Background 7 & Disordered Gambling: The Evolving Concept of Behavioral Addiction, Clark (2014)

Question 1

prevalences of gambling and gambling disorders

Answer 1

87% of the Dutch population has gambled some time in their lives. However, pathological gambling develops for relatively few of these people (1% of people who gamble).

20k pathological gamblers and 90k at-risk.

Question 2

hoeveel gamblers zoeken naar behandeling

Answer 2

It is estimated that less than 10% of problem gamblers seek treatment.

Question 3

wat zijn risicofactoren voor gambling disorders

Answer 3

• male (86%)
• gambling on fruit machines
• pathological gamlers report more mental disorders (especially anxiety & mod-related) and substance abuse.
• disadvantaged neighborhood
• physical proximity to a casino

Question 4

hoeveel mensen hebben overgewicht/obesitas

Answer 4

30% van de populatie (2x zoveel als in 1980)

Question 5

associatie tussen overeten en drug addiction

Answer 5

Neuroscience seems to point to the fact that overeating and obesity are associated with the same brain areas as in drug addiction. Thus, the same psychological and neurobiological mechanisms can play a role.

Question 6

hoe noem je de omgeving waarin obesitas meer gestimuleerd wordt

Answer 6

obesogenic (we are constantly confronted with tasty, high calorie foods through the supermarket and tv commercials).

Question 7

consequences of obesity

Answer 7

• lack of physical exercise
• increased risk of cardiovascular diseases
• diabetes
• joint complaints
• certain types of cancer
• psychological complaints (based on current cultural norms and stigmatization)

Question 8

evolutionary theories of obesity

Answer 8

From an evolutionary perspective, the preference for fatty and sweet food is understandable: there have been a lot of food scarcity periods in which people had to look for energy-rich foods in order to survive. According to evolutionary theories, this has created a brain network that regulates motivation and food-seeking, in which the nucleus accumbens (NAcc) is prominent. These theories even state that it is surprising that not everyone is overweight in our current obesogenic society: it seems that some are more sensitive to the temptation of food.

Question 9

argumenten food addiction

Answer 9

• both are compulsive
• but food does not have the same psychoactive effects as some drugs (but: addiction also does not have those)
• obese people are not a homogenous group, food addiction may only apply to a subset of those (probably those with binge eating disorder)

Question 10

gambling disorder dsm criteria

Answer 10

A. Persistent and recurrent problematic gambling behavior leading to significant impairment or distress, as indicated by the individual exhibiting ≥ 4 of the following in a 12-month period:
1. Needing to gamble with increasing amounts of money to achieve the desired excitement
2. Has made repeated unsuccessful efforts to control, cut back, or stop gambling
3. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
4. Is restless or irritable when attempting to cut down or stop gambling
5. Is often preoccupied with gambling (persistent thoughts of gambling)
6. Often gambles when feeling distressed (helpless, guilty, anxious, depressed)
7. After losing money by gambling, often returns another day to get even
8. Lies to conceal the extent of involvement with gambling
9. Relies on others to provide money to relieve desperate financial situations caused by gambling

B. The gambling behavior is not better explained by a manic episode.

Question 11

severity specifiers for gambling disorder

Answer 11

mild: 4-5
moderate: 6-7
severe: 8-9

Question 12

substance use disorder dsm criteria

Answer 12

A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 of the following in a given year:
1. Tolerance (needing increasing amounts of the substance to receive intoxication or desired effect)
2. There is a persistent desire or unsuccessful efforts to cut down or control the substance use
3. A failure to fulfill major role obligations at work, school, or home because of the substance use
4. The substance is often taken in larger amounts or over a longer period than intended
5. A great deal of time is spent on obtaining, using, or recovering from the substance
6. Craving, or a strong desire or urge to use the substance
7. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by substance’s effects
8. Important social, occupational, or recreational activities are given up or reduced because of substance use
9. Recurrent substance use in situations in which it is physically hazardous
10. Substance use is continued despite knowledge of a persistent or recurrent physical or psychological problem most likely caused or exacerbated by it
11. Withdrawal symptoms, which can be relieved by taking more of the substance

Question 13

overeenkomsten dsm criteria van GD en SUD

Answer 13

GD:

