Decision-making during gambling: an integration of cognitive and psychobiological approaches

The impact of comorbid impulsive/compulsive disorders in problematic Internet use

Background and aims Problematic Internet use (PIU) is commonplace but is not yet recognized as a formal mental disorder. Excessive Internet use could result from other conditions such as gambling disorder. The aim of the study was to assess the impact of impulsive-compulsive comorbidities on the presentation of PIU, defined using Young's Diagnostic Questionnaire. Methods A total of 123 adults aged 18-29 years were recruited using media advertisements, and attended the research center for a detailed psychiatric assessment, including interviews, completion of questionnaires, and neuropsychological testing. Participants were classified into three groups: PIU with no comorbid impulsive/compulsive disorders (n = 18), PIU with one or more comorbid impulsive/compulsive disorders (n = 37), and healthy controls who did not have any mental health diagnoses (n = 67). Differences between the three groups were characterized in terms of demographic, clinical, and cognitive variables. Effect sizes for overall effects of group were also reported. Results The three groups did not significantly differ on age, gender, levels of education, nicotine consumption, or alcohol use (small effect sizes). Quality of life was significantly impaired in PIU irrespective of whether or not individuals had comorbid impulsive/compulsive disorders (large effect size). However, impaired response inhibition and decision-making were only identified in PIU with impulsive/compulsive comorbidities (medium effect sizes). Discussion and conclusions Most people with PIU will have one or more other impulsive/compulsive disorders, but PIU can occur without such comorbidities and still present with impaired quality of life. Response inhibition and decision-making appear to be disproportionately impacted in the case of PIU comorbid with other impulsive/compulsive conditions, which may account for some of the inconsistencies in the existing literature. Large scale international collaborations are required to validate PIU and further assess its clinical, cognitive, and biological sequelae.

Gender differences in temporal relationships between gambling urge and cognitions in treatment-seeking adults

Many gambling-specific CBT programs seek to target either gambling-related urge or cognitions or both. However, little is known of the influence of one symptom type on another across time and whether these differ for men and women help-seeking problem gamblers. The aim of this study was threefold: to determine presence of measurement invariance for urge and cognition measures over time; to investigate the effect of baseline urge on end-of-treatment gambling-related cognitions - and the reciprocal relationship; and, identify whether these pathways differ across gender. Self-reported gambling urge (GUS), and gambling-related cognitions (GRCS) data from treatment-seeking problem gamblers prior to and post treatment (N = 223; 62% men) were analyzed with cross-lagged panel models, moderated by gender. Conceptualization of urge and cognitions were found to be temporally stable. There was no significant association between baseline GUS scores and post-treatment GRCS scores, nor the reverse relationship. Putatively, this infers that coexisting urge and gambling-related cognition components of problem gambling operate independently over time. Analyses revealed gambling urge had a significantly stronger tracking correlation across time for men than women when adjusting for cognition paths. This investigation provides early evidence for tailoring CBT in response to sub-population gambling-related characteristics, demonstrated across men and women.

Cognitive distortions and gambling near-misses in Internet Gaming Disorder: A preliminary study

Increased cognitive distortions (i.e. biased processing of chance, probability and skill) are a key psychopathological process in disordered gambling. The present study investigated state and trait aspects of cognitive distortions in 22 individuals with Internet Gaming Disorder (IGD) and 22 healthy controls. Participants completed the Gambling Related Cognitions Scale as a trait measure of cognitive distortions, and played a slot machine task delivering wins, near-misses and full-misses. Ratings of pleasure (“liking”) and motivation to play (“wanting”) were taken following the different outcomes, and gambling persistence was measured after a mandatory phase. IGD was associated with elevated trait cognitive distortions, in particular skill-oriented cognitions. On the slot machine task, the IGD group showed increased “wanting” ratings compared with control participants, while the two groups did not differ regarding their “liking” of the game. The IGD group displayed increased persistence on the slot machine task. Near-miss outcomes did not elicit stronger motivation to play compared to full-miss outcomes overall, and there was no group difference on this measure. However, a near-miss position effect was observed, such that near-misses stopping before the payline were rated as more motivating than near-misses that stopped after the payline, and this differentiation was attenuated in the IGD group, suggesting possible counterfactual thinking deficits in this group. These data provide preliminary evidence for increased incentive motivation and cognitive distortions in IGD, at least in the context of a chance-based gambling environment.

Gambling-Related Distortions and Problem Gambling in Adolescents: A Model to Explain Mechanisms and Develop Interventions

Although a number of gambling preventive initiatives have been realized with adolescents, many of them have been developed in absence of a clear and explicitly described theoretical model. The present work was aimed to analyze the adequacy of a model to explain gambling behavior referring to gambling-related cognitive distortions (Study 1), and to verify the effectiveness of a preventive intervention developed on the basis of this model (Study 2). Following dual-process theories on cognitive functioning, in Study 1 we tested a model in which mindware gap, i.e., susceptibility to the gambler's fallacy, and contaminated mindware, i.e., superstitious thinking, were the antecedents of gambling-related cognitive distortions that, in turn, affect gambling frequency and problem gambling. Participants were 306 male adolescents (Mage = 17.2 years). A path analysis indicated that cognitive distortions have a mediating role in the relationship that links probabilistic reasoning fallacy and superstitious thinking with problem gambling. Following these findings, in Study 2 we developed a school-based intervention aimed to reduce gambling-related cognitive distortions acting on the above cited mindware problems. A pre- and post-test design - with a 6 months follow-up - was performed with 34 male adolescents (Mage = 16.8), randomly assigned to two groups (Training and No Training), and their baseline equivalence was verified. A Mixed 2 × 2 ANOVA attested a significant Time X Group interaction, indicating a significant reduction of the cognitive distortions from pre-test to post-test only in the Training group. The follow-up attested to the stability of the training effects and the reduction of gambling frequency over time. These findings suggest that prevention strategies should address mindware problems, which can be considered as predictors of gambling-related cognitive distortions.

