The neural bases of cognitive processes in gambling disorder

Learning and memory processes in behavioural addiction: A systematic review

Similar to addictive substances, addictive behaviours such as gambling and gaming are associated with maladaptive modulation of key brain areas and functional networks implicated in learning and memory. Therefore, this review sought to understand how different learning and memory processes relate to behavioural addictions and to unravel their underlying neural mechanisms. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched four databases - PsycINFO, PubMed, Scopus, and Web of Science using the agreed-upon search string. Findings suggest altered executive function-dependent learning processes and enhanced habit learning in behavioural addiction. Whereas the relationship between working memory and behavioural addiction is influenced by addiction type, working memory aspect, and task nature. Additionally, long-term memory is incoherent in individuals with addictive behaviours. Consistently, neurophysiological evidence indicates alterations in brain areas and networks implicated in learning and memory processes in behavioural addictions. Overall, the present review argues that, like substance use disorders, alteration in learning and memory processes may underlie the development and maintenance of behavioural addictions.

Impulse and reason? Justifications in problem gambling

People often use justifications to make desirable choices, but little is known about these justificatory thoughts in gambling. We conducted an exploratory Study 1 (n = 101) and a confirmatory Study 2 (n = 154) using online surveys, recruiting gamblers with prior and current experience of trying to reduce their gambling. Using justifications recognized in the domains of eating and consumer behavior (e.g., prior use of effort, feelings of achievement), we examined whether justifications were associated with problem gambling severity, and whether they explained additional variance above trait impulsivity and cognitive distortions. In both studies, justifications were positively associated with problem gambling severity, after accounting for trait impulsivity and cognitive distortions. Additionally, justifications were positively correlated with trait urgency and cognitive distortions, indicating that such thinking may not be antithetical to impulsivity. These data provide proof-of-principle evidence that justificatory thinking occurs in the context of gambling, is related to problem gambling severity, and may therefore represent a neglected aspect of gambling-related cognitions.

The protective effects of cognitive empathy and emotional empathy on gambling disorder are mediated by risk aversion and responsible gambling attitude

BACKGROUND

Based on social cognitive theory, this study aimed to examine whether and how social abilities (i.e., cognitive empathy and emotional empathy) are associated with gambling disorder (GD) by incorporating attitudes toward general risk (i.e., risk aversion) and responsible gambling as potential mediators of this link.

METHODS

A convenience sample of 580 past-year lottery gamblers (Mage = 34.07, SD = 13.36; 50.4% female), recruited near lottery sales shops, completed an anonymous paper-version questionnaire on site. Data were collected using the DSM-5 diagnostic criteria for GD, Interpersonal Reactivity Index, Risk Aversion Scale, Positive Play Scale, and demographic items. Path analysis and mediation analysis were applied to examine the effects of cognitive empathy and emotional empathy on GD and the mediating roles of risk aversion and responsible gambling attitude.

RESULTS

Our results showed that cognitive empathy, but not emotional empathy, was significantly and negatively correlated with GD. Also, the effect of cognitive empathy on GD was fully mediated by risk aversion and responsible gambling attitude, whilst the total indirect effect of emotional empathy on GD was nonsignificant. As hypothesized, the indirect paths from both types of empathy to GD were significantly and serially mediated by risk aversion and responsible gambling attitude.

CONCLUSION

Cognitive empathy, distinct from emotional empathy, was a statistically significant correlate of GD. Moreover, the path model results also suggest that responsible gambling attitude was a salient protective factors against GD. Future GD prevention efforts may benefit from paying more attention to the role of responsible gambling attitude.

Excitatory stimulation of the ventromedial prefrontal cortex reduces cognitive gambling biases via improved feedback learning

Humans are subject to a variety of cognitive biases, such as the framing-effect or the gambler's fallacy, that lead to decisions unfitting of a purely rational agent. Previous studies have shown that the ventromedial prefrontal cortex (vmPFC) plays a key role in making rational decisions and that stronger vmPFC activity is associated with attenuated cognitive biases. Accordingly, dysfunctions of the vmPFC are associated with impulsive decisions and pathological gambling. By applying a gambling paradigm in a between-subjects design with 33 healthy adults, we demonstrate that vmPFC excitation via transcranial direct current stimulation (tDCS) reduces the framing-effect and the gambler's fallacy compared to sham stimulation. Corresponding magnetoencephalographic data suggest improved inhibition of maladaptive options after excitatory vmPFC-tDCS. Our analyses suggest that the underlying mechanism might be improved reinforcement learning, as effects only emerge over time. These findings encourage further investigations of whether excitatory vmPFC-tDCS has clinical utility in treating pathological gambling or other behavioral addictions.

Working memory performance in disordered gambling and gaming: A systematic review

BACKGROUND

Converging evidence supports that gaming and gambling disorders are associated with executive dysfunction. The involvement of different components of executive functions (EF) in these forms of behavioural addiction is unclear.

AIM

In a systematic review, we aim to uncover the association between working memory (WM), a crucial component of EF, and disordered gaming and gambling. Note that, in the context of this review, gaming has been used synonymously with video gaming.

METHODS

Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we systematically searched for studies published from 2012 onwards.

RESULTS

The search yielded 6081 records after removing duplicates, from which 17 peer-reviewed journal articles were eligible for inclusion. The association between WM and problem or disordered gaming and gambling have been categorized separately to observe possible differences. Essentially, problem gaming or gambling, compared to disorder, presents lesser severity and clinical significance. The results demonstrate reduced auditory-verbal WM in individuals with gambling disorder. Decreased WM capacity was also associated with problem gambling, with a correlation between problem gambling severity and decreased WM capacity. Similarly, gaming disorder was associated with decreased WM. Specifically, gaming disorder patients had lower WM capacity than the healthy controls.

