Gambling Disorder PDF

# Gambling disorder - 0.4%-1.1% prevalence - **'Habit and impulse disorders'** Pathological gambling - ICD 10 - **'Substance-related and addictive disorders'** Gambling disorder in DSM-5 - ICD 11 **"Disorders due to substance use and addictive behaviours"** Gambling disorder ## Diagnostic criter...

# Gambling disorder - 0.4%-1.1% prevalence - **'Habit and impulse disorders'** Pathological gambling - ICD 10 - **'Substance-related and addictive disorders'** Gambling disorder in DSM-5 - ICD 11 **"Disorders due to substance use and addictive behaviours"** Gambling disorder ## Diagnostic criteria for "pathological gambling" according to DSM-IV (e5) and ICD-10 (1) a brief comparison | DSM-IV Pathological gambling (312.31) | ICD-10 Pathological gambling (F63.0) | |:-----:|:-----:| | Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following | The disorder consists of frequent, repeated episodes of gambling that dominate the patient's life to the detriment of social, occupational, material, and family values and commitments. | | 1. Is preoccupied with gambling | A. Repeated (two or more) episodes of gambling over a period of at least one year. | | 2. Needs to gamble with increasing amounts of money | B. These episodes do not have a profitable outcome for the person, but are continued despite personal distress and interference with personal functioning in daily living. | | 3. Has repeated unsuccessful efforts to control, cut back, or stop gambling | C. The person describes an intense urge to gamble which is difficult to control, and reports that he or she is unable to stop gambling by an effort of will | | 4. Is restless or irritable when attempting to cut down or stop gambling | D. The person is preoccupied with thoughts or mental images of the act of gambling or the circumstances surrounding the act | | 5. Gambles as a way of escaping from problems or of relieving a dysphoric mood | | | 6. After losing money gambling, often returns another day to get even ("chasing" one's losses) | | | 7. Lies to conceal the extent of involvement with gambling | | | 8. Has committed illegal acts to finance gambling | | | 9. Has jeopardized or lost an important relationship, job, or educational or career opportunity because of gambling | | | 10. Relies on others to provide money to relieve a desperate financial situation caused by gambling | | | Exclusions - Excessive gambling by manic patients (F30) - Gambling and betting not otherwise specified (272.6) - Gambling in dissocial personality disorder (F60 2) | ## DSM-V Criteria for Gambling Disorder - Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period: - Tolerance-Needs to gamble with increasing amounts of money in order to achieve the desired excitement - Withdrawal - Is restless or irritable when attempting to cut down or stop gambling - Preoccupation Has persistent thoughts of reliving past gambling experiences, handicapping or planning next venture, thinking of ways to get money with which to gamble - Escape Gambles when feeling distress (eg, helpless, guilty, anxious, depressed) - Chasing-After losing money gambling often returns other day to get even ("chasing" one's losses) - Lying-Lies to family, friends and others to conceal the extent of involvement with gambling - Risks Relationships/Opportunities - Has jeopardized or lost a significant relationship, job, or educational career opportunity because of gambling - Ballout-Relies on others to provide money to relieve desperate financial situations caused by gambling - Loss of Control-Fails in an effort to control or stop gambling. - The gambling behavior is not better explained by a manic episode. ## Clinical Features - Excessive gambling in terms of money spent or time devoted. - Preoccupation with gambling with tolerance and craving. - Loss of control over gambling despite damage - Disorder affecting person & family - Financial disturbances - Social disturbances - employment/friends, eviction, marital problems, children, criminality/imprisonment - Psychological disturbances → depression & attempted suicide. ## Prevalence USA - 0.4% - 1.1% of adults → pathological gamblers - Additional 1-2% → problem gamblers ## Screening tools - South Oaks Gambling Screen (SOGS) - sensitivity (0.99) > specificity (0.75) ## Causes and pathogenesis ### Demographic associations - young age - Male sex - Non-white ethnic origin - Low socioeconomic status - Divorced or separated marital status ### Mental health co morbidity - Substance use disorders (alcohol misuse) - Major depression and dysthymia - Mania - Generalized anxiety disorder, panic disorder, specific phobias ## Neurocognition - Deficits in - inhibition - working memory - planning - cognitive flexibility - time management - Decreased activation in ventrolateral prefrontal cortex ## Neurobiology - Dopaminergic - Serotonergic - Noradrenergic - Opioidergic - But - D2/D3 antagonists worsening gambling? - D2 partial agonists worsening gambling? - D2 agonists in parkinsonism worsening gambling? ## Genetic factors - Family study of probands with pathological gambling - 1st degree relatives - higher lifetime rates of alcohol/ other substance use disorders & depression - 64% co occurring with alcohol- ??genetics overlapping - D2A1 allele of D2 receptor gene (DRD2) ## Environmental factors - Accessibility to gambling - Location and type of gambling establishment - Size and number of prizes - Near-misses - Early negative childhood experiences - Childhood exposure to gambling ## Integrative models - Bio psychosocial model - Pathways model ## Bio psychosocial model - Cognitive behavioral and diathesis-stress framework - predisposing factors → poor problem-solving and coping skills, morbid risk-taking, genetic