1. Needing to gamble with increasing amounts of money to achieve the desired excitement
2. Has made repeated unsuccessful efforts to control, cut back, or stop gambling
3. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling

SUD:

1. Tolerance (needing increasing amounts of the substance to receive intoxication or desired effect)
2. There is a persistent desire or unsuccessful efforts to cut down or control the substance use
3. A failure to fulfill major role obligations at work, school, or home because of the substance use

Question 14

gambling disorder in the dsm 5

Answer 14

In the DSM-5, gambling disorder was added alongside substance use disorders (SUD) into a chapter called Substance-Related and Addictive Disorders. This reorganization followed scientific evidence about the similarities between gambling disorder and SUD in symptom profile (tolerance, craving, withdrawal), comorbidities, heritability, and brain changes.

Question 15

wat is handig aan het onderzoeken van gokken in het kader van verslavingen

Answer 15

It is well established that chronic drug exposure is associated with neurotoxic effects on the brain. These effects include shrinkage across multiple brain regions. As gambling is unlikely to exert actively damaging effects on the brain, looking into gambling disorder might provide a means of studying the addictive process in the brain that is not disrupted by drug effects.

-> The ‘chicken and egg problem’ in addiction can be investigated in gambling disorder: are identified vulnerability factors the cause of addiction or the result of neurotoxic effects?

Question 16

one factor seems to reflect a predisposition to develop a range of addictive disorders:

Answer 16

impulsivity

Question 17

vulnerability factors for/due to alcohol disorder

Answer 17

By comparing groups with gambling disorder and SUD against nonaddicted controls, impulsivity has been identified as a shared vulnerability factor. An alcohol-dependent group showed additional deficits in response inhibition and spatial working memory. These may therefore reflect alcohol-induced changes in the lateral prefrontal cortex (PFC). Other lines of research have found similar results.

Question 18

wat laten fMRI studies zien in gambling disorder

Answer 18

Pathophysiology within the mesolimbic dopamine system also seems to be central to gambling disorder: fMRI studies have found consistent abnormalities in the striatum, medial PFC, amygdala, and insula. However, some point to a hypoactive system (reward deficiency), while others point to a hyperactive system (sensitization).

Question 19

wat laten PET studies zien in gambling disorder

Answer 19

As fMRI only provides an indirect measure of dopamine transmission, other studies have used PET scans to measure dopamine (D2) receptor binding (reflective of transmission/density). Reduced D2-receptor binding is consistently found in individuals with drug addictions as well as in preclinical models of high impulsivity. Surprisingly, no differences in D2-receptor binding between those with gambling disorder and healthy controls were found, although there were individual differences as a function of impulsivity (higher density was associated with less impulsivity). Another PET study looked at dopamine release in gambling disorder. It showed increased dopamine release in the dorsal striatum for patients with gambling disorder, while previous studies in drug-addicts had found a reduced release of dopamine.

Question 20

dus conclusie over pathofysiologie in gokken vs sud

Answer 20

While dopamine is also implicated in gambling disorder, the pathophysiology appears different from substance addiction. Further, impulsivity seems to be a vulnerability marker for addiction.

Question 21

As we know, drugs of abuse hijack the dopamine system: they are more potent (powerful) than natural rewards at activating the reward system. However, behavioral addictions can only rely on natural or conditioned reinforcement mechanisms.
-> Non-drug behaviors likely require additional ingredients to transition into addicted states.

Evidence has found that rats getting a lever choice between cocaine and sucrose (sugar) reliably opted for the latter, even when chronically using cocaine. Thus, even when drugs are more potent, animals may nevertheless prefer natural rewards.

Answer 21

oke

Question 22

computational model of addiction

Answer 22

a model that emphasizes that drug-induced stimulation of dopamine transmission is exogenous (external cause). That is, for natural rewards there is no more firing to the US over the course of Pavlovian learning (because there is no prediction error): they only fire in response to the CS. In contrast, the dopamine response does not diminish for drug rewards (the drug is the US): by stimulating the dopamine system, drugs of abuse continually elicit a US response next to a CS response, resulting in hyper-learning of drug-associated cues.