CONCLUSION

Working memory seems to be a significant predictor of gambling and gaming disorders. Therefore, holistic treatment approaches that incorporate cognitive techniques that could enhance working memory may significantly boost gambling and gaming disorders treatment success.

Annual Research Review: Emergence of problem gambling from childhood to emerging adulthood: a systematic review

BACKGROUND

The risk for problematic gambling and associated high-risk behaviors is elevated during adolescence and emerging adulthood. Activities with gambling-like features and novel forms of gambling may place youth at an increased risk for problem gambling.

AIM AND METHOD

The aim of this review is to provide an overview of the association between both activities with gambling-like features and novel gambling activities and problem gambling among youth while examining the role of psychopathology and cognitive processes. Six databases (PsychINFO, MEDLINE, PubMed, Social Work Abstracts, Technology Collection, and Scopus) were searched in November 2021 for peer-reviewed articles investigating the association between the aforementioned variables among youth up to the age of 25 years. Risk of bias was assessed using the Observational Study Quality Evaluation.

FINDINGS

Forty-five articles were included in the review. Positive associations were observed between engagement in activities with gambling-like features (e.g., video games, social casino games, loot boxes) and problem gambling. Increased involvement with novel forms of gambling (e.g., online sports betting, fantasy sports, and esports betting) were also associated with a greater risk for problematic gambling. Males reported higher rates of engagement in these activities and a greater risk of problem gambling than females. Impulsivity, risk taking, cognitive distortions, and specific emotional vulnerabilities were associated with an increased risk of problem gambling.

CONCLUSIONS

Despite the need for additional longitudinal research controlling for relevant confounders, these findings underline how engagement in activities with gambling-like features are relevant in the developmental trajectory toward problem gambling.

Potential Biological Markers and Treatment Implications for Binge Eating Disorder and Behavioral Addictions

The reward system is highly relevant to behavioral addictions such as gambling disorder (GD), internet gaming disorder (IGD), and food addiction/binge eating disorder (FA/BED). Among other brain regions, the ventral striatum (VS) has been implicated in reward processing. The main objective of the present state-of-the-art review was to explore in depth the specific role of the VS in GD, IGD and FA/BED, understanding it as a possible biomarker of these conditions. Studies analyzing brain changes following interventions for these disorders, and especially those that had explored possible treatment-related changes in VS, are discussed. More evidence is needed on how existing treatments (both pharmacological and psychobehavioral) for behavioral addictions affect the activation of the VS and related circuitry.

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.

Winning and losing in online gambling: Effects on within-session chasing

The tendency to continue or intensify gambling after losing (loss-chasing) is widely regarded as a defining feature of gambling disorder. However, loss-chasing in real gambling contexts is multifaceted, and some aspects are better understood than others. Gamblers may chase losses between multiple sessions or within a single session. Furthermore, within a session, loss-chasing can be expressed in the decision of (1) when to stop, (2) how much stake to bet, and (3) the speed of play after winning and losing. Using a large player-tracking data set (>2500 players, >10 million rounds) collected from the online commercial game Mystery Arena, we examined these three behavioral expressions of within-session loss-chasing. While the first two aspects (when to stop and how much stake to bet) have been examined previously, the current research is the first large-scale study to examine the effects of wins and losses on the speed of play in real gambling. The players were additionally assigned different involvement levels by the operator based on their gambling behavior on the operator’s own platform, which further allowed us to examine group differences in loss-chasing. We found that after winning, both the high- and low-involvement groups were less likely to stop, and increased the stake amount, thus showing win-chasing instead of loss-chasing in these two facets. After losing, both groups played more quickly though, which may reflect an urge to continue gambling (as an expression of loss-chasing). Wins and losses had a smaller influence on the speed of play for the high-involvement players, suggesting that they might have reduced sensitivity to wins and/or losses. Future work can further examine chasing in different gambling products and in people with gambling problems to assess the generalizability of these findings.

Is Empathy Associated with Gambling and Its Addiction? A Scoping Review of Empirical Studies

Considering the low levels of empathy associated with substance-related addictions and the similarities between gambling disorder (GD) and substance-related addiction, understanding the relationship between empathy and GD may clarify the mechanism of addiction development. This scoping review aimed to evaluate the empirical evidence for the potential protective role of emotional and cognitive empathy against GD development via internalizing and/or externalizing pathways. We followed the preferred reporting items for systematic review and meta-analyses extension for scoping reviews and 11 articles met the inclusion criteria. Although most of the reviewed studies used correlational designs and non-gambling-specific samples, this review highlights (1) significant relationships between both types of empathy and the neural activity of gambling behaviors, and (2) reduced cognitive empathy (i.e., fantasy and perspective taking) and increased emotional empathy (i.e., personal distress) among problem gamblers than their gambling counterparts. Despite the lack of studies directly testing the protective role of empathy against GD, the existing studies (n = 8) nevertheless shed light on the potential protective effects of both types of empathy on GD development. This review identified research gaps, which can be addressed in future studies by discovering the underlying mechanisms (e.g., internalizing and externalizing pathways) of these relationships. Experimental or longitudinal studies in gamblers investigating how different types of empathy are associated with GD via these pathways are called for as their findings have implications for prevention and intervention designs for GD and other addictive disorders.