Sub-clinical Alcohol Consumption and Gambling Disorder

While it is well established that gambling disorder is associated with alcohol use disorder, less is known regarding whether sub-clinical alcohol consumption increases gambling behavior. This study examined the effects of varying levels of alcohol consumption on clinical and cognitive measures. The sample consisted of 572 non-treatment seeking gamblers age 18-29 who were divided into three groups: non-current drinkers, current drinkers who did not qualify for an alcohol use disorder, and those with an alcohol use disorder (AUD). All subjects were assessed on gambling pathology, severity and impulsivity using the Structured Clinical Interview for Gambling Disorder, Yale Brown Obsessive Compulsive Scale for Pathologic Gambling and the Barratt Impulsive Scale-11 and select cognitive tests. In all of the clinical measures, controlling for age, gender and education, the AUD group was significantly more likely than the non-current and current drinkers to be a pathologic gambler and to be impulsive, compulsive and depressed. On cognitive tasks, controlling for age, gender and education, the AUD group had significantly worse strategy use on a spatial working memory task than both other groups. This study suggests that the relationship between alcohol and gambling may only exist when pathology in both alcohol consumption and gambling behavior is present. Examining this relationship with alcohol consumption as a continuous variable would provide additional insight into the potential effects alcohol consumption has on gambling behavior.

How does routinely delivered cognitive-behavioural therapy for gambling disorder compare to "gold standard" clinical trial?

Currently, it is unknown whether treatment outcomes derived from randomized controlled trials (RCTs) of cognitive-behavioural therapy (CBT) for problem gamblers still hold when applied to patients seen in routine practice. Thus, data from an RCT of cognitive therapy versus exposure therapy for problem gambling versus patients of a gambling help service were compared. Assessments of problem gambling severity, psychosocial impairment, and alcohol use were undertaken at baseline and post-treatment and evaluated within a counterfactual framework. Findings showed that the contrast between routine CBT for pokies and horse betting had a significant effect, indicative of a 62% lower gambling urge score if routine CBT recipients had all been horse/track betters opposed to gambling with "pokies." However, the majority of contrasts indicated therapeutic outcomes achieved in routine CBT treatments were of equivalent robustness relative to RCT conditions. The present findings infer routine practice treatment outcomes are as efficacious as those generated in RCT contexts.

An Analysis of Treatment-Seeking Behavior in Individuals with Gambling Disorder

Gambling disorder affects approximately 1.1-3.5% of the population, with the rates being higher in young adults. Despite this high prevalence, little is known regarding which pathological gamblers decide to seek treatment. This study sought to examine the differences in three groups of pathological gamblers: those who did not seek treatment (n = 94), those who sought therapy (n = 106) and those who sought medication therapy (n = 680). All subjects were assessed on a variety of measures including demographics, family history, gambling history, comorbid psychiatric disorders and an assortment of clinical variables such as the Quality of Life Inventory, Hamilton Depression and Anxiety Rating Scales, Yale Brown Obsessive Compulsive Scale for Pathologic Gambling (PG-YBOCS), Barratt Impulsiveness Scale, Eysenck Impulsiveness Questionnaire and select cognitive tasks. Those seeking treatment were more likely to be Caucasian, have lost more money in the past year due to gambling, and were more likely to have legal and social problems as a result of their gambling. Those seeking therapy or medical treatment also scored significantly higher on the PG-YBOCS. This study suggests that pathologic gamblers seeking treatment were more likely to exhibit obsessive-compulsive tendencies likely leading to the increased legal and social problems that exist in this group.

Latent class analysis of gambling subtypes and impulsive/compulsive associations: Time to rethink diagnostic boundaries for gambling disorder?

Background

Gambling disorder has been associated with cognitive dysfunction and impaired quality of life. The current definition of non-pathological, problem, and pathological types of gambling is based on total symptom scores, which may overlook nuanced underlying presentations of gambling symptoms. The aims of the current study were (i) to identify subtypes of gambling in young adults, using latent class analysis, based on individual responses from the Structured Clinical Interview for Gambling Disorder (SCI-GD); and (ii) to explore relationships between these gambling subtypes, and clinical/cognitive measures.

Methods

Total 582 non-treatment seeking young adults were recruited from two US cities, on the basis of gambling five or more times per year. Participants undertook clinical and neurocognitive assessment, including stop-signal, decision-making, and set-shifting tasks. Data from individual items of the Structured Clinical Interview for Gambling Disorder (SCI-GD) were entered into latent class analysis. Optimal number of classes representing gambling subtypes was identified using Bayesian Information Criterion and differences between them were explored using multivariate analysis of variance.

Results

Three subtypes of gambling were identified, termed recreational gamblers (60.2% of the sample; reference group), problem gamblers (29.2%), and pathological gamblers (10.5%). Common quality of life impairment, elevated Barratt Impulsivity scores, occurrence of mainstream mental disorders, having a first degree relative with an addiction, and impaired decision-making were evident in both problem and pathological gambling groups. The diagnostic item ‘chasing losses’ most discriminated recreational from problem gamblers, while endorsement of ‘social, financial, or occupational losses due to gambling’ most discriminated pathological gambling from both other groups. Significantly higher rates of impulse control disorders occurred in the pathological group, versus the problem group, who in turn showed significantly higher rates than the reference group. The pathological group also had higher set-shifting errors and nicotine consumption.

