An overview of and rationale for changes proposed for pathological gambling in DSM-5

Applying General Strain Theory to the Relationship Between Strain from Another Person's Gambling Behavior and Gambling Disorder

Prior research has identified a host of factors that increase the likelihood that an individual will develop problem gambling, clinically diagnosed as Gambling Disorder (GD), most of which would be identified by criminologists as "strains" under the framework of General Strain Theory (GST). This study utilizes propositions from GST to determine whether strain from another person's gambling may be related to why people develop GD and whether gender is a moderating factor in this relationship. Secondary data is analyzed to assess levels of strain individuals experience from another person's gambling behavior, its relationship to the individual's risk of Gambling Disorder, and the role gender plays in this relationship. Findings demonstrate a relationship between the strain from the perceived problem gambling of someone with a close relationship and having a gambling disorder. Experiencing strain from a spouse/partner who is perceived as a problem gambler has the strongest correlation with an individual also having Gambling Disorder. Considering gender as a moderating factor, this effect was stronger on men than women, calling into question the strong belief that it is primarily women who gamble to escape problems.

A Self-Guided Internet-Based Intervention for the Reduction of Gambling Symptoms: A Randomized Clinical Trial

Importance

Most individuals with problem gambling or gambling disorder remain untreated due to barriers to treatment. Limited research exists on alternative treatments.

Objective

To investigate the efficacy of a self-guided internet-based intervention for individuals with gambling problems and to identify potential outcome moderators.

Design, Setting, and Participants

This single-center randomized clinical trial was conducted from July 13, 2021, to December 31, 2022, at the University Medical Center Hamburg-Eppendorf. Participants were recruited across Germany for 2 assessments (before intervention [t0] and 6 weeks after intervention [t1]). Eligible participants were individuals aged 18 to 75 years with gambling problems, internet access, German proficiency, and willingness to participate in 2 online assessments.

Intervention

The self-guided internet-based intervention was based on cognitive behavioral therapy, metacognitive training, acceptance and commitment therapy, and motivational interviewing.

Main Outcome and Measures

The primary outcome was change in gambling-related thoughts and behavior as measured with the pathological gambling adaption of the Yale-Brown Obsessive-Compulsive Scale. Secondary outcomes were change in depressive symptoms, gambling severity, gambling-specific dysfunctional thoughts, attitudes toward online interventions, treatment expectations, and patient satisfaction.

Results

A total of 243 participants (154 [63.4%] male; mean [SD] age, 34.73 [10.33] years) were randomized to an intervention group (n = 119) that gained access to a self-guided internet-based intervention during 6 weeks or a wait-listed control group (n = 124). Completion at t1 was high (191 [78.6%]). Results showed a significantly greater reduction in gambling-related thoughts and behavior (mean difference, -3.35; 95% CI, -4.79 to -1.91; P < .001; Cohen d = 0.59), depressive symptoms (mean difference, -1.05; 95% CI, -1.87 to -0.22; P = .01; Cohen d = 0.33), and gambling severity (mean difference, -1.46; 95% CI, -2.37 to -0.54; P = .002; Cohen d = 0.40) but not in gambling-specific dysfunctional thoughts (mean difference, -1.62; 95% CI, -3.40 to 0.15; P = .07; Cohen d = 0.23) favoring the intervention group. Individuals in the intervention group who had a positive treatment expectation and more severe gambling-specific dysfunctional thoughts and gambling symptoms benefited more on the primary outcome relative to the control group.

Conclusions and Relevance

In this randomized clinical trial, the effectiveness of a self-guided internet-based intervention for individuals with self-reported problematic gambling behavior was demonstrated when measured 6 weeks after start of the intervention. The study's findings are particularly relevant given the increasing need for accessible and scalable solutions to address problematic gambling.

Trial Registration

bfarm.de Identifier: DRKS00024840.

Problem gambling in psychotic disorders: A systematic review and meta-analysis of prevalence

INTRODUCTION

Problem gambling (PBG) is more common in people with mental health disorders, including substance use, bipolar, and personality disorders, than in the general population. Although individuals with psychotic disorders might be expected to be more vulnerable to PBG, fewer studies have focused on this comorbidity. The aim of this review was to estimate the prevalence of PBG in people with psychotic disorders.

METHODS

Medline (Ovid), EMBASE, PsycINFO (Ovid), CINAHL, CENTRAL, Web of science, and ProQuest were searched on November 1, 2023, without language restrictions. Observational and experimental studies including individuals with psychotic disorders and reporting the prevalence of PBG were included. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal for systematic reviews of prevalence data. The pooled prevalence of PBG was calculated using a fixed effects generalized linear mixed model and presented through forest plots.

RESULTS

Of 1271 records screened, 12 studies (n = 3443) were included. The overall prevalence of PBG was 8.7% (95% CI = 7.8%-9.7%, I2 = 69%). A lower prevalence was found in studies with a low risk of bias (5.6%; 95% CI = 4.4%-7.0%) compared with studies with a moderate risk of bias (10.4%; 95% CI = 9.2%-11.7%). Different methods used to assess PBG also contributed to the heterogeneity found.

CONCLUSION

This meta-analysis found substantial heterogeneity, partly due to the risk of bias of the included studies and a lack of uniformity in PBG assessment. Although more research is needed to identify those at increased risk for PBG, its relatively high prevalence warrants routine screening for gambling in clinical practice.

Lifetime alcohol use disorder and gambling disorder: clinical profile and treatment response

OBJECTIVES

Gambling disorder affects 0.5-2.4% of the population and shows strong associations with lifetime alcohol use disorder. Very little is known regarding whether lifetime alcohol use disorder can impact the clinical presentation or outcome trajectory of gambling disorder.

METHODS

Data were pooled from previous clinical trials conducted on people with gambling disorder, none of whom had current alcohol use disorder. Demographic and clinical variables were compared between those who did versus did not have lifetime alcohol use disorder.

RESULTS

Of the 621 participants in the clinical trials, 103 (16.6%) had a lifetime history of alcohol use disorder. History of alcohol use disorder was significantly associated with male gender (relative risk [RR] = 1.42), greater body weight (Cohen's D = 0.27), family history of alcohol use disorder in first-degree relative(s) (RR = 1.46), occurrence of previous hospitalization due to psychiatric illness (RR = 2.68), and higher gambling-related legal problems (RR = 1.50). History of alcohol use disorder was not significantly associated with other variables that were examined, such as severity of gambling disorder or extent of functional disability. Lifetime alcohol use disorder was not significantly associated with the extent of clinical improvement in gambling disorder symptoms during the subsequent clinical trials.

CONCLUSIONS

These data highlight that lifetime alcohol use disorder is an important clinical variable to be considered when assessing gambling disorder because it is associated with several untoward features (especially gambling-related legal problems and prior psychiatric hospitalization). The study design enabled these associations to be disambiguated from current or recent alcohol use disorder.

Predictors of pathological gambling behaviours in parents population in Nigeria

The increasing incidence of psychological pains, burnout, and anxiety among gamblers in Nigeria is high. This is because pathological gambling (PG) is on the rise and it is linked to many social vices such as stealing, drug abuse, and sexual abuse. It is important to investigate the trajectories of PG in Nigeria. A cross-sectional survey design was employed in our study with 197 participants sampled from 28 gambling venues in Nigeria made up the study's sample size. Of the 197, 131 (66.5%) were males and 66 (33.5%) were females. 50 (25.4%) were within the age range of 20-30 years, 42 (21.3%) were within 31-40 years, 40 (20.3%) were within 41-50 years, 35 (17.8%) were within 51-60 years, and 30 (15.2%) were within 61 and above. Using the hierarchical regression analysis, our finding revealed a significant association between psychological distress and our respondents' pathological gambling behaviour whereas none of the sociodemographic variables made a significant contribution to their pathological gambling behaviour. We concluded that gamblers' psychological well-being is crucial to understanding their problematic gambling behaviours in the context of a developing nation such as Nigeria, and that this could be similar among our respondents. Implications of our findings were highlighted.

