Sleep and gambling severity in a community sample of gamblers

Sleep Problems and Gambling Disorder: Cross-Sectional Relationships in a Young Cohort

AIMS

To investigate the potential association between gambling disorder and symptoms of sleep problems (including insomnia and excessive daytime sleepiness). It was hypothesised that, compared to controls, individuals with gambling disorder would have significantly greater disturbance of sleep, as indicated by increased scores in: (1) sleep items on the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Rating Scale for Depression (HAM-D); (2) total score on the HAM-A and HAM-D; and (3) the Epworth Sleepiness Scale (ESS).

METHODS

Secondary analysis of previously published data from 152 young adults, aged 18-29 years. Individuals were stratified into three groups: controls, those at risk of gambling disorder, and those with gambling disorder. One-way ANOVAs with post-hoc tests were conducted to determine whether groups differed significantly in sleep item scores and total scores of the HAM-A and HAM-D, and the ESS.

RESULTS

HAM-D scale insomnia item scores were significantly higher in the disorder group, when compared to controls, this being particularly marked for middle and late insomnia. The HAM-A item score indicated significantly worse sleep quality in the disorder group, compared to at risk and control groups. Total HAM-A and HAM-D scores were significantly higher in the disorder group, but ESS scores did not differ significantly.

CONCLUSION

Measures of disruptions in sleep were significantly higher in gambling disorder than controls. Anxiety and depressive symptom severity was also significantly higher in the gambling disorder group. Further research could have implications for identification and treatment of sleep disorders and psychiatric comorbidities in gambling disorder.

Association of night-shift work with gambling and problem gambling among workers in Japan: A nationwide cross-sectional study

BACKGROUND AND AIMS

Night-shift work disturbs sleep and is associated with poor health conditions among workers. We aimed to investigate the association between night-shift work and gambling among workers and the association between night-shift work and problem gambling in working and gambling participants.

METHODS

This cross-sectional study used data from an online survey conducted between February 6 and 27, 2023 in Japan. A total of 21,134 workers participated in this study, including 9,739 respondents who had gambled in the past year. We estimated the association between night-shift work and gambling among workers and the association between night-shift work and problem gambling among those who gambled at the survey. We defined problem gambling as a score ≥ 8 on the Problem Gambling Severity Index. All estimates were weighted using a nationally representative survey in Japan. We fitted multivariable weighted logistic regression models after adjusting for 14 confounders.

RESULTS

The weighted prevalence of gambling among non-night and night-shift workers was 42.1 % and 55.4 %, respectively. When focusing on workers gambling in the survey, the prevalence of problem gambling among non-night and night-shift workers was 8.8 % and 24.2 %, respectively. The weighted multivariable logistic regression analyses showed that night-shift work was associated with gambling participation among workers (adjusted odds ratio [aOR], 1.39, 95 % confidence interval [CI] 1.25-1.53, p < 0.001). In addition, night-shift work was associated with problem gambling among those who gambled (aOR 1.94, 95 % CI 1.57-2.40, p < 0.001).

CONCLUSIONS

Night-shift work was associated with gambling among workers and with problem gambling among those who gambled.

A network analysis investigation of the comorbidity between sleep dysfunction and PTSD symptomatology among Filipino domestic workers in Macao (SAR) China

Posttraumatic stress disorder (PTSD) is highly comorbid with sleep dysfunction. This association was previously explained based on cognitive and emotional dysfunction. The current study extends this literature by investigating the symptom level comorbidity of sleep dysfunction and DSM-5 PTSD utilizing a network approach. Participants were trauma-exposed female Filipino domestic workers (N = 1241). Network analysis was applied to 23 items: 18 items from PCL-5 measuring PTSD (Community 1) and 5 items from PSQI assessing sleep dysfunction (Community 2). The results showed that the symptoms within each community had the strongest correlations. Bridge connections were identified between the sleep dysfunction and PTSD symptom communities. Symptoms with the highest bridge strength were concentration difficulties, recklessness, irritability, and sleep disturbance. This is among the first studies investigating the comorbidity between PTSD and sleep dysfunction from the network approach. Future interventions may be developed that emphasize the bridge symptoms to address comorbidity among trauma exposed migrants.

The impact of COVID-19 lockdown on gambling habit: A cross-sectional study from Italy

BACKGROUND AND AIMS

Few preliminary studies have shown an impact of COVID-19 confinement on gambling habits. We aim to evaluate short-term effects of lockdown restrictions on gambling behaviors in Italy.