Associations Between Addictive Behaviors, Individual Characteristics, and the Use of Gambling Services Within the World of Gaming: Cross-sectional Survey Study

Background

Gambling within the world of gaming is an emerging phenomenon that may share common conceptual characteristics with traditional forms of gambling. The current literature suggests a higher degree of problematic behaviors in this gambling pattern, but studies are few, prompting for further research regarding individual characteristics and comorbid conditions associated with this activity.

Objective

The aim of the study is to investigate correlations between the use of gambling services within the world of gaming and individual characteristics and addictive behaviors including problem gambling.

Methods

A cross-sectional web survey was distributed to an existing panel of online respondents in Sweden. A total of 2001 respondents were included. Chi-square and Mann-Whitney U tests, followed by a logistic regression, were used in order to determine independent variables associated with gambling in the context of gaming.

Results

A total of 2.9% (58/1984) of respondents reported past-year gambling within gaming. Significant associations were found with male sex, younger age, history of treatment-seeking for alcohol problems, and higher Gaming Addiction Scale scores.

Conclusions

The demonstrated findings strengthen previously found associations between gambling in gaming and younger age, male sex, and problematic gaming behaviors. Additionally, the association with a history of treatment needs for alcohol problems adds to the previous impression of increased problem severity and comorbidity in within-gaming gamblers.

A Comparison of Gambling-Related Cognitions and Behaviors in Gamblers from the United States and Spain

Few studies have compared the clinical characteristics of gambling disorder (GD) from a cross-cultural perspective. In the present study, we aimed to examine differences in gambling-related cognitions, gambling preferences, GD severity and other clinical and sociodemographic variables in individuals with GD in the United States and Spain. Two groups of participants with GD (from the United States of America (US; n = 109) and Spain (n = 243) were compared using the South Oaks gambling screen and the gambling-related cognitions scale. In Spain, the prevalence of participants who reported only non-strategic gambling preferences was higher, whereas in the US, participants tended to engage in a wider breadth of gambling activities. Moreover, Spanish participants reported higher GD severity, while participants in the US endorsed greater gambling-related cognitions. Our findings suggest that there may jurisdictional or cultural differences in terms of gambling-related cognitions, gambling preferences, and GD severity levels among individuals in the US versus Spain. These differences, which may reflect cultural regulatory or other factors, should be investigated further, and considered when developing and implementing interventions for GD.

Gambling, Substance Use and Violence in Male and Female Adolescents

The study systematically examined the link between history of gambling, and substance-use and violence-related measures in male and female adolescents, and compared association differences between genders in representative youth risk behavior surveillance data. An anonymous survey was administered to 2425 9th- to 12th-grade students in the state of Connecticut to assess risk behaviors that impact health. Reported past-12-months gambling was the independent variable of interest. Chi squares and adjusted odds-ratios were computed to determine gambling associations with demographic variables, substance-use, and violence-related measures, and whether associations were different between genders. Among students, 18.6% reported gambling. Reported gambling in males and females associated with lifetime use of any drugs, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, synthetic marijuana, non-medical pain-relievers, and injected drugs, in addition to past-30-days cigarette smoking, alcohol and heavy alcohol drinking, and marijuana use. Gambling associated with reported weapon-carrying, being threatened or injured with a weapon, forced sexual intercourse, bullying, and electronic bullying in males; physical dating violence in females; and physical fighting and sexual dating violence in both groups. Gambling and gender interaction terms did not associate with outcome measures except synthetic marijuana use, which trended towards significance (P = 0.052). Gambling in adolescence was similarly linked to risk behaviors involving substance-use in males and females, though gambling relationships with different violence-measures varied between genders. Assessing gambling behavior may be important for targeted preventions focused on adolescents at risk for substance-use disorder and physical violence.

The C Factor: Cognitive dysfunction as a transdiagnostic dimension in psychopathology

Research into cognitive functions across psychological disorders suggests that cognitive deficiencies may be present across multiple disorders, potentially pointing to a transdiagnostic phenomenon. More recently, a single dimension model of psychopathology, the p factor, has been proposed, in which cognitive deficits are thought to be an intrinsic construct, assumed to be transdiagnostic. However, no systematic investigation to date tested this hypothesis. The aim of the present study was to systematically review meta-analyses to assess the hypothesis that the C factor (cognitive dysfunction) is transdiagnostic in psychopathology and review potential moderators that may account for such a phenomenon. We conducted a systematic review of meta-analyses examining cognitive function across all disorders for which data were available. Included meta-analyses (n = 82), comprising 97 clinical samples, yielded 1,055 effect sizes. Twelve major disorders/categories (e.g., bipolar disorder, substance use disorders) were included, comprising 29 distinct clinical entities (e.g., euthymic bipolar disorder; alcohol use disorder). Results show that all disorders reviewed are associated with underperformance across cognitive domains, supporting the hypothesis that the C factor (or cognitive dysfunction) is a transdiagnostic factor related to p. To examine moderators that may explain or contribute to c, we first consider important interpretative limitations of neuropsychological data in psychopathology. More crucially, we review oft-neglected motivational and emotional transdiagnostic constructs of p, as prominent contributing constructs to the C factor. These constructs are offered as a roadmap for future research examining these constructs related to p, that contribute, and may account for cognitive dysfunctions in psychopathology.

Decision-Making in Gambling Disorder, Problematic Pornography Use, and Binge-Eating Disorder: Similarities and Differences

Purpose of Review

The present review attempts to provide a comprehensive and critical overview of the neurocognitive mechanisms of gambling disorder (GD), problematic pornography use (PPU) and binge-eating disorder (BED), focusing specifically on decision-making processes.