Three Contrasting Accounts of Electronic Gambling Machine Related Harm: Impacts on Community Views Towards Gambling Policy and Responsibility

This study investigated whether there was community support for prominent gambling harm reduction policies, as well as perceived responsibility for electronic gambling machine (EGM) related harm in an Australian sample (n = 906). Using a randomised experimental design, we also explored whether these outcomes were influenced by three alternative explanations for EGM-related harm: a brain-based account of gambling addiction, an account that highlighted the intentional design of the gambling environment focused on the "losses disguised as wins" (LDWs), and a media release advocating against further government intervention in the gambling sector. We observed clear majority support for most policies presented, including mandatory pre-commitment, self-exclusion, and a $1 limit on EGM bets. A substantial majority of participants agreed that individuals, governments, and industry should be held responsible for EGM-related harm. Participants presented with the explanation of LDWs attributed greater responsibility for gambling-related harm to industry and government, less agreement that electronic gambling machines are fair, and more agreement that EGMs are likely to mislead or deceive consumers. There was some limited evidence of greater support for policy intervention in this group, including a blanket ban of EGMs, clinical treatment funded by gambling taxes, mass media campaigns, and mandatory pre-commitment for EGMs. We found no evidence that a brain-based account of gambling addiction substantially undermined support for policy intervention. We predicted that the information about LDWs and the brain-based account of EGM related harm would soften attributions of personal responsibility for gambling harm. Our results did not support either of these predictions.

Features of Addiction in Binge-Eating Disorder: Considerations for Screening and Treatment

Similarities have been reported between the diagnostic and associated characteristics of binge-eating disorder (BED) and substance-related and non-substance-related disorders. This has resulted in interest in using addiction models to inform clinical care for people with BED. The purpose of this paper was to review features of addiction in BED with a focus on clinical implications. First, we briefly summarize similarities and differences in diagnostic and mechanistic features and symptoms for BED and food addiction, substance-related disorders, and non-substance-related disorders. Then we review aspects of addiction in BED that have clinical implications for screening and treatment of this condition. Similarities in diagnostic criteria between BED and substance-related and non-substance-related disorders include loss of control, greater use than intended, continued use despite adverse consequences, and marked distress. Addiction models may help inform aspects of clinical care of BED, particularly for shared antecedents and mechanisms underlying both disorders and to enhance engagement in treatment. Yet, there are large gaps in evidence regarding the effects of many aspects of addiction models to BED. More research is needed to examine the safety and efficacy of using addiction theories and frameworks for clinical strategies for BED.

The Role of Attachment in Gambling Behaviors and Gambling Disorder: A Systematic Review

In recent years, a growing number of attachment-based studies have contributed to the understanding of both substance and behavioral addictions. Although gambling is a form of addictive behavior widespread all over the world, both among young people and adults, the evidence on the association between attachment-related phenomena and gambling has not yet been systematized in literature. The aim of the present study, therefore, is to provide a systematic literature review aimed at summarizing the empirical evidence on this topic. Following the updated 2020 PRISMA guidelines, a systematic search in four electronic scientific databases (Scopus, PubMed, PsycInfo and Web of Science) was conducted. After removing duplicates, 146 records were double-screened, with 12 articles meeting the inclusion criteria. Additionally, by means of a backward search a further article was selected. Altogether, 13 articles were selected for the present systematic review. With few exceptions, the results underline the significant role played by attachment-related phenomena in gambling behaviors, highlighting that specific attachment contexts have a different influence on gambling, also depending on whether gamblers are youths or adults. In particular, while secure attachment has proven to be a protective factor for the onset of gambling behavior, insecure attachment has emerged to be a vulnerability factor in two ways. On the one hand, it directly favors gambling behaviors; on the other, it affects coping strategies and the individual's ability to identify and regulate emotions, which in turn predict gambling. Limitations, strengths, and implications of the present systematic review are discussed.

Goal-directed and habitual decision making under stress in gambling disorder: An fMRI study

The development of addictive behaviors has been suggested to be related to a transition from goal-directed to habitual decision making. Stress is a factor known to prompt habitual behavior and to increase the risk for addiction and relapse. In the current study, we therefore used functional MRI to investigate the balance between goal-directed 'model-based' and habitual 'model-free' control systems and whether acute stress would differentially shift this balance in gambling disorder (GD) patients compared to healthy controls (HCs). Using a within-subject design, 22 patients with GD and 20 HCs underwent stress induction or a control condition before performing a multistep decision-making task during fMRI. Salivary cortisol levels showed that the stress induction was successful. Contrary to our hypothesis, GD patients did not show impaired goal-directed 'model-based' decision making, which remained similar to HCs after stress induction. Bayes factors provided three times more evidence against a difference between the groups or a group-by-stress interaction on the balance between model-based and model-free decision making. Similarly, no differences were found between groups and conditions on the neural estimates of model-based or model-free decision making. These results challenge the notion that GD is related to an increased reliance on habitual (or decreased goal-directed) control, even during stress.

Computational approaches to modeling gambling behaviour: Opportunities for understanding disordered gambling

Computational modeling has become an important tool in neuroscience and psychiatry research to provide insight into the cognitive processes underlying normal and pathological behavior. There are two modeling frameworks, reinforcement learning (RL) and drift diffusion modeling (DDM), that are well-developed in cognitive science, and have begun to be applied to Gambling Disorder. RL models focus on explaining how an agent uses reward to learn about the environment and make decisions based on outcomes. The DDM is a binary choice framework that breaks down decision making into psychologically meaningful components based on choice reaction time analyses. Both approaches have begun to yield insight into aspects of cognition that are important for, but not unique to, gambling, and thus relevant to the development of Gambling Disorder. However, these approaches also oversimplify or neglect various aspects of decision making seen in real-world gambling behavior. Gambling Disorder presents an opportunity for 'bespoke' modeling approaches to consider these neglected components. In this review, we discuss studies that have used RL and DDM frameworks to investigate some of the key cognitive components in gambling and Gambling Disorder. We also include an overview of Bayesian models, a methodology that could be useful for more tailored modeling approaches. We highlight areas in which computational modeling could enable progression in the investigation of the cognitive mechanisms relevant to gambling.

The Prevalence of Symptomatology and Risk Factors in Mental Health in Mexico: The 2016-17 ENCODAT Cohort

There is little recent information about the prevalence of symptomatology of mental health disorders in representative population samples in Mexico. To determine the prevalence of mental health symptoms in Mexico and its comorbidity with tobacco, alcohol, and drug use disorder (SUD), we used the 2016-17 National Survey of Drug, Alcohol, and Tobacco Use (Encuesta Nacional de Consumo de Drogas, Alcohol y Tabaco, ENCODAT 2016-2017). The data were collected from households using a cross-sectional, stratified, multistage design, with a confidence level of 90% and a response rate of 73.6%. The final sample included 56,877 completed interviews of individuals aged 12-65, with a subsample of 13,130 who answered the section on mental health. Symptoms of mania and hypomania (7.9%), depression (6.4%), and post-traumatic stress (5.7%) were the three main problems reported. Of this subsample, 56.7% reported using a legal or illegal drug without SUD, 5.4% reported SUD at one time on alcohol, 0.8% on tobacco, and 1.3% on medical or illegal drugs, 15.9% reported symptoms related to mental health, and 2.9% comorbidity. The prevalence found is consistent with those reported in previous studies, except for an increase in post-traumatic stress, which is consistent with the country's increase in trauma.