METHODS

Within the project Lost in Italy, a web-based cross-sectional study was conducted on a representative sample of 6,003 Italians aged 18-74 years, enrolled during April 27-May 3 2020, and were asked to report gambling activity before the lockdown and at the time of interview.

RESULTS

The prevalence of participants reporting any gambling decreased from 16.3% before lockdown to 9.7% during lockdown. Traditional gambling decreased from 9.9 to 2.4% and online gambling from 9.9 to 8.0%. Among gamblers, median time of gambling grew from 4.5 to 5.1 h/month. Among non-players before lockdown, 1.1% started playing. Among players before lockdown, 19.7% increased gambling activity. Multivariate analysis showed an increase in gambling activity in younger generations (p for trend = 0.001), current smokers (odds ratio, OR 1.48), users of electronic cigarettes (OR 1.63), heated tobacco products (OR 1.82), cannabis (OR 5.16), psychotropic drugs (OR 3.93), and subjects having hazardous alcohol drinking (OR 1.93). Self-reported low quality of life (OR 1.97), low sleep quantity (OR 2.00), depressive symptoms (OR 3.06) and anxiety symptoms (OR 2.93) were significantly related to an increase in total gambling activity during lockdown.

DISCUSSION AND CONCLUSIONS

Although gambling substantially decreased during lockdown, time spent in gambling slightly increased. The strong relationship found between compromised mental health and addictive behaviors calls for urgent policies to prevent vulnerable populations from increasing and developing severe gambling addiction.

Harms associated with gambling: abbreviated systematic review protocol

BACKGROUND

According to the Gambling Commission, in 2018, almost half of the general population aged 16 and over had participated in gambling in the 4 weeks before being surveyed. Such surveys suggest that the proportion of people who are classed as 'problem' gamblers is relatively small; however, this may be related to the ways data are collected and gambling behaviour is classified. Concern about the harms associated with gambling is rising, and in response, Public Health England (PHE) has initiated this review to identify the harms associated with this activity. Harms to the gambler, their close associates and the wider society will all be included.

METHODS

Abbreviated systematic review processes will be employed. Ovid MEDLINE, Ovid Embase, Ovid Psycinfo, NICE Evidence and EBSCO SocIndex; a range of websites (for grey literature); and reference lists of included studies will be searched. Experts will be asked to identify other relevant literature. Literature published in years 2005-2019, published in English, from a country within the Organisation for Economic Development (OECD) and following an observational, qualitative or systematic review design will be included. AMSTAR2 (systematic reviews), the Newcastle-Ottawa Scale (observational studies) and the Critical Appraisal Skills Programme (CASP) qualitative checklist (qualitative studies) will be used to assess the risk of bias. A narrative synthesis will be used to summarise the results. The body of evidence will also be assessed according to the principles laid out in the CERQual approach.

DISCUSSION

This protocol provides details of the framework that has been set up to guide this systematic review. The results of this review will provide an extensive assessment of the breadth and magnitude of harms associated with gambling. This will be one of the most comprehensive reviews of gambling-related harms undertaken to date.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019154757.

[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.

The Comorbidity of Gambling Disorder among Macao Adult Residents and the Moderating Role of Resilience and Life Purpose

Macao, China’s only city with legalized casinos, has maintained a high prevalence of gambling participation and gambling disorder (GD) over the past decade. The mental health risks associated with such high levels have been overlooked. In order to estimate the comorbid prevalence of GD with depression, anxiety, and Internet gaming disorder (IGD) and to explore the potential buffering effect of psychological resilience and purpose in life, this study obtained a representative adult Chinese sample (N = 1000, 44% male, aged 18–97 years) from a telephone survey conducted between October and November of 2016. As hypothesized, the highest psychiatric comorbid prevalence was observed in the GD subgroup (n = 19, 21.1% probable IGD, 26.3% probable depression, and 37.0% probable anxiety). All these mental health problems could increase one’s proclivity to GD, and vice versa. Psychological resilience was found to buffer the association between anxiety symptoms and probable GD (χ²(1) = 4.30, p = 0.04/GD symptoms, F_change (1,162) = 6.29, p = 0.01), whereas purpose in life did not display any hypothesized moderating effect. These results indicate the usefulness of mental health screening for GD, taking into consideration its associated risks, and of fostering psychological resilience in prevention and treatment programs.

Sleepiness and impulsivity: Findings in non-treatment seeking young adults

BACKGROUND AND AIMS

Although inadequate sleep has been linked to problematic behaviors, such as poor impulse control and emotion dysregulation, little research interest has been the role of sleep and sleep deprivation on impulsive behaviors in young adults. To further examine the relationship of sleepiness to impulsivity and impulsive behaviors, this study was designed to collect data on sleepiness, and a range of impulse control disorders and cognitive measures.

