Problem Gambling

Question 1

Requirements for getting diagnosed with a gambling disorder

Answer 1

• At least 4 of the following 9 criteria:
• • Pre-occupied with gambling
• • Needs to gamble with increasing amounts (tolerance)
• • Repeated attempts to reduce or quit gambling
• • Restless or irritable when attempting to stop gambling (withdrawal)
• • Gambles as means of escape or to alleviate low mood
• • Frequently returns to get even (loss chasing)
• • Lies to conceal involvement
• • Jeopardised / lost relationship or job due to gambling
• • Forced to borrow money due to gambling debt
• Not better explained by manic episode

Question 2

all gambling disorder criterion items are not equal: examples

Answer 2

• Ex. Loss chasing is too sensitive, and too many non-problem gamblers endorse it
• Ex. Illegal acts (which has now been dropped) is insensitive, and is only endorsed by gamblers who already meet diagnosis
• Ex. Withdrawal symptoms is just right

Question 3

research on withdrawal

Answer 3

• Wray and Dickerson (1981) found psychological withdrawal symptoms from gambling were common
• Rosenthal and Lesieur (1992) found 2/3 gamblers reported more than 1 somatic withdrawal symptom

Question 4

evidence for re-classification

Answer 4

• DSM-5 task force cited 5 lines of evidence that make people with gambling addiction look like people with substance abuse disorders:
• • Symptom hallmarks (withdrawal, tolerance)
• • Comorbidities
• • Shared heritability/genetics
• • Neuroimaging/neurocognitive similarities
• • Effective treatments

Question 5

assessments of problem gambling

Answer 5

• DSM diagnosis involves a face-to-face interview with a clinician
• We need short, self-report instruments for problem gambling:
• ex. South Oaks Gambling Screen
• ex. Problem gambling severity index

Question 6

South Oaks gambling screen

Answer 6

• Based on DSM-III
• Probable pathological gambling score >5
• Uses lifetime statements (“have you ever…”)

Question 7

Problem gambling severity index

Answer 7

• Becoming “gold standard” measure
• Just asks about the last year of your life (“In the past 12 months…”)
• Uses rankings from 0 (never) to 3 (almost always), total scores
• • 1-2 = low-risk
• • 3-7 = moderate risk
• • 8+ = problem gambling
• Limitation: very reliant on money –> time could also be an indicator of problem gambling

Question 8

prevalence data: worldwide

Answer 8

• Problem gamblers (those who don’t quite meet threshold for psychiatric diagnosis) tend to be about 3-4% of population worldwide
• Pathological gamblers tend to be 1-3% of population worldwide
• However, Australia’s rates are higher

Question 9

accessibility vs. adaptation

Answer 9

• As gambling access increases, rates of problem gambling typically rise –> “accessibility”
• But in Canada, rates are now dropping –> is society adapting to gambling expansion and increased availability?

Question 10

gambling regulation and gambling harms

Answer 10

• A “sweet spot” exists between prohibiting gambling and unregulated expansion –> regulation can typically keep harms under control
• The U-shaped curve

Question 11

Prevalence data: British Columbia

Answer 11

• 72.5% of British Columbians gamble
• 61% of people who’ve gambled in the last year are classified (based on PGSI) as non-problem
• 27% are non-gamblers
• 8% are low-risk problem gamblers
• 3% are moderate problem gamblers
• 1% are high-risk problem gamblers
• 2008 prevalence survey showed 4.6% problem gamblers, so rate of PG may have dropped

Question 12

demographic predictors of gambling in prevalence surveys

Answer 12

• problem gamblers more like to be:
• • male
• • younger age
• • lower SES
• • belong to ethnic minority (ie. First Nations)
• • experience other mental health problems

Question 13

comorbidity and problem gambling

Answer 13

• Pathological gambling 0.6%
• People with 1+ symptom of problem gambling 2.3%
• Substance use disorders, anxiety disorders, mood disorders most prevalent in this populations

Question 14

temporal ordering

Answer 14

Anxiety & Mood Disorders often occur before the gambling problem -> Gambling to cope / escape negative emotions?

Question 15

age when gambling started

Answer 15

• Problem gamblers tend to be involved in gambling much earlier than everyone else –> often during teenage years
• • Before age 21 (legal US age), 80% of problem gamblers have already started
• Gambling Disorder – as well as drug addictions – can be regarded as developmental disorders

Question 16

genes or environment? Results of Vietnam war veteran twin study

Answer 16

• 1.4% had problem gambling; 6% had subclinical levels
• Problem gambling heritability: 40-50% (estimated from MZ-DZ disparity)
• Overlap in genetics of PG and alcohol dependence: 12-20%
• Leaves 50-60% responsibility from environment

Question 17

environmental risk factors for gambling

Answer 17

• Exposure to parental gambling in childhood/adolescence
• • Stronger than effects of gambling alone
• • Stronger for paternal gambling
• Childhood adversity
• • In youth pathological gamblers, 20% reported physical abuse, 18% sexual abuse
• • In adult sample, 61% reported childhood maltreatment
• Critical role of gene x environment interactions

Question 18

neurocognitive changes

Answer 18

• Problem gamblers were unimpaired on Wisconsin Card Sort task (measure of executive function)
• However, show deficiencies in things like Iowa gambling task (as previously discussed)

Question 19

fMRI of reward in problem gambling

Answer 19

• Task: picking cards randomly, if you get red you win money, if you get black you lose money
• Win-related activity in healthy group shows huge brain response; response is significantly weaker in group with gambling problems (use name network, but activation low)
• • This is correlated with how severe their gambling problem was

Question 20

fMRI to natural rewards

Answer 20

• Straight men given cue indicating whether they’re about to get a monetary or erotic reward
• • Study of how quickly they respond to cues -> control group responds similarly to money and erotic rewards; gamblers respond faster to monetary cues (money matters more to them)
• • Activation of ventral striatum only activated for money in problem gamblers; but activated for money and erotic rewards in control

Question 21

Dopamine binding (Volkow)

Answer 21

reduced dopamine D2 binding in drug abusers preferring various different substances

Question 22

gambling in parkinson’s disease

Answer 22

• Dopamine agonist meds can trigger excessive gambling
• Most linked to 2 drugs: pramipexole & ropinirole, that bind to D3 receptors
• Constellation with other impulse control / reward problems (hypersexuality, shopping)

Question 23

3 main points

Answer 23

• Gambling Disorder has both genetic and environmental risk factors
• Cognitive and brain imaging data indicate:
• • involvement of vmPFC and ventral striatum
• • similarities with Substance Use Disorders (but also some differences, e.g. drugs can have additional toxic effects)
• Complex evidence for both reward deficiency and incentive salience as key theories from drug addiction