Neural cue-reactivity in pathological gambling as evidence for behavioral addiction: a systematic review

Increasing incidence of problem gambling has led to prioritizing the problem from the point of view of public health. Additionally, gambling disorder has been recently classified as a behavioral addiction, with implications for both its diagnosis and treatment. However, the shared neural substrate of addictions, to substances and behavioral, is still discussed. Thus, this systematic review aims to provide up-to-date knowledge from the past five years (2017-2022) concerning the neural correlates of gambling related stimuli (cue-reactivity) on the basis of a previous review (Brevers et al., Cognitive, Affective and Behavioral Neuroscience 18:718-729, 2019). A total of five studies were included in the review. Activation of brain areas related to memory, reward and executive functions could be the underlying mechanism of this behavioral addiction. Specifically, nucleus accumbens and striatum (ventral and dorsal), parahippocampal regions, the right amygdala and several prefrontal cortex regions have systematically been found more active in those subjects exposed to gambling-related cues. Also, the insula could play a pivotal role connecting these three systems in a highly integrated neural network with several implications for reward processing modulation, associative learning and top-down attentional regulation to improve saliency of addiction-related cues. These results are consistent with previous findings on other substance addictions, such as alcohol, tobacco, marijuana or cocaine. The study of neural reactivity to stimuli related to addiction could be useful as a biomarker of the severity of the disorder, the efficacy of the treatment, the risk of relapse, in addition to being an objective criterion to measure the effectiveness of prevention campaigns.

Directing Technology Addiction Research in Information Systems

In this second part of a series of articles to direct technology addiction research in the information systems discipline, we discuss the history, conceptualization, and measurement of technology addiction. We admit that it is possible to label the phenomenon as overuse or excessive use as long as it is defined and measured by the presence and the magnitude of the six core symptoms of behavioral addictions: salience, mood modification, tolerance, withdrawal, conflict, and relapse. The advantage of this terminology is that it does not attribute one's problems to helplessness and does not pathologize the behavior, implying that it may possibly be corrected. Nevertheless, we posit that the term technology addiction is currently the most reasonable choice that may need to be adjusted as we learn more about this phenomenon and its potential similarities to and differences from established behavioral addictions. Dependence, obsessive/compulsive use, and pathological/problem use terms should not be used as synonyms for technology addiction as a form of mental disorder. Researchers should not include the name of the IT artifact as the subject of addiction (e.g., "Facebook addiction"). Instead, they should focus on the activity that is mediated through the IT artifact (e.g., "addiction to Facebook use").

Affective impulsivity moderates the relationship between disordered gambling severity and attentional bias in electronic gaming machine (EGM) players

BACKGROUND AND AIMS

Attentional bias to gambling-related stimuli is associated with increased severity of gambling disorder. However, the addiction-related moderators of attentional bias among those who gamble are largely unknown. Impulsivity is associated with attentional bias among those who abuse substances, and we hypothesized that impulsivity would moderate the relationship between disordered electronic gaming machine (EGM) gambling and attentional bias.

METHODS

We tested whether facets of impulsivity, as measured by the UPPS-P (positive urgency, negative urgency, sensation seeking, lack of perseverance, lack of premeditation) and the Barratt Impulsiveness Scale-11 (cognitive, motor, non-planning) moderated the relationship between increased severity of gambling disorder, as measured by the Problem Gambling Severity Index (PGSI), and attentional bias. Seventy-five EGM players participated in a free-viewing eye-tracking paradigm to measure attentional bias to EGM images.

RESULTS

Attentional bias was significantly correlated with Barratt Impulsiveness Scale-11 (BIS-11) motor, positive urgency, and negative urgency. Only positive and negative urgency moderated the relationship between PGSI scores and attentional bias. For participants with high PGSI scores, higher positive and negative urgency were associated with larger attentional biases to EGM stimuli.

DISCUSSION

The results indicate that affective impulsivity is an important contributor to the association between gambling disorder and attentional bias.

Gambling problems among Lebanese adults: Arabic-Language version of the South Oaks Gambling Screen (SOGS) scale validation and correlates

BACKGROUND

In the DSM-5, gambling disorder is recognized as the only behavioral addiction. The number of people with mental health disorders is increasing in Lebanon, especially since the economic crisis and the COVID-19 pandemic. The South Oaks Gambling Screen (SOGS), the most used tool in the world in terms of pathological gambling, has never been translated to Arabic, culturally adapted in a way that suits the Lebanese population and validated. This study's objectives were to validate an Arabic-language version of the SOGS and assess factors associated with probable pathological gambling among Lebanese adults.

METHODS

This study was carried out between February and April 2021, during the lockdown period imposed by the Lebanese government. A total of 601 individuals participated in this study by filling the online questionnaire.

RESULTS

A factor analysis, using the principal component analysis, was performed on the SOGS scale items. The SOGS items were able to explain 73.35% of the variance, with an internal reliability of KR20 = 0.947 for the total scale. The results of the confirmatory factor analysis confirmed the results of the factor analysis. More problematic alcohol use (aOR = 1.17), and more depression (aOR = 1.13) were significantly associated with higher odds of probable pathological gambling, whereas females (aOR = 0.27) had significantly lower odds of probable pathological gambling compared to males.

CONCLUSION

Our study validated an Arabic-language version of the South Oaks Gambling Screen (SOGS) for use in Lebanon, and showed some factors associated with probable pathological gambling (male gender, alcohol use disorder and depression). This reliable and valid version will hopefully contribute towards better screening for gambling disorder in Lebanon.

Alexithymia, Dissociation, and Family Functioning in a Sample of Online Gamblers: A Moderated Mediation Study

The diffusion of the internet and technological progress have made gambling on online platforms possible, also making it more anonymous, convenient, and available, increasing the risk of pathological outcomes for vulnerable individuals. Given this context, the present study explores the role of some protective and risk factors for problematic gambling in online gamblers by focusing on the interaction between alexithymia, dissociation, and family functioning. A sample of 193 online gamblers (Mage = 28.8 years, SD = 10.59; 17% females, 83% males) completed the South Oaks Gambling Screen, Twenty-Items Toronto Alexithymia Scale, Dissociative Experience Scale-II, and Family Adaptability and Cohesion Evaluation Scales-IV through an online survey. MANOVA, ANOVA and moderated mediation analyses were carried out to analyse the data. Significant differences in cohesive family functioning, alexithymia and dissociation have been found between online gamblers with problematic, at-risk or absent levels of gambling disease. Furthermore, the results showed a significant and positive association between alexithymia and problematic online gambling, partially mediated by dissociation, with the moderation of cohesive family functioning. Such data may have relevant clinical implications, highlighting the interaction of some core personal and environmental variables that may be involved in the etiology of online pathological gambling and could be kept in mind to tailor preventive interventions.

Behavioral addiction and autism spectrum disorder: A systematic review

BACKGROUND

According to DSM-5 criteria, Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by deficiencies in social communication and interaction along with the presence of restrictive and repetitive patterns of behavior. Few studies have explored the prevalence of behavioral addiction in individuals with ASD. Since addiction and ASD share common characteristics, individuals with ASD may be more vulnerable to addictive behaviors. Some typical behavioral addictions include internet, gaming, and gambling addiction. While most previous studies on ASD and addiction have looked at chemical addiction, behavioral addiction has not been thoroughly studied to date.