METHODS

Young non-treatment-seeking adults were recruited from two US cities and completed a screening form for sleepiness, along with demographic, clinical, and cognitive measures relevant to impulsivity. Relationships between these explanatory variables and total sleepiness scores were analyzed using partial least squares. Significant explanatory variables were identified (p < .05, bootstrap).

RESULTS

Higher levels of sleepiness were significantly associated with higher ADHD symptoms, gambling disorder symptoms, Internet addiction symptoms, and personality-related impulsiveness. Sleepiness was also associated with set-shifting errors, and with gambling more points (abnormal decision-making), but not with significant impairment in response to inhibition, or other aspects of decision-making.

CONCLUSIONS

This study confirms a cross-sectional relationship between sleepiness and a range of impulsive measures at the level of behavior (ADHD, gambling, and Internet addiction) and personality traits. Longitudinal research would be required to explore causal mechanisms and the direction of any such effects. Screening for such mental health diagnoses in people with sleep problems may be valuable, as enquiring patients with such impulsive symptoms about sleep, in order to maximize quality of life.

Health Outcomes in Individuals with Problem and Pathological Gambling: An Analysis of the 2014 North Carolina Behavioral Risk Factor Survey System (BRFSS)

Problem and pathological gambling refers to subclinical and clinical levels of maladaptive gambling, respectively, and is associated with specific sociodemographic characteristics as well as a number of poor health outcomes. We examined such demographic, physical health, mental health, and health-related behaviors in a sample of 7045 low-risk gamblers and 244 problem/pathological gamblers. Participants completed the 2014 North Carolina Behavioral Risk Factor Surveillance System telephone survey. Using the National Opinion Research Center's Diagnostic Screen for Gambling Disorders-CLiP, participants were categorized as either "problem/pathological gamblers" or "low-risk gamblers." Problem/pathological gamblers were younger, more likely to be male, of ethnic minority status, unmarried, and of lower education than low-risk gamblers. No physical health variables differentiated the groups but problem/pathological gamblers reported experiencing significantly more adverse childhood experiences and engaging in significantly more tobacco and alcohol use compared to low-risk gamblers. Moreover, gender moderated relationships between gambling group and several of the alcohol use variables such that male problem/pathological gamblers exhibited greater alcohol use behavior than male low-risk gamblers but no such relationship was present in females. Overall, this study expands the current knowledgebase on disordered gambling and highlights the need to assess disordered gambling in public health samples. Clinical implications are discussed.

Telecommunications Network Measurements of Online Gambling Behavior in Switzerland: A Feasibility Study

BACKGROUND

Methodological shortcomings of gambling studies relying on self-report or on data sets derived from gambling operators tend to result in biased conclusions. The aim of this study was to analyze online gambling behavior using a novel network database approach.

METHODS

From October 13 to October 26, 2014, telecommunications network data from a major telecommunications provider in Switzerland were analyzed. Netflows between mobile devices and a poker operator were quantified to measure the gambling duration and session number.

RESULTS

Time spent gambling during night and working hours was compared between devices with longest (red group), intermediate (orange group), and shortest gambling time (green group). Online gambling behavior differed depending on overall gambling time, F (2, 3,143). Night and working hours gambling was the highest in the red group (53%), compared to the orange (50.1%) and the green groups (41.5%). Post hoc analyses indicated significant differences between the orange and green groups (p < 0.05). No differences were observed between the red and orange groups (p = 0.850), and the red and green groups (p = 0.053).

CONCLUSIONS

On mobile devices, distinct gambling patterns were observed depending on the overall gambling time. This methodology could also be used to investigate online gaming, social media use, and online pornography.

Understanding the Mechanisms Underlying Gambling Behaviour and Sleep

Problem gambling and sleep difficulty threaten health. Using the basis of self-regulatory theory, potential mechanisms for these problems were investigated. Fifty-nine treatment-seeking gamblers completed the Pittsburgh Sleep Quality Index (sleep difficulty), the Sleep Hygiene Index (negative sleep habits), the Problem Gambling Severity Index and measures of self-regulatory capacity and arousability with data entered into regression analyses. Results supported the relationship between problem gambling and greater sleep difficulty (β = .18, t = 3.22, p < .01). Self-regulatory capacity mediated the relationship between problem gambling and sleep difficulty (R (2) change = .15, F(2, 57) = 12.14, β = -.45, t = -3.45, p < .001) as well as between problem gambling and negative sleep habits; R (2) change = .17, F(2, 57) = 13.57, β = -.28, t = -3.76, p < .001. Arousability predicted sleep difficulty (β = .15, t = 3.07, p < .01) and negative sleep habits (β = .40, t = 5.40, p < .01) but showed no relationship with problem gambling (r = .09, ns). Self-regulatory capacity represents an important mediator of the relationship between problem gambling and sleep-related behaviour and if targeted could reduce behavioural threats to health.