Conclusions

Even problem gamblers who had a relatively low total SCI-PG scores (mean endorsement of two items) exhibited impaired quality of life, objective cognitive impairment on decision-making, and occurrence of other mental disorders that did not differ significantly from those seen in the pathological gamblers. Furthermore, problem/pathological gambling was associated with other impulse control disorders, but not increased alcohol use. Groups differed on quality of life when classified using the data-driven approach, but not when classified using DSM cut-offs. Thus, the current DSM-5 approach will fail to discriminate a significant fraction of patients with biologically plausible, functionally impairing illness, and may not be ideal in terms of diagnostic classification. Cognitive distortions related to ‘chasing losses’ represent a particularly important candidate treatment target for early intervention.

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Current classification of gambling pathology relies on total number of criteria met for gambling disorder (DSM-5)

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This approach can be seen as somewhat arbitrary and may overlook meaningful gambling subtypes

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Latent class analysis (LCA) was used to identify candidate subtypes of gambling in 582 gamblers.

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Compared to the reference class, both problem gamblers and gambling disorder classes showed relatively impaired quality of life, and more psychiatric morbidity.

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Both problem gamblers and gambling disorder classes also showed higher impulsivity scores and impaired decision-making.

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LCA classification was sensitive to group quality of life differences, whereas DSM-5 classification was not.

Deciphering Decision Making: Variation in Animal Models of Effort- and Uncertainty-Based Choice Reveals Distinct Neural Circuitries Underlying Core Cognitive Processes

Maladaptive decision-making is increasingly recognized to play a significant role in numerous psychiatric disorders, such that therapeutics capable of ameliorating core impairments in judgment may be beneficial in a range of patient populations. The field of "decision neuroscience" is therefore in its ascendancy, with researchers from diverse fields bringing their expertise to bear on this complex and fascinating problem. In addition to the advances in neuroimaging and computational neuroscience that contribute enormously to this area, an increase in the complexity and sophistication of behavioral paradigms designed for nonhuman laboratory animals has also had a significant impact on researchers' ability to test the causal nature of hypotheses pertaining to the neural circuitry underlying the choice process. Multiple such decision-making assays have been developed to investigate the neural and neurochemical bases of different types of cost/benefit decisions. However, what may seem like relatively trivial variation in behavioral methodologies can actually result in recruitment of distinct cognitive mechanisms, and alter the neurobiological processes that regulate choice. Here we focus on two areas of particular interest, namely, decisions that involve an assessment of uncertainty or effort, and compare some of the most prominent behavioral paradigms that have been used to investigate these processes in laboratory rodents. We illustrate how an appreciation of the diversity in the nature of these tasks can lead to important insights into the circumstances under which different neural regions make critical contributions to decision making.

Cognitive distortions among older adult gamblers in an Asian context

Aims

The study aims to describe the construct of cognitive distortions based on the narratives of older adult gamblers (aged 60 years and above) in Singapore.

Methods

Singapore residents (citizens or permanent residents) aged 60 years and above, who were current or past regular gamblers were included in the study. Participants were recruited using a combination of venue based approach, referrals from service providers as well as by snowball sampling. In all, 25 in-depth interviews were conducted with older adult gamblers. The six-step thematic network analysis methodology was adopted for data analysis.

Results

The mean age of the participants was 66.2 years. The majority were male (n = 18), of Chinese ethnicity (n = 16), with a mean age of gambling initiation at 24.5 years. Among older adult gamblers, cognitive distortions emerged as a significant global theme comprising three organizing themes–illusion of control, probability control and interpretive control. The organizing themes comprised nine basic themes: perception of gambling as a skill, near miss, concept of luck, superstitious beliefs, entrapment, gambler’s fallacy, chasing wins, chasing losses, and beliefs that wins are more than losses.

Conclusions

Cognitive distortions were endorsed by all gamblers in the current study and were shown to play a role in both maintaining and escalating the gambling behaviour. While the surface characteristics of the distortions had a culture-specific appearance, the deeper characteristics of the distortions may in fact be more universal than previously thought. Future research must include longitudinal studies to understand causal relationships between cognitive distortions and gambling as well as the role of culture-specific distortions both in the maintenance and treatment of the disorder.

Gambling disorder: an integrative review of animal and human studies

Gambling disorder (GD), previously called pathological gambling and classified as an impulse control disorder in DSM-III and DSM-IV, has recently been reclassified as an addictive disorder in the DSM-5. It is widely recognized as an important public health problem associated with substantial personal and social costs, high rates of psychiatric comorbidity, poor physical health, and elevated suicide rates. A number of risk factors have been identified, including some genetic polymorphisms. Animal models have been developed in order to study the underlying neural basis of GD. Here, we discuss recent advances in our understanding of the risk factors, disease course, and pathophysiology. A focus on a phenotype-based dissection of the disorder is included in which known neural correlates from animal and human studies are reviewed. Finally, current treatment approaches are discussed, as well as future directions for GD research.

Confirmatory factor analysis of the Spanish version of the Gamblers' Beliefs Questionnaire in a sample of Argentinean gamblers

INTRODUCTION

Cognitive distortions are related to gambling frequency and gambling severity. Having a culturally sensitive measure to assess cognitive distortions will facilitate the early detection of people who might be at risk of developing problematic gambling behaviors. The Gamblers' Beliefs Questionnaire was translated into Spanish (GBQ-S) but no previous study explored the structure of the GBQ-S in a non-US sample with different levels of gambling involvement.

AIM

The present study examined the factor structure of the GBQ-S in a community sample of gamblers from Argentina. It also analyzed the association between cognitive distortions and type of gambling activity and frequency of gambling behaviors and the predictive utility of the GBQ-S on gambling severity.