Recent findings

GD, PPU and BED have been associated with decision-making impairments both under risk and ambiguity. Features such as intelligence, emotions, social variables, cognitive distortions, comorbidities, or arousal may condition decision-making processes in these individuals.

Summary

Impairments in decision-making seem to be a shared transdiagnostic feature of these disorders We also hypothesized the EG relative to the NEG group would demonstrate weaker relationships between problem-gambling severity and health/functioning measures (e.g., substance use) and gambling behaviors (e.g., more time spent gambling) given that EG would account for some of the variance in the relationships between ARPG and these measures. However, there is varying support for the degree to which different features may affect decision-making. Therefore, the study of decision-making processes can provide crucial evidence for understanding addictions and other disorders with addiction-like symptomatology.

Comparing football bettors' response to social media marketing differing in bet complexity and account type - An experimental study

BACKGROUND AND AIMS

The current study aimed to assess how sports bettors respond to advertised bets on social media and whether this differs dependent upon bet complexity and social media account type.

METHODS

Employing a 3 × 2 repeated measures design, 145 regular football bettors were recruited to take part in an online study requiring them to rate bets advertised upon social media, providing indications of their likelihood to bet, confidence in the bet and how much they would stake on the bet. Advertised bets differed in terms of complexity (low, medium and high) and each bet was presented separately on both an operator account and an affiliate account.

RESULTS

Data analysis highlighted a significant interaction between bet complexity and account type, with bettors rating themselves as being more likely to bet and more confident in bets which were presented on an affiliate account for medium complexity bets but not for low or high complexity bets.

DISCUSSION AND CONCLUSIONS

This study provides initial evidence that affiliate marketing of sports betting increases bettor's confidence in certain types of bets. This heightens previously addressed concerns around affiliate marketing, given that affiliates are financially incentivised to attract custom toward gambling operators. Future research should explore risk factors for increased uptake of affiliate marketing, and the impact on gambling behaviour.

Schizophrenia symptom severity and motivations for gambling in individuals with schizophrenia or schizoaffective disorder

Individuals with schizophrenia are over three times more likely to have problem and pathological gambling (PPG) than the general population (Cunningham-Williams et al., 1998; Desai and Potenza, 2009), but little is known about this co-occurrence and how PPG relates to specific symptom dimensions of psychotic disorders. Although cognitive distortions in PPG have been linked to gambling motivations (e.g., distorted thoughts about odds of winning), how psychotic symptoms in schizophrenia or related disorders relate to gambling motivations have not been examined systematically to date. Individuals with schizophrenia or schizoaffective disorder (n = 170) completed structured face-to-face interviews regarding problem-gambling severity, gambling motivations, and five symptom factors of psychosis (Positive, Negative, Disorganized/Concrete, Depressed, and Excited). Different symptom dimensions of psychosis showed distinct patterns of relationships with motivations to gamble and gambling onset. PPG in schizophrenia was associated with elevated scores on the Depressed factor. Psychotic symptom severity was associated with increased motivation to gamble for financial reasons and decreased motivations to gamble for service, and possibly social or interpersonal, reasons. Age of gambling onset was inversely associated with psychotic symptom severity, particularly positive features. Our findings suggest that motivations for gambling may differ in the context of schizophrenia and relate to specific symptom clusters.

Common neurobiological and psychological underpinnings of gambling and substance-use disorders

Both psychological and neurobiological studies in gambling disorder have increased in the past 10-15 years. This review examines the current state of the literature, with a focus on recent magnetic resonance imaging (MRI) studies in gambling disorder. The review compares and contrasts findings across gambling and substance-use disorders. Additionally, features with arguably particular relevance to gambling disorder (e.g., "near-miss" processing) are described, as well as their relationship to choice behaviors. More broadly, the review informs on how these studies advance our understanding of brain-behavior relationships relating to decision-making and key features of addictive disorders.

Dimensions of Impulsivity in Gambling Disorder

Impulsivity is a multidimensional construct. Although gambling disorder (GD) has been associated with high impulsivity, impulsivity across multiple domains has not been thoroughly investigated in this population. We first aimed to examine whether associations between three facets of impulsivity (response impulsivity, choice impulsivity and impulsive tendency) varied between GD patients and healthy controls (HC). We next aimed to evaluate relationships between these three types of impulsivity, as proposed by theoretical models of impulsivity, and their associations with GD severity. The sample included 97 treatment-seeking adult men with GD, diagnosed according to DSM-5 criteria, and 32 male HCs recruited from the general population. Greater impulsivity in all three domains was found in men with GD in comparison to men without GD. Associations between impulsivity facets were found in both groups, with response impulsivity being the only domain associated with GD severity. Our findings confirm that multiple domains of impulsivity are relevant in GD. Future studies should examine the extent to which treatments aimed at targeting specific aspects of impulsivity improve outcomes.

Current pharmacotherapy for gambling disorder: a systematic review

Introduction: Gambling disorder is classified as an addictive disorder and is associated with significant distress and impairment in personal, social, occupational or other important areas of functioning. Although no pharmacotherapy has a formal indication for gambling disorder, data suggest potential benefits of specific medications.Area covered: This systematic review evaluated findings from 19 randomized controlled trials testing pharmacotherapies for the treatment of gambling disorder.Expert opinion: Few randomized controlled trials have studied pharmacotherapies for gambling disorder. Though results are limited, opioid antagonists like naltrexone showed promise in the pharmacological treatment of gambling disorder. Pharmacotherapy combined with psychotherapy treatments for gambling disorder may provide better rates of patient retention in comparison to pharmacology-only treatments, though further research is needed in this area. Future studies should address gaps relating to considerations of racial, ethnic, gender and other individual differences in clinical studies. Because gambling disorder often co-occurs with other psychiatric disorders, additional research is needed to test treatments for dually diagnosed patients.