AIMS

The objective of this study was to investigate the presence of behavioral addiction among individuals diagnosed with autism spectrum disorder.

METHODS AND PROCEDURES

A systematic literature search of five databases was conducted in accordance with the PRISMA guidelines. Search results were reviewed for the predetermined inclusion criteria independently by two authors.

OUTCOMES AND RESULTS

The search yielded 539 publications after the removal of duplicates. 61 met the inclusion criteria for title and abstract review. Full texts were reviewed resulting in an additional 31 being removed. The remaining 30 included 4 case reports and 26 original studies. Results included 27 studies that found a positive correlation (15 of significance, 12 of unknown significance) between a behavioral addiction and either ASD or Autistic traits, 1 found a significant negative correlation, 3 did not find a correlation.

CONCLUSIONS AND IMPLICATIONS

This review is inconclusive about links between ASD and behavioral addictions. While a vast majority of studies show a positive correlation, many do not provide the statistical analysis to show if the correlations are significant. In addition, a positive correlation between ASD and behavioral addiction is observed in the presence of comorbid mental health conditions in many of the studies. Further research with proper controls and statistical analysis is needed to determine whether the development of behavioral addiction is directly influenced by ASD or if the presence of a comorbid mental health condition is the true cause.

Problematic online gambling among adolescents: A systematic review about prevalence and related measurement issues

BACKGROUND AND AIMS

Despite its illegality among adolescents, online gambling is a common practice, which puts their mental health and well-being at serious risk. This systematic review summarises international scientific literature from the last 20 years on problematic online gambling among adolescents (11-21 years old) to determine its prevalence and to analyse related measurement issues.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and a protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, IC: CRD42020162932). Five academic databases were consulted, which resulted in an initial sample of 658 papers.

RESULTS

Sixteen studies met the inclusion criteria for this review. All studies were cross-sectional and targeted students from elementary school, secondary school or university. Most followed a convenience sampling procedure. The primary measurement instruments used were the DSM-IV-MR-J and SOGS-RA. Between 0.77% and 57.5% of adolescents present some degree of problematic online gambling (problem, pathological or disordered) depending on the instruments used, the study samples and the timeframe analysed. Between 0.89% and 1% of adolescents exhibited an online gambling disorder.

DISCUSSION AND CONCLUSION

There is a great heterogeneity in the methodology of the reviewed studies (samples, measurement instruments, cut-off points and criteria applied). The limited number of studies and the limited generalizability of their results suggest the need for further research and for development of specific instruments to assess different levels of problematic online gambling in representative samples of adolescents based on clinical 'gold standard' criteria and more accurate cut-off points.

The Mediating Role of Psychological Distress in Excessive Gambling among Young People: A Four-Country Study

Background and aims: Loneliness and a low sense of mastery are associated with excessive gambling, but the underlying processes of these relationships remain unstudied. Because psychological distress can increase vulnerability to excessive gambling, we investigated its mediating role in these relationships among young people. To meet the need for cross-country research, we also observed how these relationships occur in four countries with different cultures. Design, setting, and participants: Demographically balanced cross-sectional survey data were collected from 15–25-year-olds in Finland (n = 1200; 50% male), the United States (n = 1212; 49.8% male), South Korea (n = 1192; 49.6% male), and Spain (n = 1212; 51.2% male). Measurements: Excessive gambling was measured with the South Oaks Gambling Screen, psychological distress was assessed with the 12-item General Health Questionnaire, loneliness was measured with the three-item Loneliness Scale, and low sense of mastery was assessed with the Pearlin Mastery Scale. Associations were examined first using zero-inflated negative binomial regression analyses with excessive gambling as the outcome. In addition, path analyses were performed to study how loneliness and low sense of mastery relate to excessive gambling, with psychological distress as the mediating variable. Findings: Loneliness and low sense of mastery were associated indirectly with excessive gambling via psychological distress in all country samples. Low sense of mastery was also directly associated with excessive gambling. There was a direct association between loneliness and excessive gambling only in samples from South Korea and Spain. Conclusions: Psychological distress is an important factor in understanding how loneliness and sense of mastery relate to gambling.

What's in a Name? Evaluating the Public Stigma of Gambling Disorder

Public stigma of gambling disorder has negative effects on the mental health and functioning of affected individuals and impedes treatment-seeking. One factor thought to be implicated in stigma is the label used to describe the condition. The aims of this research were to: (1) evaluate whether different labels for problematic gambling behavior influence public stigma; and (2) compare public stigma of gambling disorder to other health conditions. Separate samples of university student (Study 1) and general population (Study 2) participants were randomly assigned to label conditions and completed questionnaires assessing stigma and attitudes towards the assigned label. In Study 1, the eight conditions included four gambling labels (problem gambling, pathological gambling, gambling disorder, and gambling addiction) and four psychiatric or health comparison labels (depression, obsessive-compulsive disorder, alcohol use disorder, and asthma). In Study 2, compulsive buying disorder was added as a fifth psychiatric comparison for a total of nine conditions. The results indicated that the four gambling label conditions elicited similar attitudes and stigma. Those conditions were also more stigmatized than the depression, obsessive-compulsive disorder, and asthma conditions. The gambling conditions elicited similar stigmatizing attitudes as alcohol use disorder but were slightly more stigmatized than compulsive buying disorder, with these conditions showing both similarities and differences across the stigma-related outcomes. The results were largely consistent across both samples and contribute to knowledge of the nature and origins of gambling-related stigma.

Youth and gambling disorder: What about criminal behavior?

BACKGROUND AND AIMS

The commission of illegal acts has been associated with gambling disorder (GD). However, little is known about young adults with GD who commit GD-related crimes. Therefore, the main aim of this study was to compare sociodemographic, clinical, personality and psychopathological features among young adults with GD with and without a history of illegal behaviors. Our second aim was to analyze the specific associations between these factors through a path analysis.

METHODS

A total of 808 treatment-seeking young adults who met criteria for GD were assessed at a public hospital unit specialized in behavioral addictions. Participants completed self-reported questionnaires to explore GD, personality traits, and psychopathological symptomatology.

RESULTS

Of the total sample, 291 patients (36.0%) had committed GD-related offences. Illegal acts were related to younger age and unemployment status. Greater levels of psychopathology, as well as earlier GD onset, longer GD duration and greater GD severity were also associated with the presence of criminal behaviors. Differences in personality traits were also found between these two groups.

DISCUSSION AND CONCLUSIONS

The GD group with a history of illegal acts showed dysfunctional personality traits and higher levels of psychopathology. Therefore, specific GD treatments and harm reduction interventions should be designed for these patients.

Self-compassion Buffers Impaired Decision-Making by Potential Problem Gamblers in a Casino Setting

Self-compassionate individuals treat themselves kindly when undergoing stress. The present study examined self-compassion's relationship to risky decision-making on a gambling task by 240 problem and non-problem gamblers who were tested in a casino setting. Multi-level modeling analyses showed that participants expressed differential rates of learning to avoid risks on the gambling task, depending on their status as potential problem/non-problem gamblers and their level of self-compassion. Among potential problem gamblers, participants higher in self-compassion showed significant gains in performance over decision-making trials, which approximated those of non-problem gamblers and adults without impairments in the population. In contrast, potential problem gamblers lower in self-compassion showed chance levels of performance, which approximated those of adults with impairments. In some circumstances, self-compassion can disinhibit individuals from taking greater risks. For potential problem gamblers in a casino setting, however, the benefits of self-compassion as a means to reinforce self-control appear to outweigh the risks.