PARTICIPANTS

508 youth and adults completed the GBQ-S.

RESULTS

The CFA showed an overall acceptable fit to the data confirming the proposed two-factor model. Scores of the two GBQ sub-scales were positively and significantly correlated with scores on gambling severity. Cognitive distortions have a significant effect on gambling severity after controlling for frequency of engagement in gambling activities. Luck and perseverance, but not illusion of control, was positively related to gambling severity.

DISCUSSION

scores measured by the GBQ-S exhibit adequate psychometric properties for the accurate assessment of cognitive distortions across adults and youth from the general community of Argentina.

Winning and losing: Effects on impulsive action

In the present study, we examined the effect of wins and losses on impulsive action in gambling (Experiments 1-3) and nongambling tasks (Experiments 4-5). In each experiment, subjects performed a simple task in which they had to win points. On each trial, they had to choose between a gamble and a nongamble. The gamble was always associated with a higher amount but a lower probability of winning than the nongamble. After subjects indicated their choice (i.e., gamble or not), feedback was presented. They had to press a key to start the next trial. Experiments 1-3 showed that, compared to the nongambling baseline, subjects were faster to initiate the next trial after a gambled loss, indicating that losses can induce impulsive actions. In Experiments 4 and 5, subjects alternated between the gambling task and a neutral decision-making task in which they could not win or lose points. Subjects were faster in the neutral decision-making task if they had just lost in the gambling task, suggesting that losses have a general effect on action. Our results challenge the dominant idea that humans become more cautious after suboptimal outcomes. Instead, they indicate that losses in the context of potential rewards are emotional events that increase impulsivity. (PsycINFO Database Record

Amplified Striatal Responses to Near-Miss Outcomes in Pathological Gamblers

Near-misses in gambling games are losing events that come close to a win. Near-misses were previously shown to recruit reward-related brain regions including the ventral striatum, and to invigorate gambling behavior, supposedly by fostering an illusion of control. Given that pathological gamblers are particularly vulnerable to such cognitive illusions, their persistent gambling behavior might result from an amplified striatal sensitivity to near-misses. In addition, animal studies have shown that behavioral responses to near-miss-like events are sensitive to dopamine, but this dopaminergic influence has not been tested in humans. To investigate these hypotheses, we recruited 22 pathological gamblers and 22 healthy controls who played a slot machine task delivering wins, near-misses and full-misses, inside an fMRI scanner. Each participant played the task twice, once under placebo and once under a dopamine D2 receptor antagonist (sulpiride 400 mg), in a double-blind, counter-balanced design. Participants were asked about their motivation to continue gambling throughout the task. Across all participants, near-misses elicited higher motivation to continue gambling and increased striatal responses compared with full-misses. Crucially, pathological gamblers showed amplified striatal responses to near-misses compared with controls. These group differences were not observed following win outcomes. In contrast to our hypothesis, sulpiride did not induce any reliable modulation of brain responses to near-misses. Together, our results demonstrate that pathological gamblers have amplified brain responses to near-misses, which likely contribute to their persistent gambling behavior. However, there is no evidence that these responses are influenced by dopamine. These results have implications for treatment and gambling regulation.

The agranular and granular insula differentially contribute to gambling-like behavior on a rat slot machine task: effects of inactivation and local infusion of a dopamine D4 agonist on reward expectancy

RATIONALE

Rats, like humans, are susceptible to the reinforcing effects of reward-related stimuli presented within a compound stimulus array, putatively analogous to the so-called near-miss effect. We have previously demonstrated using a rodent slot machine task (rSMT) that the reward expectancy these stimuli elicit is critically mediated by the dopamine D4 receptor. D4 receptors are principally located in prefrontal regions activated during slot machine play in humans, such as the insular cortex. The insula has recently attracted considerable interest as it appears to play a crucial role in substance and behavioral addictions. However, the insula is a heterogeneous area, and the relative contributions of subregions to addictive behaviors are unclear.

METHODS

Male Long Evans rats were trained to perform the rSMT, and then bilateral cannula targeting either the granular or agranular insula were implanted. The effects of inactivation and local administration of a D4 agonist were investigated.

RESULTS

Temporary inactivation of the agranular, but not the granular insula impaired performance on the rSMT. In contrast, local infusion of the D4 agonist PD168077 into the agranular insula had no effect on task performance, but when administered into the granular insula, it improved animals' ability to differentiate winning from non-winning trials. The agranular insula may therefore modulate decision making when conflicting stimuli are present, potentially due to its role in generating a cohesive emotional percept based on both externally and internally generated signals, whereas the granular insular is not critical for this process. Nevertheless, D4 receptors within the granular insula may amplify the incentive salience of aversive environmental stimuli.

DISCUSSION

These data provide insight into the neurobiological mechanism underpinning maladaptive reward expectancy during gambling and provide further evidence that D4 receptors represent a potential target for developing pharmacotherapies for problem gambling.

Racial-ethnic related clinical and neurocognitive differences in adults with gambling disorder

Recent epidemiological data suggest that the lifetime prevalence of gambling problems differs depending on race-ethnicity. Understanding variations in disease presentation in blacks and whites, and relationships with biological and sociocultural factors, may have implications for selecting appropriate prevention strategies. 62 non-treatment seeking volunteers (18-29 years, n=18 [29.0%] female) with gambling disorder were recruited from the general community. Black (n=36) and White (n=26) participants were compared on demographic, clinical and cognitive measures. Young black adults with gambling disorder reported more symptoms of gambling disorder and greater scores on a measure of compulsivity. In addition they exhibited significantly higher total errors on a set-shifting task, less risk adjustment on a gambling task, greater delay aversion on a gambling task, and more total errors on a working memory task. These findings suggest that the clinical and neurocognitive presentation of gambling disorder different between racial-ethnic groups.