Dopamine and Gambling Disorder: Prospects for Personalized Treatment

Purpose of Review

To address variation in the severity of gambling disorder, this review evaluates the contribution of mesocorticolimbic dopamine neurons to potential behavioral endophenotypes, the influence of individual differences in the dopamine system on gambling and related behaviors, and the possible role for dopaminergic medications in the treatment of gambling disorder.

Recent Findings

Newer work has suggested that dopaminergic dysfunction can lead to increased reward anticipation and a greater sensitivity to uncertainty, which in turn may drive addictive gambling behaviors. In addition, increased impulsivity, a well-recognized risk factor for gambling disorder, has been linked to dopaminergic dysfunction. More recently, emerging evidence has suggested that dopaminergic medications can influence the discounting of delayed rewards.

Summary

Dopaminergic drugs that increase the salience of long-term over short-term goals may ameliorate symptoms of impulsive individuals with gambling disorder. More broadly, improved understanding of intermediate behavioral and other phenotypes with a defined neurobiological substrate may allow for personalized treatment of gambling disorder and other psychiatric conditions.

Gambling and Social Cognition: a Systematic Review

Purpose of Review

The aim of this article was to review current research regarding social cognition (SC) in gambling disorder (GD), to (i) compile and synthetize the current state of existing literature on this topic, and (ii) propose cognitive remediation therapy approaches focused on SC for clinicians.

Recent Findings

It is well known that disordered gamblers show impairment regarding non-social cognitive functions such as inhibition, attention, and decision-making. Furthermore, patients with substance use disorders also present certain deficits regarding social information processing which are difficult to differentiate from the intrinsic toxic effects linked to drugs or alcohol consumption.

Summary

To date, relatively little research has been undertaken to explore SC in gambling disorder (GD) with neuropsychological tasks. Preliminary results suggest impaired non-verbal emotion processing, but only one study has directly measured SC in GD. As a consequence, future research on this framework should propose diverse measures of SC, while controlling for other factors such as personality traits and subtypes of disordered gamblers.

Addictive behaviors in alcohol use disorder: dysregulation of reward processing systems and maladaptive coping strategies

DSM-5 has included within the substance-related and addictive disorders diagnostic category behavioral addictions, such as gambling disorder. Some scholars also considered ICD-11 compulsive sex as a behavioral addiction. Furthermore, an addiction model of dysfunctional eating behaviors has been proposed. Consistently, the existence of common addiction mechanisms related to substance and non-substance related disorders has been hypothesized. Nevertheless, this approach was called into question, especially considering alternative processes which might be implicated in such conditions. This study aims to compare these opposite theoretical positions concerning substance- and nonsubstance related disorders, investigating the latent structure of addictive behaviors among alcohol use disorder (AUD) individuals. Addictive behaviors were self-reported assessed using the Shorter PROMIS Questionnaire (SPQ). We recruited 456 (59.2% male; 40.8% female) AUD treatment-seeking patients. Two latent structures were tested using a confirmatory factor analytic approach. We compared a one-factor (i.e., common addiction mechanisms) with a two-factor solution (i.e., dysregulation of reward processing systems and maladaptive coping strategies). The two-factor solution showed adequate goodness-of-fit indexes. Specifically, dysregulation of the reward processing systems dimension predicted the SPQ illicit and prescription drugs, gambling, and sex subscales. Conversely, the maladaptive coping strategies dimension predicted the SPQ compulsive buying, binge eating and food restriction subscales. The latent dimensions significantly correlated with each other. Compulsive sex might be preliminarily considered as a behavioral addiction. AUD individuals might show complex patterns of maladaptive behaviors functionally related to different latent processes. Differential treatment approaches are suggested to treat these conditions.

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.

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.

Approach bias for erotic stimuli in heterosexual male college students who use pornography

BACKGROUND AND AIMS

Addicted individuals often demonstrate relatively automatic action tendencies in response to addiction-related stimuli, whereby they approach rather than avoid addictive stimuli. This study assessed whether an approach bias for erotic stimuli exists among heterosexual college-aged males who report using pornography.

METHODS

We tested 72 male undergraduate students using an approach-avoidance task employing erotic stimuli, during which participants were instructed to push or pull a joystick in response to image orientation. To simulate approach and avoidance movements, pulling the joystick enlarged the image and pushing shrunk the image. Frequency and severity of pornography use was assessed using a Brief Pornography Screener and the Problematic Pornography Use Scale (PPUS).

RESULTS

Participants demonstrated a significant approach bias for erotic stimuli as compared to neutral stimuli, and this approach bias significantly correlated with pornography-use measures. Moreover, individuals with problematic pornography use (as classified by the PPUS) showed more than double the approach bias than did non-problematic users.

DISCUSSION AND CONCLUSION

The observation of cognitive biases for erotic stimuli in individuals with problematic pornography use indicate similarities between behavioral and substance addictions.