A comparison of fraud to fund gambling with fraud for other reasons

In order to compare the characteristics, including diagnosed mental disorder, of people who commit fraud offences to fund gambling with those who committed fraud for other reasons, we examined a complete series of reports prepared for legal proceedings by two of the authors from between January 2002 and June 2019. A total of 160 fraud offenders were located, of whom 48 (30%) reported offending to fund gambling. Females made up 47.5% of the total sample and 43.8% of the gamblers. Of the problem gambling group, 44% had diagnoses of anxiety or depression, 44% had substance use disorder, 17% had bipolar and other psychosis, and 38% reported childhood trauma. There were no significant differences in the frequencies of diagnosis of mental illness or previous criminal convictions compared to the non-gambling group. Two thirds reported only gambling on poker machines. Only 19% of gamblers reported seeking treatment prior to being charged.

Brain Network Underlying Executive Functions in Gambling and Alcohol Use Disorders: An Activation Likelihood Estimation Meta-Analysis of fMRI Studies

BACKGROUND

Neuroimaging and neuropsychological studies have suggested that common features characterize both Gambling Disorder (GD) and Alcohol Use Disorder (AUD), but these conditions have rarely been compared.

METHODS

We provide evidence for the similarities and differences between GD and AUD in neural correlates of executive functions by performing an activation likelihood estimation meta-analysis of 34 functional magnetic resonance imaging studies involving executive function processes in individuals diagnosed with GD and AUD and healthy controls (HC).

RESULTS

GD showed greater bilateral clusters of activation compared with HC, mainly located in the head and body of the caudate, right middle frontal gyrus, right putamen, and hypothalamus. Differently, AUD showed enhanced activation compared with HC in the right lentiform nucleus, right middle frontal gyrus, and the precuneus; it also showed clusters of deactivation in the bilateral middle frontal gyrus, left middle cingulate cortex, and inferior portion of the left putamen.

CONCLUSIONS

Going beyond the limitations of a single study approach, these findings provide evidence, for the first time, that both disorders are associated with specific neural alterations in the neural network for executive functions.

Effects of exposure to chronic uncertainty and a sensitizing regimen of amphetamine injections on locomotion, decision-making, and dopamine receptors in rats

Gambling disorder (GD) is a behavioral addiction that may be linked to alterations in dopamine (DA) systems. Gambling involves chronic exposure to uncertain reward, which can sensitize the activity of DA systems. Here we explored how combinations of Pavlovian and instrumental uncertainty impact DA sensitization and risky decision-making. Experiment 1: 40 rats underwent 66 uncertainty exposure (UE) sessions during which they responded for saccharin. Animal responding was reinforced according to a fixed or variable (FR/VR) ratio schedule that turned on a conditioned stimulus (CS; light), which predicted saccharin on 50% or 100% of trials. Animals responded under one of the four conditions: FR-CS100% (no uncertainty), VR-CS100%, FR-CS50%, and VR-CS50% (maximal uncertainty). DA sensitization was inferred from an enhanced locomotor response to d-amphetamine (d-AMPH; 0.5 mg/kg) challenge. The rat gambling task (rGT) was used to assess decision-making. Experiment 2: 24 rats received 5 weeks of sensitizing d-AMPH or saline doses, followed by locomotor activity and rGT testing. Experiment 3: Effects of UE and a sensitizing d-AMPH regimen on DA D1, D2, and D3 receptor binding were assessed in 44 rats using autoradiography. Compared to FR-CS100%, VR-CS100% and VR-CS50% rats displayed a greater locomotor response to d-AMPH, and VR-CS50% rats demonstrated riskier decision-making. Chronic d-AMPH-treated rats mirrored the effects of VR-CS50% groups on these two indices. Both VR-CS50% and d-AMPH-treated groups had increased striatal DA D2 receptor binding. These results suggest that chronic uncertainty exposure, similar to exposure to a sensitizing d-AMPH regimen, sensitized the function of DA systems and increased risky decision-making.

The Multidimensional Structure of Problem Gambling: An Evaluation of Four Gambling Categorization Instruments from an International Online Survey of Gamblers

To examine the underlying dimensionality and structure of problem gambling using a comprehensive range of problem gambling assessments from an international online survey of gamblers. A total of 12,521 gamblers from 105 countries were recruited through banner advertising placed on a popular online gambling portal to take an online survey. Although participants were recruited online, the majority of the sample (71.6%) gambled only at land-based venues in the past 12 months. A total of 5081 individuals completed all items from the four problem gambling assessments. Participants were allocated to answer one of the four problem gambling assessments and the remaining unique items from the three other problem gambling assessments. The order of assessments were counterbalanced. Two optimal scaling procedures were independently employed to estimate the number of dimensions within the data: exploratory categorical principal component bootstrap analysis and multidimensional scaling. Nonlinear canonical correlation was then used to establish how well each of the four assessment instruments captured the identified dimensions. A final confirmatory principal component analysis was run to understand and characterise the nature of the dimensions that were identified. Both the categorical principal component bootstrap analysis and multidimensional scaling indicated the data was multidimensional, with four dimensions (including a single dominant dimension) providing the best characterisation of the data. The nonlinear canonical correlation analysis found that the Problem and Pathological Gambling Measure and the National Opinion Research Center DSM-IV Screen for Gambling Problems operationalization of the Diagnostic and Statistical Manual of Mental Disorders Four (DSM-IV) criteria best captured these multiple dimensions. Confirmatory principal component analysis suggest a core experience of generic problem gambling symptomology and three other components: "financial problems", "health and relationship issues", and "difficulty controlling gambling". Problem gambling symptomology appears to be multi-dimensional. Certain assessments capture this heterogeneity better than others and thereby provide a more complete and accurate assessment of this construct.

Gambling and Cannabis Use: Clinical and Policy Implications

Eleven US States and the District of Columbia legally allow personal (i.e., recreational) cannabis use by adults, and an additional 22 states allow use of cannabis for medicinal purposes. Of these jurisdictions, only two do not have some form of legalized gambling available (https://www.casino.org/local/guide/). In contrast to this rapid increase in legally available marijuana is the limited knowledge about the intersection of cannabis use and gambling. This paper strives to define the current status of the relevant literatures and consider the implication for future gambling research. We describe the research literature on the prevalence of cannabis use and co-existing gambling problems and the effects of cannabis use on gambling-related cognitive functions and decision-making. We also discuss clinical considerations with treating problem gamblers with a cannabis use disorder. Finally, the potential implications for responsible gambling practices and policies and the most pressing gaps in the research literature are offered.

[Gambling and Gaming disorders and physical health of players: A critical review of the literature]

CONTEXT

Gambling and gaming disorders have been introduced as addictions in the DSM-5 and have been announced for the next edition of the ICD. Links between gambling and gaming and psychiatric comorbidities have been thoroughly investigated, but so far the impact of gambling and gaming on physical health has been overlooked.

OBJECTIVE

Our aim was to evaluate the impact of gaming and gambling disorders on the physical health of gamers and gamblers.

SOURCES

We conducted a systematic review of the literature, using PubMed/Medline to retrieve studies with the following: keywords: "gambling" ; "pathological gambling" ; "gambling health" ; "gaming" ; "pathological gaming" and "gaming health".

PAPERS SELECTION

Selected studies all reported on the physical health of gamers and gamblers with addiction. We obtained 133 articles from the Medline database. After screening abstracts and introductions and full reading of papers we retrieved 25 articles for this review. Seventeen articles reporting 56,179 subjects with gambling disorder and 8 articles reporting 63,887 subjects with gaming disorder.