Chronic D2/3 agonist ropinirole treatment increases preference for uncertainty in rats regardless of baseline choice patterns

D_2/3 receptor agonists are effective treatments for Parkinson's disease (PD), but can precipitate impulse control disorders (ICDs) including gambling disorder (GD). The neurobiological mechanisms underlying this devastating side-effect of dopamine agonist replacement therapy (DRT), and any dependence on the dopamine depletion caused by PD, are unclear. It is also unclear whether previous biases towards risk or uncertainty are a risk factor for developing these ICDs. We investigated whether chronic D_2/3 agonist administration (5 mg/kg/day ropinirole for 28 days) altered performance of a rat model of gambling-like behaviour, the rodent betting task (rBT), and examined if baseline behaviour predicted this behavioural change. The rBT captures individual differences in subjective preference for uncertain outcomes: animals choose between guaranteed or probabilistic reinforcement of equal expected value. Chronic ropinirole dramatically increased selection of the uncertain option in two-thirds of animals, regardless of baseline preferences. The effect on choice in the rBT was replicated in a dorsolateral striatal 6-hydroxydopamine (6-OHDA) rat model of early PD. These studies are the first to look at individual differences in response to chronic, rather than pulsatile, dosing of DRT in a rodent model of gambling behaviour. These findings suggest that DRT-induced PG may stem from increases in subjective valuation of uncertainty. Such symptoms likely arise because of changes in dopaminergic striatal signalling caused by DRT rather than from an interaction between pre-morbid behaviours or PD itself.

Anxiety, Gambling Activity, and Neurocognition: A Dimensional Approach to a Non-Treatment-Seeking Sample

Background and aims Previous analyses have highlighted significant associations between gambling disorder (GD)/subsyndromal GD and increased rates of anxiety symptoms and anxiety disorders relative to the general population. However, less is known about how anxiety symptoms influence the clinical presentation of gambling problems. The objective of this study was to evaluate the association between anxiety symptoms, gambling activity, and neurocognition across the spectrum of gambling behavior. Methods The sample consisted of 143 non-treatment-seeking young adults (aged 18-29 years), in which 63 individuals (44.1%) were classified as recreational gamblers, 47 (32.9%) as having subsyndromal GD, and 33 (23.1%) met criteria for GD. Results The main findings were: (a) there was a positive correlation between anxiety severity and gambling severity measured by the number of DSM-5 GD criteria met; (b) there was a positive correlation between anxiety severity and attentional impulsiveness; (c) subjects with suicidality presented higher levels of anxiety; and (d) the severity of anxiety symptoms was negatively correlated with the quality of life. Discussion and conclusions This study suggests that anxiety may be associated with relevant clinical variables in the broad spectrum of gambling activity. Therefore, proper management of anxiety symptoms might improve the clinical presentation of gamblers in different areas.

Exploring the measurement structure of the Gambling Related Cognitions Scale (GRCS) in treatment-seekers: A Bayesian structural equation modelling approach

Knowledge of a problem gambler's underlying gambling related cognitions plays an important role in treatment planning. The Gambling Related Cognitions Scale (GRCS) is therefore frequently used in clinical settings for screening and evaluation of treatment outcomes. However, GRCS validation studies have generated conflicting results regarding its latent structure using traditional confirmatory factor analyses (CFA). This may partly be due to the rigid constraints imposed on cross-factor loadings with traditional CFA. The aim of this investigation was to determine whether a Bayesian structural equation modelling (BSEM) approach to examination of the GRCS factor structure would better replicate substantive theory and also inform model re-specifications. Participants were 454 treatment-seekers at first presentation to a gambling treatment centre between January 2012 and December 2014. Model fit indices were well below acceptable standards for CFA. In contrast, the BSEM model which included small informative priors for the residual covariance matrix in addition to cross-loadings produced excellent model fit for the original hypothesised factor structure. The results also informed re-specification of the CFA model which provided more reasonable model fit. These conclusions have implications that should be useful to both clinicians and researchers evaluating measurement models relating to gambling related cognitions in treatment-seekers.

Inactivation of the orbitofrontal cortex reduces irrational choice on a rodent Betting Task

Cognitive biases may play a significant role in disorders of decision making such as pathological gambling and addiction. Understanding the neurobiology of these biases could lead to more effective pharmacological and therapeutic treatments for disorders in which aberrant decision making is prominent. The rodent Betting Task (rBT) was designed to measure one commonly observed decision-making heuristic in rodents, namely "escalation of commitment" in which subjects become more risk averse as the stakes increase, even if the odds of success remain constant. In the rodent task, the animal is presented with a choice between two options of equivalent expected value, such that reward on one option is guaranteed while the other has a 50% chance of double the prize or nothing. Past work has shown that a subset of animals (termed wager sensitive) adopt an irrationally risk-averse choice preference in which they shift their choice away from the uncertain option as the bet size grows larger. In the current study, the orbitofrontal (OFC), prelimbic (PrL), and infralimbic cortex (IL) were inactivated to evaluate the contributions made by these regions to choice behavior on the rBT. Inactivation of the OFC (but not the IL or the PrL) selectively ameliorated the risk-averse choice pattern characteristic of wager-sensitive animals. This finding suggests that the OFC may have a relatively unique role in promoting this type of non-normative decision-making under uncertainty, an effect that is potentially related to its role in representing the subjective value of reinforcing outcomes.