Locating gambling problems across a continuum of severity: Rasch analysis of the Quinte Longitudinal Study (QLS)

Addressing gambling problems across a continuum requires understanding of low severity problems, as well as severe levels of problem gambling or disorder. The aims of this study were thus to derive a map of how problematic gambling behaviours and harms are situated across a continuum, and identify the best available indicators of low severity problems to inform assessment and secondary prevention. This involved the Rasch analyses of baseline data from the Quinte Longitudinal Study (QLS); a community-based survey involving random-digit dialling of numbers around Belleville, Canada. Participants were n = 1305 adults with non-zero scores across 26-items from: the Problem Gambling Severity Index (PGSI); the NORC DSM Screen for Gambling Problems (NODS); and the Problem and Pathological Gambling Measure (PPGM). Results indicated that item-level measures except chasing losses provided fit to the Rasch model, and most were clustered within a narrow region of the continuum which resembled addictive disorders. At the most severe end were mainly items about harms, while there were few items representing low severity levels (feeling guilty, betting more than one can afford, attempts to reduce gambling, gambling more than intended). There was Differential Item Functioning (DIF) for several indicators of low severity problems. The findings suggest that measures remain closely aligned with psychiatric models and are suited for discriminating across severe levels of problem gambling or addictive disorder. Although cognitive-affective and behavioural indicators comprise the best available indicators of low severity symptoms, there is an urgent need for improvements in conceptualisation and measurement.

Effect of transcranial direct current stimulation on decision making and cognitive flexibility in gambling disorder

Decision making and cognitive flexibility are two components of cognitive control that play a critical role in the emergence, persistence, and relapse of gambling disorder. Transcranial direct current stimulation (tDCS) over the dorsolateral prefrontal cortex (DLPFC) has been reported to enhance decision making and cognitive flexibility in healthy volunteers and individuals with addictive disorders. In this triple-blind randomized sham-controlled parallel study, we aimed to determine whether tDCS over DLPFC would modulate decision making and cognitive flexibility in individuals with gambling disorder. Twenty participants with gambling disorder were administered Iowa Gambling Task (IGT) and Wisconsin Card Sorting Test (WCST). Subsequently, participants were administered three every other day sessions of active right anodal /left cathodal tDCS (20 min, 2 mA) or sham stimulation over bilateral DLPFC. WCST and IGT were readministered following the last session. Baseline clinical severity, depression, impulsivity levels, and cognitive performance were similar between groups. TDCS over the DLPFC resulted in more advantageous decision making (F_1,16 = 8.128, p = 0.01, ɳp² =0.33) and better cognitive flexibility (F_1,16 =8.782, p = 0.009, ɳp² = 0.35), representing large effect sizes. The results suggest for the first time that tDCS enhanced decision making and cognitive flexibility in gambling disorder. Therefore, tDCS may be a promising neuromodulation-based therapeutic approach in gambling disorder.Trial registration: Clinicaltrials.gov NCT03477799.

Hungry to gamble? Ghrelin as a predictor of persistent gambling in the face of loss

Ghrelin, a peptide hormone associated with appetite, is also linked to increased reward seeking behaviors, including food, sex, and drug seeking behaviors through the stimulation of the mesolimbic dopaminergic system. Moreover, plasma ghrelin concentrations are increased by cues that predict rewards, suggesting that cues could facilitate cravings and ultimately relapse. In this project we examined the effects of an overnight fast, a manipulation known to increase ghrelin concentrations, on gambling behaviors. We also examined if cues associated with gambling would also increase ghrelin and, if so, we examined if these increases were associated with gambling behavior. One hundred and one (37 females) participants were asked to fast overnight or after breakfast and then asked to complete food and gambling craving questionnaires. Participants were then presented with gambling cues (a casino like environment in the lab) or a control cue (a cubicle with a computer). After the cue, subjects filled gambling craving questionnaires, and were allowed to gamble. Following 25 practice spins, the slot machines were fixed so that all subsequent spins were losses, and the number of spins in spite of losses were quantified. Blood samples were collected throughout the experiment. Results showed that the gambling cues significantly increased ghrelin concentrations particularly in fasted individuals, and that ghrelin concentrations 20 min after the cue were the best predictor for gambling persistence in the face of continued loss (p < 0.05). Our results suggest that cues that predict the opportunity to gamble have an acute effect on ghrelin concentrations that is facilitated by fasting, and that ghrelin concentrations are a significant predictor of gambling persistence.

Pharmacological insights into impulsive-compulsive spectrum disorders associated with dopaminergic therapy

Impulsive-compulsive spectrum disorders are associated with dopamine agonist therapy in some patients. These untoward outcomes occur with direct-acting, full and partial agonists at D2 dopamine family receptors. The disorders typically emerge during chronic treatment, and exhibit common features that are independent of the neurological or psychiatric pathology for which the initial therapy was indicated. It is well-documented that the brain is 'plastic', changing in response to alterations to internal factors (e.g., disease processes), as well as external factors (e.g., therapies). The complexities of these clinical scenarios have eluded a clear depiction of the neurobiology for impulsive-compulsive spectrum disorders and engendered considerable debate regarding the mechanistic underpinnings of the disorders. In this opinion, we use pharmacological concepts related to homeostatic compensation subsequent to chronic receptor activation to provide a unifying construct. This construct helps explain the occurrence of impulsive-compulsive spectrum disorders across disease states, and during therapy with full and partial agonists.