vulnerabilities - early gambling experiences → early large wins, multiple small wins early - adverse psychosocial experiences → stress - Assumes homogeneity of gambling disorders ## Pathways model - Heterogeneity of gambling disorders - 3 main pathways → 3 subtypes of gamblers - **Behaviorally conditioned** - pre morbid changes absent - associated effects of conditioning & distorted cognitions - **Emotionally vulnerable** -pre-existing depression & anxiety - **Antisocial Impulsivist** - preexisting impulsivity & antisocial features risk seeking. ## Types of pathological gambling - Sub cultural gambling - out of the personal background - Impulsive gambling-dependence features - Neurotic gambling-response to an emotional problem. - Symptomatic gambling in mental illness (secondary to depression) - Psychopathic gambling-part of the antisocial personality disorder. ## Treatment ### Recovery by own - <10% gambling disorders seek formal treatment. - Recovery rate of 1/3 ### Self strategies - involvement in time-consuming activities incompatible with gambling - avoidance of conditioned cues to gamble (gambling venues) ## Psychosocial treatment - Behavioural models learned patterns of reinforcement within a functional framework (antecedents, behaviours & consequences) - reducing avoidance - exposure to high-risk situations - behavioral experiments to challenge distorted thoughts - development of skills in various areas (assertiveness, problem solving & relaxation ## Brief treatment - Telephone gambling help lines and websites - A telephone-based motivational interview contact + mailed self-help CBT workbook ## Cognitive treatment models ### Cognitive distortions - Magnification of gambling skill - Overrating one's ability to win at gambling ### Superstitious beliefs - Talismanic superstitions → possession of certain objects increases the probability of winning (ring, hat) - Behavioral superstitions → certain rituals can Increase winning probability (playing only certain slot machines / placing smaller bets if they do not throw dice by themselves) - Cognitive superstitions → certain mental states (prayer, hope) ## Interpretative biases - Attributional biases - overestimating dispositional factors (skills, abilities) to explain wins & underestimating situational factors (luck, probability) - Gambler's fallacy -a win is due after a series of losses - Chasing-only way to recover loss is to continue to gamble - Anthropomorphism-attributing human characteristics to Inanimate or non-human gambling objects (slot machine, lottery card, bingo card, horses) - Learning from losses -losses are perceived as valuable learning experiences - Hindsight bias -retrospectively evaluating gambling decisions as correct or incorrect on basis of whether they lead to wins or losses - Illusions of control over luck - Luck perceived as an important variable - uncontrollable variable (luck oscillates between periods of good and bad) - controllable variable (luck manipulated through superstitious behaviors - trait variable (certain people are lucky with certain games) - contagion (luck affected by other areas of life:) - Illusory associations - Perceiving illusory associations to sallent features environment with gambling outcomes - noticing that certain days more likely to win ## Temporal telescoping - wins are actually nearer temporally - Selective memory - Selectively recalling wins & difficulty in recalling losses ## Predictive Skill - gambling decisions on the basis of interpretations assigned to subjectively important cues - internal (gut sensations, intuitions) - external (omens, weather phenomena) - behaviour by other gamblers ## CBT - challenging irrational thought processes - strongest evidence base - Pallesen S et al 2005 (meta analysis of RCCT) - Cowlishaw S et al 2012 (Cochrane review) - CBT = Motivational interviewing >> Waiting list - Carlbring P et al 2010 (RCCT) ## Psychopharmacological treatment - Opioid receptor antagonists - naltrexone and nalmefene - modulate DA transmission in mesolimbic path - 2RCTs - Reduce -the intensity of urges to gamble - gambling thoughts & behaviour - SSRI-Fluvoxamine & paroxetine - mixed results - N-acetyl cysteine - glutamate modulator - improvement in glutamatergic tone in nucleus accumbens - topiramate no evidence ## Gamblers Anonymous - Modified from Alcoholics Anonymous - Started in 1957 USA - Now in 55 countries worldwide - Program of 12 steps and 12 traditions - Establish alternative social contacts - Periods of success are marked with celebrations and rewards - Co relational data -better gambling outcomes ## Family therapy models - Self-help workbook - Gambling adaptation of the Community Reinforcement and Family Therapy (CRAFT) model - family members are trained to use behavioral principles to reinforce non-gambling behavior in gamblers - 3 goals - Gambling abstinence - Engaging to treatment - Improve functioning - 2 RCCTS ## Practical points - Assessment of the problem - History as in substances - Motivation - At least initially, an immediate period of total abstinence from gambling. - Supervision of the finances - Temporary control of money by some one trusted - Income in to bank account directly under partner control - Listing debts/outstanding savings/income - Agreeable repayment plan feasible with income to Wied - After reasonable abstinence, gradually incorporating in to financial decisions ## Coping skill group therapy - Congruence couple therapy - to help individuals achieve congruence in internal, interpersonal, intergenerational and spiritual dimensions. - Uncontrolled trials → positive results ## Counselling - Strengthening social relationships/marital harmony - Review leisure time activities in spare time - Avoiding cues initially