Aberrant neural signatures of decision-making: Pathological gamblers display cortico-striatal hypersensitivity to extreme gambles

Pathological gambling is an addictive disorder characterized by an irresistible urge to gamble despite severe consequences. One of the hallmarks of pathological gambling is maladaptive and highly risky decision-making, which has been linked to dysregulation of reward-related brain regions such as the ventral striatum. However, previous studies have produced contradictory results regarding the implication of this network, revealing either hypo- or hypersensitivity to monetary gains and losses. One possible explanation is that the gambling brain might be misrepresenting the benefits and costs when weighting the potential outcomes, and not the gains and losses per se. To address this issue, we investigated whether pathological gambling is associated with abnormal brain activity during decisions that weight the utility of possible gains against possible losses. Pathological gamblers and healthy human subjects underwent functional magnetic resonance imaging while they accepted or rejected mixed gain/loss gambles with fifty-fifty chances of winning or losing. Contrary to healthy individuals, gamblers showed a U-shaped response profile reflecting hypersensitivity to the most appetitive and most aversive bets in an executive cortico-striatal network including the dorsolateral prefrontal cortex and caudate nucleus. This network is concerned with the evaluation of action-outcome contingencies, monitoring recent actions and anticipating their consequences. The dysregulation of this specific network, especially for extreme bets with large potentials consequences, offers a novel understanding of the neural basis of pathological gambling in terms of deficient associations between gambling actions and their financial impact.

Experiences and Perceptions of Problem Gamblers on Cognitive and Exposure Therapies When Taking Part in a Randomised Controlled Trial: A Qualitative Study

In South Australia (SA) problem gambling is mainly a result of the widespread availability of electronic gaming machines. A key treatment provider in SA offers free cognitive and behavioural therapy (CBT) to help-seeking problem gamblers. The CBT program focuses on the treatment of clients' urge to gamble using exposure therapy (ET) and cognitive therapy (CT) to restructure erroneous gambling beliefs. The aim of this study was to explore treatment specific and non-specific effects for CT alone and ET alone using qualitative interviews. Interviewees were a sub-sample of participants from a randomised trial that investigated the relative efficacy of CT versus ET. Findings revealed that all interviewees gained benefit from their respective therapies and their comments did not appear to favour one therapy over another. Both treatment specific and treatment non-specific effects were well supported as playing a therapeutic role to recovery. Participants' comments in both therapy groups suggested that symptom reduction was experienced on a gambling related urge-cognition continuum. In addition to symptom improvement from therapy-specific mechanisms, ET participants described a general acquisition of "rational thought" from their program of therapy and CT participants had "taken-over" their gambling urges. The findings also highlighted areas for further improvement including therapy drop-out.

[Gambling addiction: insights from neuroscience and neuroimaging]

Although most people consider gambling as a recreational activity, some individuals lose control over their behavior and enter a spiral of compulsive gambling leading to dramatic consequences. In its most severe form, pathological gambling is considered a behavioral addiction sharing many similarities with substance addiction. A number of neurobiological hypotheses have been investigated in the past ten years, relying mostly on neuroimaging techniques. Similarly to substance addiction, a number of observations indicate a central role for dopamine in pathological gambling. However, the underlying mechanism seems partly different and is still poorly understood. Neuropsychological studies have shown decision-making and behavioral inhibition deficits in pathological gamblers, likely reflecting frontal lobe dysfunction. Finally, functional MRI studies have revealed abnormal reactivity within the brain reward system, including the striatum and ventro-medial prefrontal cortex. These regions are over-activated by gambling cues, and under-activated by monetary gains. However, the scarcity and heterogeneity of brain imaging studies currently hinder the development of a coherent neurobiological model of pathological gambling. Further replications of results and diversification of approaches will be needed in the coming years in order to strengthen our current model.

Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research

Background Behavioral addiction research has been particularly flourishing over the last two decades. However, recent publications have suggested that nearly all daily life activities might lead to a genuine addiction. Methods and aim In this article, we discuss how the use of atheoretical and confirmatory research approaches may result in the identification of an unlimited list of "new" behavioral addictions. Results Both methodological and theoretical shortcomings of these studies were discussed. Conclusions We suggested that studies overpathologizing daily life activities are likely to prompt a dismissive appraisal of behavioral addiction research. Consequently, we proposed several roadmaps for future research in the field, centrally highlighting the need for longer tenable behavioral addiction research that shifts from a mere criteria-based approach toward an approach focusing on the psychological processes involved.

COMT genotype, gambling activity, and cognition

Neuropsychological studies of adults with problem gambling indicate impairments across multiple cognitive domains. Catechol-O-methyltransferase (COMT) plays a unique role in the regulation of dopamine in the prefrontal cortex, and has been implicated in the cognitive dysfunction evident in problem gambling. This study examined adults with varying levels of gambling behavior to determine whether COMT genotype was associated with differences in gambling symptoms and cognitive functioning. 260 non-treatment-seeking adults aged 18-29 years with varying degrees of gambling behavior provided saliva samples for genotyping COMT val158met (rs4680). All subjects underwent clinical evaluations and neurocognitive assessment of decision-making, working memory, and impulsivity. The Val/Val COMT genotype was associated with the largest percentage of subjects with gambling disorder (31.8%), a rate significantly different from the Val/Met (13.2%) group (p = 0.001). The Val/Val COMT group was also associated with significantly more gambling disorder diagnostic criteria being met, greater frequency of gambling behavior, and significantly worse cognitive performance on the Cambridge Gamble Task (risk adjustment and delay aversion) and the Spatial Working Memory task (total errors). This study adds to the growing literature on the role of COMT in impulsive behaviors by showing that the Val/Val genotype was associated with specific clinical and cognitive elements among young adults who gamble, in the absence of differences on demographic measures and other cognitive domains. Future work should consider using genotyping to explore whether certain polymorphisms predict subsequent development of impulsive behaviors including gambling disorder, and treatment outcomes.