RESULTS

All papers described the physical health of individuals with gaming and gambling disorders. For gambling, data showed the existence of digestive disorder (20 to 40%), sleeping disorders (35 to 68%), headaches (20 to 30%) and cardiovascular disorders: tachycardia (9%) and coronary artery disease (2 to 23%). Results were mostly significant when compared to the general population. For gaming, available studies reported qualitative data. Most frequently reported symptoms were sleeping complaints, joint pain, headaches and visual problems. These symptoms were more frequently described for teenagers. Sleeping complaints were the most frequently reported symptom.

LIMITS

Although we found that the physical health of gamers and gamblers with addiction was impaired, no study investigated the causal role of addiction, gaming, and gambling. Further studies are needed to better understand how behavioral addictions impact physical heath.

CONCLUSION

Data reported in this review documented that individuals with gaming or gambling disorders have an impaired physical health. Knowledge of the symptoms reported could help primary care physicians to better screen for gambling and gaming disorders among their patients.

Spatial and sociodemographic correlates of gambling participation and disorder among female Filipino migrant workers in Macao, People's Republic of China

BACKGROUND AND AIMS

Correlates and risk factors for gambling disorder among vulnerable or transient populations such as transnational migrant workers are unknown. The current study examined sociodemographic and spatial correlates of gambling disorder among female Filipino domestic workers in Macao (SAR), China.

DESIGN

Survey-based, respondent-driven sampling study administered from November 2016 to August 2017.

SETTING

Macao (SAR), which encompassed 38 casinos within its 30.4 km² area at the time of this study.

PARTICIPANTS

Representative sample of N = 1194 female Filipino domestic workers in Macao.

MEASUREMENTS

Symptoms of gambling disorder based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Correlates evaluated included sociodemographic information, proximity to venues, perceived social support, and symptoms of depression and anxiety.

FINDINGS

Prevalence of gambling disorder was 5.1%. Multivariable regression analyses indicated that likelihood of gambling participation (i.e., ever gambling) was associated with current indebtedness (RR = 1.56, 95%CI = 1.08-2.25, p = .017) and worse self-reported health (RR = 1.31, 95%CI = 1.04-1.65, p = .02). Increased symptoms of gambling disorder were independently associated with lower perceived social support (RR = 0.92, 95%CI = 0.87-0.98, p = .006), increased dependents relying upon monthly remittances (RR = 1.10, 95%CI = 1.06-1.16, p < .001), increased depression severity (RR = 1.16, 95%CI = 1.07-1.25, p < .001), decreased salary quintile (RR = 0.97, 95%CI = 0.94-1.00, p = .04), and proximity to the nearest Mocha Club gaming venues (RR = 1.04, 95%CI = 1.02-1.07, p = .005). The association between proximity to casinos and increased symptoms of gambling disorder was significant only for domestic workers living apart from employers (RR = 1.07, 95%CI = 1.00-1.14, p = .04).

CONCLUSIONS

Increased spatial proximity to gambling venues and greater financial and psychosocial burdens are associated with gambling disorder among domestic workers in Macao.

Behavioural Isomorphism, Cognitive Economy and Recursive Thought in Non-Transitive Game Strategy

Game spaces in which an organism must repeatedly compete with an opponent for mutually exclusive outcomes are critical methodologies for understanding decision-making under pressure. In the non-transitive game rock, paper, scissors (RPS), the only technique that guarantees the lack of exploitation is to perform randomly in accordance with mixed-strategy. However, such behavior is thought to be outside bounded rationality and so decision-making can become deterministic, predictable, and ultimately exploitable. This review identifies similarities across economics, neuroscience, nonlinear dynamics, human, and animal cognition literatures, and provides a taxonomy of RPS strategy. RPS strategies are discussed in terms of (a) whether the relevant computations require sensitivity to item frequency, the cyclic relationships between responses, or the outcome of the previous trial, and (b) whether the strategy is framed around the self or other. The negative implication of this taxonomy is that despite the differences in cognitive economy and recursive thought, many of the identified strategies are behaviorally isomorphic. This makes it difficult to infer strategy from behavior. The positive implication is that this isomorphism can be used as a novel design feature in furthering our understanding of the attribution, agency, and acquisition of strategy in RPS and other game spaces.

Investigating the influence of 'losses disguised as wins' on decision making and motivation in rats

Multiline slot machines encourage continued play through 'losses disguised as wins' (LDWs), outcomes in which the money returned is less than that wagered. Individuals with gambling problems may be susceptible to this game feature. The cognitive and neurobiological mechanisms through which LDWs act are unknown. In a novel rat operant task, animals chose between a 'certain' lever, which always delivered two sugar pellets, or an 'uncertain' lever, resulting in four sugar pellets on 50% of trials. LDWs were then introduced as a return of three sugar pellets on 30-40% of uncertain rewarded trials. For half the rats, winning outcomes were paired with audiovisual feedback (cues). In a second study, the basolateral amygdala (BLA) was inactivated during initial presentation of LDWs. While LDWs shifted most rats' choice toward the certain lever, a subgroup of LDW vulnerable rats continued to choose the uncertain option, when the reward rate diminished. This profile of LDW vulnerability was reproduced after inactivating the BLA. Persistent choice of uncertain outcomes despite lower reward rates may reflect impaired functioning within the BLA. Future work using this model may provide insight into the neurobiological mechanisms contributing to the motivational properties of LDWs and their contribution to problematic gambling.

Impulsivity, risk gambling, and heavy episodic drinking among adolescents: A moderator analysis of psychological health

Introduction

Adolescence is associated with an increased inclination for risk behaviors, like gambling and heavy episodic drinking (HED). While impulsivity is a well-documented risk factor, the purpose of this study is to explore if there are variables modulating this association. The study examined the effects of impulsivity and psychological health on risk gambling and HED, and whether psychological health functions as a moderator, i.e., protective factor.

Methods

Data was extracted from the Stockholm School Survey, collected in 2014 and 2016 among students in the ninth grade of primary school (15-16 years) and second grade of upper secondary school (17-18 years) in Stockholm (n = 21,886). Impulsivity, psychological problems, risk gambling, HED, and a number of sociodemographic control variables were measured using self-report data. The statistical method was binary logistic regression.

Results

Results showed that risk gambling (3.4%) and HED (22.8%) were prevalent among Swedish pupils. Impulsivity and-to a weaker extent-psychological problems as well as several sociodemographic variables were risk factors for risk gambling and HED. Furthermore, psychological problems negatively moderated the association between impulsivity and HED among girls.

Conclusions

This study supports evidence that impulsivity represents a risk factor for risk behaviors, and-contrary to the a priori hypothesis-indicates that the association between impulsivity and HED in female students might be attenuated by the presence of psychological problems. Prevention measures should particularly address adolescents exhibiting the mentioned risk factors and aim at reducing psychological problems, but not necessarily target the adolescents showing impulsivity and psychological problems simultaneously.

Gambling disorder

Gambling disorder is characterized by a persistent, recurrent pattern of gambling that is associated with substantial distress or impairment. The prevalence of gambling disorder has been estimated at 0.5% of the adult population in the United States, with comparable or slightly higher estimates in other countries. The aetiology of gambling disorder is complex, with implicated genetic and environmental factors. Neurobiological studies have implicated cortico-striato-limbic structures and circuits in the pathophysiology of this disorder. Individuals with gambling disorder often go unrecognized and untreated, including within clinical settings. Gambling disorder frequently co-occurs with other conditions, particularly other psychiatric disorders. Behavioural interventions, particularly cognitive-behavioural therapy but also motivational interviewing and Gamblers Anonymous, are supported in the treatment of gambling disorder. No pharmacological therapy has a formal indication for the treatment of gambling disorder, although placebo-controlled trials suggest that some medications, such as opioid-receptor antagonists, may be helpful. Given the associations with poor quality of life and suicide, improved identification, prevention, policy and treatment efforts are needed to help people with gambling disorder.