Cognitive Control and Criminogenic Cognitions in South Asian Gamblers

It has been suggested that criminogenic thinking is likely to be a correlate of gambling. The primary aim of the current study was to assess whether gamblers and non-gamblers differ on measures of cognitive control and criminogenic cognitions. The secondary aim was to assess the association between cognitive control and criminogenic cognitions amongst gamblers and non-gamblers. The sample included 159 male participants (78 gamblers and 81 non-gamblers) with an age range from 15 to 25 years (M = 20.07, SD = 2.77), recruited from different snooker clubs in Lahore, Pakistan. Participants were individually administered color word interference test (CWIT) taken from Delis Kaplan executive function system, Lie Bet Questionnaire, and Criminogenic Cognition Scale in order to assess cognitive control, gambling, and criminogenic thinking patterns respectively. Raw scores of completion time and number of errors on four conditions of CWIT were taken as the measures of cognitive control. Results from repeated measure ANOVA indicated that gamblers committed significantly more errors on cognitive control measure and scored significantly higher on two criminogenic cognition subscales including notion of entitlement and insensitivity to the impact of crime. Furthermore, age and education were also found to be significant covariates of specific criminogenic cognitions and cognitive control respectively. Results from correlational analyses showed that error measure, but not the time measure, of cognitive control was significantly and positively correlated with short term orientation, notion of entitlement, negative attitude toward authority, and insensitivity to the impact of crime. Implications of the findings are suggested along with future directions.

The multiplicative effect of combining alcohol with energy drinks on adolescent gambling

PURPOSE

There has been increased concern about the negative effects of adolescents consuming a combination of alcohol mixed with energy drinks (AmED). To date, few studies have focused on AmED use and gambling. The present study analyzed the multiplicative effect of AmED consumption, compared to alcohol alone, on the likelihood of at-risk or problem gambling during adolescence.

METHODS

Data from the ESPAD®Italia 2015 study, a cross-sectional survey conducted in a nationally representative sample of students (ages 15 to 19years) were used to examine the association between self-reported AmED use (≥6 times,≥10 times, and ≥20 times during the last month) and self-reported gambling severity. Multivariate models were used to calculate adjusted prevalence ratios to evaluate the association between alcohol use, AmED use, and gambling among a representative sample of adolescents who reported gambling in the last year and completed a gambling severity scale (n=4495).

RESULTS

Among the 19% students classed as at-risk and problem gamblers, 43.9% were classed as AmED consumers, while 23.6% were classed as alcohol consumers (i.e. did not mix alcohol with energy drinks). In multivariate analyses that controlled for covariates, AmED consumers were three times more likely to be at-risk and problem gamblers (OR=3.05) compared to non-consuming adolescents, while the effect became less pronounced with considering those who consumed alcohol without the addition of energy drinks (OR=1.37).

CONCLUSIONS

The present study clearly established that consuming AmED might pose a significantly greater risk of experiencing gambling-related problems among adolescents.

White matter integrity between left basal ganglia and left prefrontal cortex is compromised in gambling disorder

Pathological gambling (PG) is a behavioral addiction characterized by an inability to stop gambling despite the negative consequences, which may be mediated by cognitive flexibility deficits. Indeed, impaired cognitive flexibility has previously been linked to PG and also to reduced integrity of white matter connections between the basal ganglia and the prefrontal cortex. It remains unclear, however, how white matter integrity problems relate to cognitive inflexibility seen in PG. We used a cognitive switch paradigm during functional magnetic resonance imaging in pathological gamblers (PGs; n = 26) and healthy controls (HCs; n = 26). Cognitive flexibility performance was measured behaviorally by accuracy and reaction time on the switch task, while brain activity was measured in terms of blood oxygen level-dependent responses. We also used diffusion tensor imaging on a subset of data (PGs = 21; HCs = 21) in combination with tract-based spatial statistics and probabilistic fiber tracking to assess white matter integrity between the basal ganglia and the dorsolateral prefrontal cortex. Although there were no significant group differences in either task performance, related neural activity or tract-based spatial statistics, PGs did show decreased white matter integrity between the left basal ganglia and prefrontal cortex. Our results complement and expand similar findings from a previous study in alcohol-dependent patients. Although we found no association between white matter integrity and task performance here, decreased white matter connections may contribute to a diminished ability to recruit prefrontal networks needed for regulating behavior in PG. Hence, our findings could resonate an underlying risk factor for PG, and we speculate that these findings may extend to addiction in general.

The Role of Pleasure Neurobiology and Dopamine in Mental Health Disorders

Recent evidence and research has demonstrated that the pleasure response and associated neurotransmitters and brain circuits play a significant role in substance use disorders (SUDs). It was thought that negative behaviors associated with SUDs resulted from negative choices, but it is now known that chemical changes in the brain drive those behaviors. Several mental health disorders (e.g., eating disorders, non-suicidal self-injury, compulsive sex behaviors, internet gaming, gambling) are also thought to involve those same pleasure responses, neurotransmitters, and brain regions. Studies have shown that the use of naltrexone, a dopamine antagonist, can reduce symptoms of these disorders. It is important for nurses to understand the underlying physiology of mental health disorders that are thought to have an addictive or craving component. This understanding can help reduce stigma. Educating patients about likely neurobiological causes for their disorders can also help reduce guilt and shame. Nurses should educate patients about these disorders and evidence-based treatments, including off-label use of naltrexone. [Journal of Psychosocial Nursing and Mental Health Services, 55(9), 17-21.].

Effectiveness of two web-based cognitive bias modification interventions targeting approach and attentional bias in gambling problems: study protocol for a pilot randomised controlled trial

BACKGROUND

Disordered gamblers have phenotypical and pathological similarities to those with substance use disorders (SUD), including exaggerated automatic cognitive processing of motivationally salient gambling cues in the environment (i.e., attentional and approach bias). Cognitive bias modification (CBM) is a family of computerised interventions that have proved effective in successfully re-training these automatic cognitive biases in SUD. CBM interventions can, in principle, be administered online, thus showing potential of being a low-cost, low-threshold addition to conventional treatments. This paper presents the design of a pilot randomised controlled trial exploring the effectiveness of two web-based CBM interventions targeting attentional and approach bias towards gambling cues in a sample of Dutch and Belgian problematic and pathological gamblers.