Does gender moderate the subjective measurement and structural paths in behavioural and cognitive aspects of gambling disorder in treatment-seeking adults?

INTRODUCTION

Gender differences have been observed in the pathogenesis of gambling disorder and gambling related urge and cognitions are predictive of relapse to problem gambling. A better understanding of these mechanisms concurrently may help in the development of more directed therapies.

METHODS

We evaluated gender effects on behavioural and cognitive paths to gambling disorder from self-report data. Participants (N=454) were treatment-seeking problem gamblers on first presentation to a gambling therapy service between January 2012 and December 2014. We firstly investigated if aspects of gambling related urge, cognitions (interpretive bias and gambling expectancies) and gambling severity were more central to men than women. Subsequently, a full structural equation model tested if gender moderated behavioural and cognitive paths to gambling severity.

RESULTS

Men (n=280, mean age=37.4years, SD=11.4) were significantly younger than women (n=174, mean age=48.7years, SD=12.9) (p<0.001). There was no gender difference in conceptualising latent constructs of problem gambling severity, gambling related urge, interpretive bias and gambling expectancies. The paths for urge to gambling severity and interpretive bias to gambling severity were stronger for men than women and statistically significant (p<0.001 and p=0.004, respectively) whilst insignificant for women (p=0.164 and p=0.149, respectively). Structural paths for gambling expectancies to gambling severity were insignificant for both men and women.

CONCLUSION

This study detected an important signal in terms of theoretical mechanisms to explaining gambling disorder and gender differences. It has implications for treatment development including relapse prevention.

Differential Involvement of the Agranular vs Granular Insular Cortex in the Acquisition and Performance of Choice Behavior in a Rodent Gambling Task

Substance-related and addictive disorders, in particular gambling disorder, are known to be associated with risky decision-making behavior. Several neuroimaging studies have identified the involvement of the insular cortex in decision-making under risk. However, the extent of this involvement remains unclear and the specific contributions of two distinct insular subregions, the rostral agranular (RAIC) and the caudal granular (CGIC), have yet to be examined. Animals were trained to perform a rat gambling task (rGT), in which subjects chose between four options that differed in the magnitude and probability of rewards and penalties. In order to address the roles of the RAIC and CGIC in established choice behavior, pharmacological inactivations of these two subregions via local infusions of GABA receptor agonists were performed following 30 rGT training sessions. The contribution made by the RAIC or CGIC to the acquisition of choice behavior was also determined by lesioning these areas before behavioral training. Inactivation of the RAIC, but not of the CGIC, shifted rats' preference toward options with greater reward frequency and lower punishment. Before rGT acquisition, lesions of the RAIC, but not the CGIC, likewise resulted in a higher preference for options with greater reward frequency and lower punishment, and this persisted throughout the 30 training sessions. Our results provide confirmation of the involvement of the RAIC in rGT choice behavior and suggest that the RAIC may mediate detrimental risky decision-making behavior, such as that associated with addiction and gambling disorder.

Obesity and gambling: neurocognitive and clinical associations

OBJECTIVE

Research on health correlates in gamblers has found an association between gambling and obesity. The neurocognitive underpinnings of impulsivity may be useful targets for understanding and ultimately treating individuals with both gambling and obesity problems.

METHOD

207 non-treatment seeking young adults (18-29 years) with subsyndromal gambling disorder were recruited from the community. Subjects were grouped according to weight ('normal weight' BMI<25, 'overweight' BMI≥25; or 'obese' BMI≥30). Measures relating to gambling behaviour and objective computerized neurocognitive measures were collected.

RESULTS

Of the 207 subjects, 22 (10.6%) were obese and 49 (23.7%) were overweight. The obese gamblers consumed more nicotine (packs per day equivalent) and reported losing more money per week to gambling. Obese gamblers exhibited significant impairments in terms of reaction times for go trials on the stop-signal test (SST), quality of decision making and risk adjustment on the Cambridge Gamble Test (CGT), and sustained attention on the rapid visual information processing task (RVP).

CONCLUSION

Obesity was associated with decision making and sustained attention impairments in gamblers, along with greater monetary loss due to gambling. Future work should use longitudinal designs to examine the temporal relationship between these deficits, weight, other impulsive behaviour, and functional impairment.

Involvement of the rostral agranular insular cortex in nicotine self-administration in rats

Our prior work demonstrated the involvement of the caudal granular subregion of the insular cortex in a rat model of nicotine self-administration. Recent studies in various animal models of addiction for nicotine and other drugs have identified a role for the rostral agranular subregion (RAIC). The current research was undertaken to examine the involvement of the RAIC in a rat model of nicotine self-administration. We investigated the inactivating effects of local infusions of a γ-aminobutyric acid agonist mixture (baclofen/muscimol) into the RAIC on nicotine self-administration under a fixed-ratio 5 (FR-5) schedule and on reinstatement of nicotine seeking induced by nicotine-associated cues in rats. We also evaluated the effects of RAIC inactivation on food self-administration under an FR5 schedule as a control. Inactivation of the RAIC decreased nicotine, but not food, self-administration. RAIC inactivation also prevented the reinstatement, after extinction, of nicotine seeking induced by nicotine-associated cues. Our study indicates that the RAIC is involved in nicotine-taking and nicotine-seeking in rats. Modulating insular cortex function appears to be a promising approach for nicotine dependence treatment.

