The psychopharmacology of pathological gambling

Cold pressor pain and gambling disorder: implications for the opioid system

OBJECTIVE

Gambling disorder (GD) is a common, disabling condition that often is exacerbated by stressful life events. Under stress, the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis are activated. The question, therefore, arises as to whether an abnormal sympathetic response can be found in individuals with GD.

METHOD

Adult individuals with GD and no current co-occurring mental disorders were enrolled. Participants completed impulsivity and gambling-related questionnaires and underwent cold pressor evaluation. GD participants were compared with controls on measures of heart rate, blood pressure, and pain.

RESULTS

Fifteen people with GD and 18 controls completed the study. Kaplan-Meier analysis indicated that the GD group withdrew their hand from the painful stimulus more rapidly than controls (Wilcoxon chi-square = 3.87, p = 0.049), suggestive of lesser pain tolerance. Subjective pain ratings and cardiovascular measurements did not significantly differ between groups.

CONCLUSIONS

Individuals with GD manifested a relative intolerance to pain on the cold pressor paradigm, even though they physiologically did not seem to experience greater pain. Given the role of the opioid system in pain processing, it would be valuable in future work to examine whether cold pressor measures can predict response to treatments in GD, including with opioid antagonists.

Pathological gambling: an overview of assessment and treatment

Pathological gambling has so far received scant attention in the psychiatric literature. It has a prevalence rate of about 1% in most countries, and with the deregulation of gambling in the UK the prevalence is set to rise here. Pathological gambling can adversely affect the individual, family and society, and also carries high rates of psychiatric comorbidity. Early identification and appropriate treatment can limit the long-term adverse consequences and improve outcome. This article reviews assessment techniques and tools, and treatment strategies for pathological gambling.

Treatment of Gambling Problems in Asia: Comprehensive Review and Implications for Asian Problem Gamblers

Much research has been conducted in the treatment of gambling problems. However, very little is reported specifically on treating Asian problem gamblers. Thus, this article reviewed the general problem gambling treatment literature as well as the limited Asian problem gambling treatment literature to provide a discussion of interventions that can be used with Asian problem gamblers. The general literature showed that behavioral, cognitive, and combined cognitive behavioral treatments (CBT) have the most treatment outcome literature and appear to be the most effective in treating gambling problems. Although, pharmacotherapy also looks promising, it may be more suitable for problem gamblers with comorbid mood problems or impulsivity. Research on other forms of treatments also exists (e.g., 12-step and psychodynamic treatment approaches) but are not as robust. Only three studies have reported on the effectiveness of treatment with Asian problem gamblers. The first study is case study. The second study presents data from a treatment program for Asian problem gambling and the last one presents preliminary findings of a telephone delivered treatment program with eight Asian American gamblers. These studies support the general treatment literature in showing that CBT and pharmacotherapy have a role to play in treating Asian problem gamblers. Based on the general and Asian problem gambling treatment literature, a discussion of treatment of Asian problem gamblers is provided including the use of CBT and other forms of treatment, issues to address in treatment, and variables that can assist treatment.

Gambling on the stock market: an unexplored issue

OBJECTIVE

Stock market investment (SMI) is one of the most socially acceptable types of gambling, which, however, can turn into a gambling problem. Because it is barely examined, we compared a series of clinical, psychopathologic, and personality variables in SMI gambling patients (both as primary and secondary problem) with a group of traditional pathologic gamblers (PGs).

METHOD

A total sample of 1470 PGs (1376 patients without SMIs [PG-SMI], 76 patients with SMI as a secondary gambling problem [PG+SMI], and 18 patients with SMI as a primary gambling problem [SMI+PG]) participated in this study. All participants were diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The following instruments were used: the South Oaks Gambling Screen, the Symptom Check List-90 Items-Revised, the Temperament and Character Inventory-Revised, and other clinical and psychopathologic indices.

RESULTS

The 3 patient groups' profiles were statistically similar in psychometrical measures. The risk of having SMI increased for patients with higher education, and the presence of SMI as a primary problem in PGs increased with university study level and higher scores on the personality trait of cooperativeness.

CONCLUSIONS

The results of this study indicate comparability of SMI gamblers with PGs in their general clinical profile and in psychopathology and personality.

Outcome of pharmacological treatments of pathological gambling: a review and meta-analysis

Although several qualitative reviews on pharmacological interventions for pathological gambling have been published, no quantitative review of this field has been conducted.