Effects of Gambling Diagnostic Criteria Changes from DSM-IV to DSM-5 on Mental Disorder Comorbidity Across Younger, Middle-Aged, and Older Adults in a Nationally Representative Sample

Changes in Diagnostic and Statistical Manual (DSM) criteria for a gambling disorder from DSM-IV to DSM-5 included a drop in the minimum number of criteria required to qualify for a diagnosis. This threshold reduction resulted in a near doubling of prevalence in non-gambling focused populations. However, the impact of this change on psychiatric comorbidity with gambling is unknown. The current study aimed to: (a) examine whether the diagnostic change affected the severity of those diagnosed with a gambling disorder with respect to mental disorder comorbidity, and (b) determine whether this relationship differed across younger (18-34 years old), middle-aged (35-54 years old), and older (55 years old and over) age groups. This study utilized data from the National Epidemiological Survey for Alcohol and Related Conditions. Results indicated that the prevalence of comorbid mental health/substance use disorders did not significantly change between the DSM-IV pathological gambling group and DSM-5 gambling disorder group in the overall sample. However, among older adults, the DSM-5 gambling disorder were more likely to exhibit any anxiety disorder as well as any comorbid mental health/substance-use disorder compared to the DSM-IV pathological gamblers. No other significant differences were observed in mental health or substance-use disorders within age-specific groupings. Findings suggest that the new, less restrictive DSM-5 criteria for gambling addiction capture older gamblers with more severe clinical presentations in terms of co-occurring mental disorders, contrary to our expectation that the lowered threshold for diagnosis would result in less severe clinical cases.

Are Video Games a Gateway to Gambling? A Longitudinal Study Based on a Representative Norwegian Sample

The scope and variety of video games and monetary gambling opportunities are expanding rapidly. In many ways, these forms of entertainment are converging on digital and online video games and gambling sites. However, little is known about the relationship between video gaming and gambling. The present study explored the possibility of a directional relationship between measures of problem gaming and problem gambling, while also controlling for the influence of sex and age. In contrast to most previous investigations which are based on cross-sectional designs and non-representative samples, the present study utilized a longitudinal design conducted over 2 years (2013, 2015) and comprising 4601 participants (males 47.2%, age range 16-74) drawn from a random sample from the general population. Video gaming and gambling were assessed using the Gaming Addiction Scale for Adolescents and the Canadian Problem Gambling Index, respectively. Using an autoregressive cross-lagged structural equation model, we found a positive relationship between scores on problematic gaming and later scores on problematic gambling, whereas we found no evidence of the reverse relationship. Hence, video gaming problems appear to be a gateway behavior to problematic gambling behavior. In future research, one should continue to monitor the possible reciprocal behavioral influences between gambling and video gaming.

A Multivariate Evaluation of 25 Proximal and Distal Risk-Factors for Gambling-Related Harm

Individual differences in the risk of developing gambling-related harm play an important role in theoretical models and practical interventions. The present study attempted comprehensive measurement and evaluation of 25 known risk factors for gambling-related harm in order to determine which factors provided large and unique explanatory power. We surveyed 1650 regular gamblers from an online panel, screening in 1174 (466 male) who passed all checks of attention and response consistency. We evaluated each risk factor based on bivariate correlations with harms, then made separate multivariate evaluations of proximal (e.g., gambling motivations) and distal (e.g., religiosity) risk factors. Almost all bivariate correlations were significant, but most distal factors were not significant in multivariate models. Trait impulsivity was the most important risk factor by a large margin. Excessive consumption, less use of safe gambling practices, and more fallacies were key proximal risks of harm. Many well-known correlates of gambling harm (e.g., youth, lower educational attainment) do not show a direct role in the development of gambling harm when controlling for other factors. The results support theoretical models that emphasise early conditioning and biological vulnerability (manifested through impulsivity). Since maladaptive cognitive and behavioural schemas appear to be more important than motivations (e.g., escape, excitement, ego), interventions may benefit by targeting these proximal drivers of harm.

Prior Exposure to Salient Win-Paired Cues in a Rat Gambling Task Increases Sensitivity to Cocaine Self-Administration and Suppresses Dopamine Efflux in Nucleus Accumbens: Support for the Reward Deficiency Hypothesis of Addiction

Rats trained to perform a version of the rat gambling task (rGT) in which salient audiovisual cues accompany reward delivery, similar to commercial gambling products, show greater preference for risky options. Given previous demonstrations that probabilistic reinforcement schedules can enhance psychostimulant-induced increases in accumbal DA and locomotor activity, we theorized that performing this cued task could perpetuate a proaddiction phenotype. Significantly more rats developed a preference for the risky options in the cued versus uncued rGT at baseline, and this bias was further exacerbated by cocaine self-administration, whereas the choice pattern of optimal decision-makers was unaffected. The addition of reward-paired cues therefore increased the proportion of rats exhibiting a maladaptive cognitive response to cocaine self-administration. Risky choice was not associated with responding for conditioned reinforcement or a marker of goal/sign-tracking, suggesting that reward-concurrent cues precipitate maladaptive choice via a unique mechanism unrelated to simple approach toward, or responding for, conditioned stimuli. Although "protected" from any resulting decision-making impairment, optimal decision-makers trained on the cued rGT nevertheless self-administered more cocaine than those trained on the uncued task. Collectively, these data suggest that repeated engagement with heavily cued probabilistic reward schedules can drive addiction vulnerability through multiple behavioral mechanisms. Rats trained on the cued rGT also exhibited blunted locomotor sensitization and lower basal accumbal DA levels, yet greater cocaine-induced increases in accumbal DA efflux. Gambling in the presence of salient cues may therefore result in an adaptive downregulation of the mesolimbic DA system, rendering individuals more sensitive to the deleterious effects of taking cocaine.SIGNIFICANCE STATEMENT Impaired cost/benefit decision making, exemplified by preference for the risky, disadvantageous options on the Iowa Gambling Task, is associated with greater risk of relapse and treatment failure in substance use disorder. Understanding factors that enhance preference for risk may help elucidate the neurobiological mechanisms underlying maladaptive decision making in addiction, thereby improving treatment outcomes. Problem gambling is also highly comorbid with substance use disorder, and many commercial gambling products incorporate salient win-paired cues. Here we show that adding reward-concurrent cues to a rat analog of the IGT precipitates a hypodopaminergic state, characterized by blunted accumbal DA efflux and attenuated locomotor sensitization, which may contribute to the enhanced responsivity to uncertain rewards or the reinforcing effects of cocaine we observed.

Episodic and Binge Gambling: An Exploration and Preliminary Quantitative Study

The DSM-5 includes provisions for episodic forms of gambling disorder, with such changes aligned with earlier accounts of potential binge gambling behaviours. However, there is little research that indicates the utility of these classifications of episodic or binge gambling, and this study considered their characteristics in a clinical sample. It involved administration of a new binge gambling screening tool, along with routine measures, to n = 214 patients entering a specialist treatment clinic for gambling problems. Results indicated that episodic gambling was common in this clinical context, with 28 and 32% of patients reporting gambling episodes that were (a) regular and alternating, and (b) irregular and intermittent, respectively. These patterns were distinguished by factors including associations with covariates that indicated differences from continuous gamblers. For example, the irregular episodic gamblers, but not the regular pattern, demonstrated lower levels of problem gambling severity and comorbidity. Rates of potential binge gambling, which was defined in terms of additional criteria, were around 4% and numbers were insufficient for comparable analyses. The findings support inclusion of episodic forms of gambling disorder in the DSM-5, but highlight the need for improved recognition and research on heterogeneous forms of episodic gambling.