Cognitive versus exposure therapy for problem gambling: Randomised controlled trial

BACKGROUND

Problem gambling-specific cognitive therapy (CT) and behavioural (exposure-based) therapy (ET) are two core cognitive-behavioural techniques to treating the disorder, but no studies have directly compared them using a randomised trial.

AIMS

To evaluate differential efficacy of CT and ET for adult problem gamblers at a South Australian gambling therapy service.

METHODS

Two-group randomised, parallel design. Primary outcome was rated by participants using the Victorian Gambling Screen (VGS) at baseline, treatment-end, 1, 3, and 6 month follow-up.

FINDINGS

Of eighty-seven participants who were randomised and started intervention (CT = 44; ET = 43), 51 (59%) completed intervention (CT = 30; ET = 21). Both groups experienced comparable reductions (improvement) in VGS scores at 12 weeks (mean difference -0.18, 95% CI: -4.48-4.11) and 6 month follow-up (mean difference 1.47, 95% CI: -4.46-7.39).

CONCLUSIONS

Cognitive and exposure therapies are both viable and effective treatments for problem gambling. Large-scale trials are needed to compare them individually and combined to enhance retention rates and reduce drop-out.

Associations between sensitivity to punishment, sensitivity to reward, and gambling

The majority of individuals gamble during their lifetime; however only a subset of these individuals develops problematic gambling. Gray's Reinforcement Sensitivity Theory may be relevant to understanding gambling problems. Differences in sensitivity to punishments and rewards can influence an individual's behavior and may be pertinent to the development of gambling problems. This study examined the functional associations between sensitivity to punishment (SP), sensitivity to reward (SR), and gambling problems in a sample of 2254 college students. Zero-inflated negative binomial regression was used to predict gambling problems as well as the absence of gambling problems. Gambling problems were hypothesized to be positively associated with SR and inversely associated with SP. In addition, SP was hypothesized to moderate the association between SR and gambling problems, attenuating the strength of the association. As hypothesized, SR was positively associated with gambling problems. However, SP did not moderate the relationship between SR and gambling problems. SP did, however, moderate the relationship between SR and the likelihood of never experiencing gambling problems. The results demonstrate that individual differences in SP and SR are functionally associated with gambling problems.

A neuropsychological investigation of decisional certainty

The certainty that one feels following a decision increases decision-making efficiency, but can also result in decreased decision accuracy. In the current study, a neuropsychological approach was used to examine the impact of damage to the ventromedial prefrontal cortex (vmPFC) on core psychological processes promoting decision certainty: selective exposure, overconfidence, and decisiveness. Given previous research demonstrating that vmPFC damage disrupts the generation of negative emotional (somatic) states that have been associated with selective exposure and overconfidence, it was hypothesized that damage to the vmPFC would disrupt engagement in selective exposure, decrease overconfidence, and increase indecision. Individuals with vmPFC damage exhibited increased indecision, but contrary to our hypothesis, engaged in similar levels of selective exposure and overconfidence as the comparison groups. These results indicate that indecision may be an important psychological mechanism involved in decision-making impairments associated with vmPFC injury. The results also suggest that the vmPFC may not be critical for selective exposure or overconfidence, which provides support for a recent "desirability" account of selective exposure.

Impact of ADHD symptoms on clinical and cognitive aspects of problem gambling

BACKGROUND

Problem gambling is common across cultures, and has been conceptualized in terms of impulsivity. While elevated rates of attention deficit hyperactivity disorder (ADHD) have been observed in problem gamblers, the relationship between these two conditions, and other dissociable forms of impulsivity, has received little research attention.

METHODS

N=126 non-treatment seeking young adults with problem gambling were recruited from the community, and were grouped according to the presence or absence of probable current ADHD. Clinical and cognitive measures pertaining to impulsivity were collected via detailed psychiatric assessment, questionnaires, and computerized neuropsychological tests. These variables were compared between groups.

RESULTS

Probable current ADHD was identified in 21.4% of the sample, and was associated with earlier age at onset of gambling behaviors, higher Barratt impulsivity scores (all three subscales), greater caffeine intake, worse response inhibition (Stop-Signal Test), and impaired decision-making (greater proportion of points gambled, Cambridge Gamble Test). Problem gamblers with and without ADHD did not differ on demographic characteristics or the rate of other psychiatric disorders, depression scores, nicotine and alcohol consumption, and body mass index. No significant group differences were found for general response speed, working memory, or executive planning.

CONCLUSIONS

ADHD is common in young adults with dysfunctional gambling behaviors and is associated with elevated questionnaire and cognitive based measures of impulsivity, along with heightened caffeine use. Future work should study the causal nature between these factors and the treatment implications of these findings.

Optimal inference with suboptimal models: addiction and active Bayesian inference

When casting behaviour as active (Bayesian) inference, optimal inference is defined with respect to an agent's beliefs - based on its generative model of the world. This contrasts with normative accounts of choice behaviour, in which optimal actions are considered in relation to the true structure of the environment - as opposed to the agent's beliefs about worldly states (or the task). This distinction shifts an understanding of suboptimal or pathological behaviour away from aberrant inference as such, to understanding the prior beliefs of a subject that cause them to behave less 'optimally' than our prior beliefs suggest they should behave. Put simply, suboptimal or pathological behaviour does not speak against understanding behaviour in terms of (Bayes optimal) inference, but rather calls for a more refined understanding of the subject's generative model upon which their (optimal) Bayesian inference is based. Here, we discuss this fundamental distinction and its implications for understanding optimality, bounded rationality and pathological (choice) behaviour. We illustrate our argument using addictive choice behaviour in a recently described 'limited offer' task. Our simulations of pathological choices and addictive behaviour also generate some clear hypotheses, which we hope to pursue in ongoing empirical work.