METHODS/DESIGN

Participants (N = 182) are community-recruited adults experiencing gambling problems, who have gambled at least twice in the past 6 months and are motivated to change their gambling behaviour. After a baseline assessment session, participants are randomly assigned to one of four experimental conditions (attentional or approach bias training, or the placebo version of the two trainings) and complete six sessions of training. At baseline and before each training session, participants receive automated personalised feedback on their gambling motives and reasons to quit or reduce gambling. The post-intervention, 1-month, and 3-month follow-up assessments will examine changes in gambling behaviour, with frequency and expenditure as primary outcomes, and depressive symptoms and gambling-related attentional and approach biases as secondary outcomes. Secondary analyses will explore possible moderators (interference control capacity and trait impulsivity) and mediators (change in cognitive bias) of training effects on the primary outcomes.

DISCUSSION

This study is the first to explore the effectiveness of an online CBM intervention for gambling problems. The results of this study can be extremely valuable for developing e-health interventions for gambling problems and further understanding the role of motivational implicit cognitive processes underlying problematic gambling behaviour.

TRIAL REGISTRATION

Netherlands Trial Register, NTR5096 . Registered on 11 March 2015.

Deficit of state-dependent risk attitude modulation in gambling disorder

Gambling disorder (GD) is often considered as a problem of trait-like risk preference. However, the symptoms of GD cannot be fully understood by this trait view. In the present study, we hypothesized that GD patients also had problem with a flexible control of risk attitude (state-dependent strategy optimization), and aimed to investigate the mechanisms underlying abnormal risk-taking of GD. To address this issue, we tested GD patients without comorbidity (GD group: n=21) and age-matched healthy control participants (HC group: n=29) in a multi-step gambling task, in which participants needed to clear 'block quota' (required units to clear a block, 1000-7000 units) in 20 choices, and conducted a task-functional magnetic resonance imaging (fMRI) experiment. Behavioral analysis indeed revealed a less flexible risk-attitude change in the GD group; the GD group failed to avoid risky choice in a specific quota range (low-quota condition), in which risky strategy was not optimal to solve the quota. Accordingly, fMRI analysis highlighted diminished functioning of the dorsolateral prefrontal cortex (dlPFC), which has been heavily implicated in cognitive flexibility. To our knowledge, the present study provided the first empirical evidence of a deficit of state-dependent strategy optimization in GD. Focusing on flexible control of risk attitude under quota may contribute to a better understanding of the psychopathology of GDs.

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.

Understanding Within-Session Loss-Chasing: An Experimental Investigation of the Impact of Stake Size on Cognitive Control

Loss-chasing is a central feature of problematic gambling, yet it remains a poorly conceived and understood concept. Loss-chasing is believed to stem from an erosion of cognitive control when gambling. The opportunity to gamble at significantly disparate stake sizes on a gambling activity is considered to be a risk factor for loss-chasing. This study investigated the impact of gambling at disparate stake sizes on executive processes integral to maintaining cognitive control when gambling, namely response inhibition and reflection impulsivity. Frequent adult non-problem gamblers (n = 32) participated in a repeated measures experiment; and gambled at three disparate stake sizes (£20, £2 and no stake per bet) on a simulated gambling task. Participants' response inhibition performance and reflection impulsivity levels after gambling at various stake sizes were compared via a go/no-go task and information sampling task, respectively. Quality of decision-making i.e. the evaluation of available information to make probability judgements was impaired after gambling at higher stakes in comparison to lower stakes, indicating an increase in reflection impulsivity. No effect on response inhibition was observed. Although exploratory, this suggests that the opportunity for participants to substantially increase stake size on a gambling activity may be a risk factor for impaired cognitive performance when gambling, and perhaps create vulnerability for within-session loss-chasing in some players.

Right inferior frontal cortex activity correlates with tolcapone responsivity in problem and pathological gamblers

Failures of self-regulation in problem and pathological gambling (PPG) are thought to emerge from failures of top-down control, reflected neurophysiologically in a reduced capacity of prefrontal cortex to influence activity within subcortical structures. In patients with addictions, these impairments have been argued to alter evaluation of reward within dopaminergic neuromodulatory systems. Previously we demonstrated that augmenting dopamine tone in frontal cortex via use of tolcapone, an inhibitor of the dopamine-degrading enzyme catechol-O-methyltransferase (COMT), reduced delay discounting, a measure of impulsivity, in healthy subjects. To evaluate this potentially translational approach to augmenting prefrontal inhibitory control, here we hypothesized that increasing cortical dopamine tone would reduce delay discounting in PPG subjects in proportion to its ability to augment top-down control. To causally test this hypothesis, we administered the COMT inhibitor tolcapone in a randomized, double-blind, placebo-controlled, within-subject study of 17 PPG subjects who performed a delay discounting task while functional MRI images were obtained. In this subject population, we found that greater BOLD activity during the placebo condition within the right inferior frontal cortex (RIFC), a region thought to be important for inhibitory control, correlated with greater declines in impulsivity on tolcapone versus placebo. Intriguingly, connectivity between RIFC and the right striatum, and not the level of activity within RIFC itself, increased on tolcapone versus placebo. Together, these findings support the hypothesis that tolcapone-mediated increases in top-down control may reduce impulsivity in PPG subjects, a finding with potential translational relevance for gambling disorders, and for behavioral addictions in general.