METHODS

Studies of pharmacological interventions of pathological gambling were identified by computer searches in the PsychINFO and MEDLINE databases covering the period from 1966 to July 2006, as well as from relevant reference lists. The inclusion criteria were as follows: the target problem had to be pathological gambling, the interventions were pharmacological, the study was written in English, and the study reported outcomes particularly pertaining to gambling. A total of 130 potential studies were identified of which 16 met the inclusion criteria. A total of 597 subjects were included in the outcome analyses of these studies. The grand mean age was 43.3 years. The overall proportion of men was 62.8%. The included studies were coded for outcome measures of pathological gambling. For each condition, means and SDs for gambling-related outcome measures were compiled at 2 points in time: baseline and posttreatment.

RESULTS

At posttreatment, the analysis showed that the pharmacological interventions were more effective than no treatment/placebo, yielding an overall effect size of 0.78 (95% confidence interval, 0.64-0.92). A multiple regression analysis showed that the magnitude of effect sizes at posttreatment was lower in studies using a placebo-control condition compared with studies using a predesign/postdesign without any control condition. Effect sizes were also negatively related to the proportion of male participants in the included studies. No differences in outcome between the 3 main classes of pharmacological interventions (antidepressants, opiate antagonists, mood stabilizers) were detected.

CONCLUSION

Pharmacological interventions for pathological gambling may be an adequate treatment alternative in pathological gambling.

Pathological gambling and mood disorders: clinical associations and treatment implications

BACKGROUND

The rapidly expanding gambling business has resulted in an increasing number of gamblers, and the problem is likely to get worse in the future. Traditionally, mood and gambling symptoms have been known to overlap. In the present review we attempt to examine the diagnostic associations and implications for treatment.

METHOD

Selected published papers on the frequencies of mood disorders among patients who have gambling disorder or gambling disorder among patients who have mood disorder have been reviewed. Recently emerging new treatment methods for gambling disorder have been reviewed and a brief summary has been added.

RESULTS

SCID based study results show a close link between gambling and mood disorders. The prevalence of manic disorder reaches to approximately one fourth of the pathological gambling disorder population. The prevalence of depression is much higher, reaching to over half of the population in some studies.

LIMITATIONS

The studies included in the present paper involve inpatients, outpatients, subjects recruited through advertisements and prison populations. Thus the data need to be interpreted as such. Standardized assessment instruments are not used in all studies. Methodological issues such as primary or secondary nature of depression have not been addressed adequately in these studies. The findings, however, offer new insights for the assessment and treatment of complicated gambling disorder cases.

CONCLUSIONS

A high prevalence rate of manic and depressive disorders has been recorded among pathological gambling disorder patients. A rational treatment approach to each defined subset of complicated gambling disorder is discussed.

Advancing Treatment Strategies for Pathological Gambling

Experiences from treatment trials are described. The use of structured instruments for subject characterization and symptom change assessment is discussed and the challenges of treating specific groups (e.g., those with co-occurring alcohol use disorders) explored. Treatment for pathological gambling might be advanced most rapidly through collaborative multi-center efforts.

Antidepressant treatment-associated behavioural expression of hypomania: a case series

OBJECTIVE

Emerging literature suggests that hypomanic behaviour may be clinically more important than elated mood in spontaneous hypomania. This report describes dysfunctional behavioural activation as a milder expression of antidepressant-associated hypomania.

METHOD

Five outpatients with mood disorders developed problem behaviours following antidepressant treatment. These behaviours include gambling, excessive spending, increased sexual activity, excessive shopping and socially inappropriate verbal aggression. These behaviours were not accompanied with noticeable euphoria or persistent dysphoria and were not characteristics of the individual's personality functioning. They were reported by significant others and patients had no history of primary impulsive, substance abuse or personality disorders.

RESULTS

The observed antidepressant-associated behavioural activation was suggestive of hypomanic behaviours not of impulse control disorders because of; (a) absence of other accountable mental or medical disorders characterized by impulsivity, (b) the evidence of close association between impulsivity and hypomanic/manic states, (c) increasing awareness of the diagnostic importance of behavioural disturbances in hypomania, (d) the substantial evidence relating antidepressant treatment to the emergence of hypomania, but not to impulse control disorders, (e) the well documented therapeutic effect of selective serotonin reuptake inhibitors (SSRIs) in impulse control disorders.

CONCLUSIONS

In accordance with the recent proposed revision in the diagnostic criteria of hypomania, the observed dysfunctional behavioural activation during antidepressant treatment may represent milder expression of antidepressant-associated hypomania. More research is warranted to study the behavioural expression of hypomania secondary to antidepressants.

