI. A shorter survey could probably have counteracted the partial attrition, as many seemed to consider the survey too long. Many participants also chose to end the questionnaire after the questions on MMORPGs, when the questions became more serious and personal. This group may have been individuals with high psychological distress and/or Internet addiction. Being confronted with uncomfortable feelings, they may have perceived the questions as stressful. The relatively low numbers of players who were estimated to fulfill the criteria for Internet addiction indicate that this group might be underrepresented in this study. Also, the play time of the participants in this study indicates that a group of hardcore players spending even more time each week might not have been included in our sample. The estimation of time spent on playing is also somewhat uncertain, and preferably should have been measured with exact data on play time received directly from the game developers.

Finally, the comparisons of the new negative escapism scale and Yee's original scale were not tested with significance tests, making the perceived advantage of the new scale less certain.

Future research

A very strong correlation between negative escapism and symptoms of Internet addiction was found. Negative escapism might therefore serve a purpose in the future in screening for Internet addiction. The relationship between playing MMORPG and social phobia should also be further explored, since the negative escapism scale bears resemblance to social phobia (e.g., “How often do you play in order to avoid real-life social encounters or situations?”), and previous research also points to a relationship between playing MMORPGs and social anxiety.⁹

It would also be interesting to see if there could be other reasons why people play MMORPGs than the ones dealt with here—reasons that are more positive for the individual. The scale for mechanics and different social aspects seem to be two dimensions that are more positive for the individual. The flow phenomenon²⁰ could also be one of these reasons. Mood management theory could be used as another theoretical framework to study this further.²¹

Conclusion

The present study shows that using MMPORGS to avoid negative experiences in everyday life, captured in the concept of negative escapism, is of greater importance than other factors and motivations to play when it comes to predict symptoms of Internet addiction, psychological distress, and life satisfaction. The original theory by Yee was based on an unstable and unclear concept of escapism, which required further exploration. We found that applying basic learning theory makes the picture clearer and the results more coherent. The present study points to the fact that we should look to the function of playing games in a given context: is it a function of entertainment or avoidance? It also asks us if this behavior has reached a level where it starts to become a problem for the individual.

It is recommended that escapism should be defined foremost as escape from negative aspects of real life, or avoidance behavior. We also recommend that future studies should use our revised version (MTPI-R) instead of Yee's¹¹ original scale (MTPI) to take advantage of the enhanced conceptual clarity and predictive power of the negative escapism subscale.

Footnotes

Author Disclosure Statement

No competing financial or other interests exist.

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