Disordered Gambling Prevalence: Methodological Innovations in a General Danish Population Survey

We study Danish adult gambling behavior with an emphasis on discovering patterns relevant to public health forecasting and economic welfare assessment of policy. Methodological innovations include measurement of formative in addition to reflective constructs, estimation of prospective risk for developing gambling disorder rather than risk of being falsely negatively diagnosed, analysis with attention to sample weights and correction for sample selection bias, estimation of the impact of trigger questions on prevalence estimates and sample characteristics, and distinguishing between total and marginal effects of risk-indicating factors. The most significant novelty in our design is that nobody was excluded on the basis of their response to a 'trigger' or 'gateway' question about previous gambling history. Our sample consists of 8405 adult Danes. We administered the Focal Adult Gambling Screen to all subjects and estimate prospective risk for disordered gambling. We find that 87.6% of the population is indicated for no detectable risk, 5.4% is indicated for early risk, 1.7% is indicated for intermediate risk, 2.6% is indicated for advanced risk, and 2.6% is indicated for disordered gambling. Correcting for sample weights and controlling for sample selection has a significant effect on prevalence rates. Although these estimates of the 'at risk' fraction of the population are significantly higher than conventionally reported, we infer a significant decrease in overall prevalence rates of detectable risk with these corrections, since gambling behavior is positively correlated with the decision to participate in gambling surveys. We also find that imposing a threshold gambling history leads to underestimation of the prevalence of gambling problems.

Effects of a depression-focused internet intervention in slot machine gamblers: A randomized controlled trial

BACKGROUND

Problematic and pathological gambling have been linked to depression. Despite a high demand for treatment and negative financial consequences, only a small fraction of problematic and pathological gamblers seek professional help. The existing treatment gap could be narrowed by providing low-threshold, anonymous internet-based interventions. The aim of the present study was to examine the acceptance and efficacy of an online-intervention for depression ("Deprexis") in a sample of problematic and pathological slot-machine gamblers. We hypothesized that the intervention group would show a greater reduction in both depressive and gambling-related symptoms compared to a wait-list control group.

METHOD

A total of 140 individuals with self-reported gambling and mood problems were randomly allocated either to the intervention group or to a wait-list control group. After 8 weeks, all participants were invited for re-assessment. The Patient Health Questionnaire - 9 (PHQ-9) served as the primary outcome assessment. Problematic gambling was measured with the Pathological Gambling Adaptation of Yale-Brown Obsessive Compulsive Scale (PG-YBOCS) and the South Oaks Gambling Screen (SOGS). The trial is registered with the German Registry for Clinical Studies (DRKS00013888).

RESULTS

ITT analyses showed that the intervention led to a significant reduction in depressive symptoms as well as gambling-related symptoms compared to the control group, with moderate to strong effect sizes. PP analyses failed to yield significant results due to high rates of non-completion and limited statistical power. Moderator analyses indicated that Deprexis was particularly beneficial in reducing problematic gambling for those scoring high on baseline gambling-related symptoms and for those who gamble due to loneliness.

DISCUSSION

Results of the present study suggest that Deprexis might be a useful adjunct to traditional interventions for the treatment of problematic gambling. The potential of internet-based interventions that are more targeted at issues specific to gambling should be evaluated in future studies.

TRIAL REGISTRATION

German Registry for Clinical Studies DRKS00013888.

Behavioral Addictions as Mental Disorders: To Be or Not To Be?

Should excessive and problematic engagement in nonsubstance use behaviors be mental disorders? The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) repositioned gambling disorder in the substance use disorders section and introduced Internet gaming disorder in the research appendix; the International Classification of Diseases (ICD-11) is also considering it. This article outlines pros and cons of considering behavioral addictions as mental disorders and also reviews the DSM-5 decision-making processes. It focuses on three conditions: gambling disorder, Internet gaming disorder (IGD), and Internet addiction (IA). We detail assessment methods and prevalence rates for these conditions and outline psychiatric comorbidities, demographic and biological risk factors, and promising treatment approaches. We also briefly discuss other putative behavioral addictions: eating/food, sex, exercise, shopping, and tanning "addictions." Overall, data are inconclusive, and consistent terminology and methodology are needed to define and evaluate these conditions more fully prior to considering them mental disorders.

An overview of gambling disorder: from treatment approaches to risk factors

Gambling disorder (GD) has been reclassified recently into the "Substance-Related and Addictive Disorders" category of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a landmark occurrence for a behavioral addiction. GD is characterized by recurrent, maladaptive gambling behavior that results in clinically significant distress. Although the number of randomized controlled trials assessing the effectiveness of pharmacological treatments is limited, some pharmacological treatments, notably opiate antagonists, have been employed in the treatment of GD. Patients with GD often present cognitive distortions and specific personality traits, making treatment more difficult. Cognitive behavioral therapy has become the most common psychological intervention for treating gambling problems, and it is effective in reducing gambling behavior. In this brief overview, we provide a report on the state of pharmacological and psychological treatments for gambling disorder. Risk factors and potential future lines of research are addressed.

Stress moderates the relationships between problem-gambling severity and specific psychopathologies

The purpose of this study was to examine the extent to which stress moderated the relationships between problem-gambling severity and psychopathologies. We analyzed Wave-1 data from 41,869 participants of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC). Logistic regression showed that as compared to a non-gambling (NG) group, individuals at-risk gambling (ARG) and problem gambling (PPG) demonstrated higher odds of multiple Axis-I and Axis-II disorders in both high- and low-stress groups. Interactions odds ratios were statistically significant for stress moderating the relationships between at-risk gambling (versus non-gambling) and Any Axis-I and Any Axis-II disorder, with substance-use and Cluster-A and Cluster-B disorders contributing significantly. Some similar patterns were observed for pathological gambling (versus non-gambling), with stress moderating relationships with Cluster-B disorders. In all cases, a stronger relationship was observed between problem-gambling severity and psychopathology in the low-stress versus high-stress groups. The findings suggest that perceived stress accounts for some of the variance in the relationship between problem-gambling severity and specific forms of psychopathology, particularly with respect to lower intensity, subsyndromal levels of gambling. Findings suggest that stress may be particularly important to consider in the relationships between problem-gambling severity and substance use and Cluster-B disorders.

Alterations in the Emotional Regulation Process in Gambling Addiction: The Role of Anger and Alexithymia

This study aims at the assessment of alexithymia and anger levels in 100 treatment-seeking pathological gamblers compared with controls, who were matched for age, gender and education. Furthermore a positive correlation between alexithymia, anger and severity of gambling disorder and a relationship between gambling behaviour and anger after controlling for alexithymia, are investigated. Finally the role that gender plays in anger in pathological gamblers was also evaluated. Psychological assessment includes the South Oaks Gambling Screen, State-Trait Anger Expression Inventory-2 and the twenty-item Toronto Alexithymia Scale. Statistical analysis of the results shows a higher level of anger in pathological gamblers than in controls, together with alterations in emotional processing. Severity of gambling behaviour positively correlates with alexithymia scores, state-anger and trait-anger. Moreover, a significant contribution of anger in predicting gambling behaviour was suggested after controlling for alexithymia. In conclusion, anger and alexithymia must be regarded as relevant components of the assessment of pathological gamblers, in order to select the best therapeutical strategies to prevent self-defeating behaviours and to reduce drop-out from treatments.