Pathological gambling: a comprehensive review of biobehavioral findings

In this review, findings of biobehavioral research into pathological gambling (PG) are discussed, focusing on neuropsychological, psychophysiological, neuroimaging, neurochemical and genetic studies. Neuropsychological studies indicate deficiencies in certain executive functions. Psychophysiological studies indicate that arousal in PG is of importance when reward is present. Neuroimaging studies point to abnormalities in brain functioning. Recent research into the neurochemistry of PG indicates that abnormalities exist in different neurotransmitter systems. Finally, genetic studies indicate the existence of abnormal dopamine receptor genes in PG. Methodological and theoretical factors that may explain discrepancies between studies include differences in screening and assessment, heterogeneity of gambling problems and different underlying cognitive or motivational mechanisms. Results from the PG studies fit in with recent theoretical models of addiction and PG, which stress the involvement of brain reward pathways, neurotransmitter abnormalities, the frontal cortex and the psychophysiological stress system. A framework for future studies is suggested, indicating the need for studies that integrate knowledge from different research areas, and that employ stricter diagnostic screening methods and inclusion of clinical control groups.

Disrupted sensory gating in pathological gambling

BACKGROUND

Some neurochemical evidence as well as recent studies on molecular genetics suggest that pathologic gambling may be related to dysregulated dopamine neurotransmission.

METHODS

The current study examined sensory (motor) gating in pathologic gamblers as a putative measure of endogenous brain dopamine activity with prepulse inhibition of the acoustic startle eye-blink response and the auditory P300 event-related potential. Seventeen pathologic gamblers and 21 age- and gender-matched healthy control subjects were assessed. Both prepulse inhibition measures were recorded under passive listening and two-tone prepulse discrimination conditions.

RESULTS

Compared to the control group, pathologic gamblers exhibited disrupted sensory (motor) gating on all measures of prepulse inhibition. Sensory motor gating deficits of eye-blink responses were most profound at 120-millisecond prepulse lead intervals in the passive listening task and at 240-millisecond prepulse lead intervals in the two-tone prepulse discrimination task. Sensory gating of P300 was also impaired in pathologic gamblers, particularly at 500-millisecond lead intervals, when performing the discrimination task on the prepulse.

CONCLUSIONS

In the context of preclinical studies on the disruptive effects of dopamine agonists on prepulse inhibition, our findings suggest increased endogenous brain dopamine activity in pathologic gambling in line with previous neurobiological findings.

Advances in the pharmacological treatment of pathological gambling

In the present paper we discuss the current status of drug treatment for pathological gambling and the scientific rationales underlying the various pharmacological approaches. Specifically, we summarize the treatment study results of serotonin reuptake inhibitors, mood stabilizers, opioid antagonists, and atypical antipsychotics in pathological gambling. We also discuss dosage strategies, the duration of treatment, issues surrounding medication compliance, and approaches to treatment-refractory pathological gambling, such as pharmacological and behavioral augmentation.

Gambling: an addictive behavior with health and primary care implications

Over the past several decades, and particularly during the last 10 to 15 years, there has been a rapid increase in the accessibility of legalized gambling in the United States and other parts of the world. Few studies have systematically explored the relationships between patterns of gambling and health status. Existing data support the notion that some gambling behaviors, particularly problem and pathological gambling, are associated with nongambling health problems. The purpose of this article is to provide a perspective on the relationship between gambling behaviors and substance use disorders, review the data regarding health associations and screening and treatment options for problem and pathological gambling, and suggest a role for generalist physicians in assessing problem and pathological gambling. A rationale for conceptualization of pathological gambling as an addictive disorder and a model proposing stress as a possible mediating factor in the relationship between gambling and health status are presented. More research is needed to investigate directly the biological and health correlates associated with specific types of gambling behaviors and to define the role for generalist physicians in the prevention and treatment of problem and pathological gambling.

Personality dimensions in pathological gambling disorder and obsessive-compulsive disorder

This study was conducted to investigate the similarities and differences in the personality dimensions of patients with pathological gambling disorder (PGD) and obsessive-compulsive disorder (OCD). Thirty-three subjects with PGD, 41 with OCD and 40 normal controls were assessed with the Tridimensional Personality Questionnaire (TPQ), which assesses three personality dimensions: novelty seeking, reward dependence, and harm avoidance. Compared with OCD subjects, PGD subjects expressed significantly greater novelty seeking, impulsiveness, and extravagance. The PGD subjects also reported significantly less anticipatory worry, fear of uncertainty, and harm avoidance than the OCD subjects. Compared with controls, the PGD subjects expressed significantly greater novelty seeking, impulsiveness, and extravagance. These results suggest that the personality dimensions of pathological gamblers may differ significantly from both those of OCD patients and normal controls.