Question 23

hoe is pavlovian conditioning te zien in gokken

Answer 23

Comparable Pavlovian processes as for drug-seeking seem to occur in gambling behavior. fMRI results show that patients with gambling disorder show greater brain activity when anticipating gambling rewards (in response to the CS; spinning of the wheels) but reduced activity in response to actual wins.

-> Just as for SUDs, patients with gambling disorder show increased responding to addiction-related cues (CSs). However, they do show reduced responding to actual rewards (US).

Question 24

wat was er aan het geupdated model toegevoegd

Answer 24

• big win hypothesis: many people with gambling disorder retrospectively describe winning big payouts in the first times they ever gambled. this leads to positive prediction errors that will activate the neural systems of reinforcement learning
• asymmetry in temporal-difference learning: financial gains (positive prediction error) promote learning acquisitio, but financial losses (negative prediction errors) do not trigger unlearning, but rather promote hindsight bias (state splitting).

Question 25

hindsight bias in gambling disorder =

Answer 25

explaining away of losses in a manner that does not ruin the players belief in their ability to win.

Question 26

gambling-related cognitive distortions=

Answer 26

systematic errors in processing under conditions of chance.

• illusion of control: thinking one is developing some kind of skill over an outcome that is only determined by chance, by making a choice (which lottery?) or performing an instrumental action (rolling a dice).
• gambler’s fallacy: thinking a random event is less or more likely to happen, based on the outcome of previous events. but past events do not chang the probability of a certain outcome.

Question 27

near misses=

Answer 27

outcomes that are perceived as having been close to a win, but that are in fact objective losses. most gambling games deliver purposeful near misses, these are played longer than machines that deliver none. near misses are perceived to be more aversive than complete misses (bij bv fruit machines), but do increase the desire to keep on playing. near misses may fuel the illusion of control in these games, where outcomes are actually random.

Question 28

near misses in the brain

Answer 28

anterior insula shows overlapping activity to wins and near misses. near misses increase neral signal in brain reward circuitries, compared to full misses.

Question 29

gambling and the insula experiment

Answer 29

Participants with lesions to the insula (G1), the ventromedial PFC (G2), the amygdala (G3), or no-lesions (controls) performed 2 different gambling tasks. Results showed that:
- G2, G3 & controls: enhanced motivation to play following near misses and gambler’s fallacy.
- Insula lesions: no enhanced motivation following near misses and no gambler’s fallacy.

-> The insula seems to be causally involved in cognitive distortions in gambling addiction.

Question 30

Gambling disorder is currently the only behavioral addiction in the DSM-V. However, other conditions have been marked for further research (internet gaming, obesity).

Answer 30

oke

Question 31

a common concern with behavioural addiction is…

Answer 31

how to avoid everyday passions from being gradually pathologized as addictions.

Question 32

wat is een argument voor dat obesity een food addiction zou moeten zijn

Answer 32

• Drug self-administration experiments in animals show comparable phenomena for food rewards. Reduced D2-receptor density was found in nondrug users with high body mass index (BMI) and fMRI studies show similar profiles to studies in drug addiction and gambling disorder.
• Further, there is a persistent bias towards an option of immediate gratification with long-term negative consequences (body shape, physical health).
• In contrast, binge-eating does not evidently involve prediction-error signaling distortions or deficits in chance processing as in gambling disorders.

Question 33

CBT for gambling disorder: deze componenten zijn belangrijk

Answer 33

• Focus on the clients’ request for help and their motivation to achieve their goal.
• Psychoeducation on the nature and characteristics of pathological gambling.
• Functional analysis to identify both the triggering and sustaining factors of gambling. These factors largely determine treatment interventions and their sequence (such as learning self-control mechanisms, training skills, etc.).
• Exerting ‘stimulus control’ to stop gambling and regain control over the behaviour in the short term. These measures include, for example, reducing the availability of money, banning them from access to casinos or a gambling hall, using a filter to prevent online gambling, and transferring their finances to a significant other. This also includes increasing the rewarding value of alternative, pleasurable activities.
• Challenging “gambling illusions” or irrational thoughts.
• Relapse prevention, which aims to train patients to identify high-risk situations for relapse, such as social pressure, negative emotions (e.g., anxiety, depression, and anger), and interpersonal conflict, and to provide appropriate strategies for dealing with problematic situations.