[Sleep disorders and addictions: Impact on quality of life and relapse vulnerability]

There is a bidirectional association between sleep disorders and addiction. Sleep problems negatively impact the quality of life of subjects with addictions (psychological state, pain perception, drug use). Sleep disorders are associated with a higher risk of relapse among sujects with addiction. The association between sleep disorders and relapse may be related to poor quality of life or to a higher level of craving. Maintaining abstinence and reducing craving episodes among subjects with addiction is the first-line treatment to reduce sleep disorders. Specific interventions focused on sleep disorders are needed when sleep disorders persist during abstinence and may improve global addiction outcome.

Impact of Impulse Control Disorders on Sleep-Wake Regulation in Parkinson's Disease

Sleep disturbances are common in patients with Parkinson's disease (PD) and are even more prevalent in patients with behavioural addictions, such as pathological gambling, compulsive sexual behaviour, compulsive buying, binge eating, punding, and the compulsive use of dopamine replacement therapy. An overview of the relationship between these impulse control disorders and sleep disturbances is given and potential underlying mechanisms and treatment strategies are covered.

Suicidal ideation and familicidal-suicidal ideation among individuals presenting to problem gambling services: a retrospective data analysis

BACKGROUND

Studies have consistently reported high rates of suicidal ideation (SI) among individuals with disordered gambling. None have explored gambling-related familicidal-suicidal ideation (FSI).

AIMS

This study examined the (1) prevalence of SI and FSI among treatment-seeking gamblers in Hong Kong, (2) characteristic profile of factors associated with SI and FSI, and (3) factors that predict SI and FSI.

METHOD

This is a retrospective analysis of data collected at initial clinical assessments from a specialized gambling counseling centre in Hong Kong. Participants were gamblers (N = 3,686) who sought treatment at the centre between 2003 and 2012. Information about socio-gambling demographics, physical and mental health status, current presenting problems, self-rated South Oaks Gambling Screen (SOGS, Chinese version), and occurrence of SI or FSI were examined. Descriptive analysis and ordinal regression analysis were used to investigate the characteristics of the gamblers and the association of variables.

RESULTS

In our sample, 720 (20.0%) individuals reported SI, and 22 (0.6%) individuals reported FSI at the initial assessment. Individuals with SI and FSI differed from the nonsuicidal individuals in terms of their demographics, gambling experiences and severity, mental and physical wellbeing, and types of gambling-related problems. The adjusted ordinal regression model shows that participating in table games in casinos and having familial and financial problems seem to enhance the likelihood of having SI and FSI.

CONCLUSION

While mental health issues are significantly related to SI and FSI among gambling treatment seekers, the impacts of physical, family, and financial strains should not be underestimated.

Psychometric properties of the Barratt Impulsiveness Scale in patients with gambling disorders, hypersexuality, and methamphetamine dependence

Although the Barratt Impulsiveness Scale (BIS; Patton, Stanford, & Barratt, 1995) is a widely-used self-report measure of impulsivity, there have been numerous questions about the invariance of the factor structure across clinical populations (Haden & Shiva, 2008, 2009; Ireland & Archer, 2008). The goal of this article is to examine the factor structure of the BIS among a sample consisting of three populations exhibiting addictive behaviors and impulsivity: pathological gamblers, hypersexual patients, and individuals seeking treatment for methamphetamine dependence to determine if modification to the existing factors might improve the psychometric properties of the BIS. The current study found that the factor structure of the BIS does not replicate in this sample and instead produces a 12-item three-factor solution consisting of motor-impulsiveness (5 items), non-planning impulsiveness (3 items), and immediacy impulsiveness (4 items). The clinical utility of the BIS in this population is questionable. The authors suggest future studies to investigate comparisons with this modified version of the BIS and other impulsivity scales such as the UPPS-P Impulsive Behavior Scale in clinical populations when assessing disposition toward rash action.

Sleepiness and cognition in young adults who gamble and use alcohol

BACKGROUND AND AIMS

Past research suggests that sleep problems are associated with increased risky decision-making. Similarly, gambling disorder and alcohol use disorder are also associated with increased risky decision-making. Individuals with gambling disorder or alcohol use disorder have also reported higher rates of sleep problems compared to normal healthy controls. As such, we sought to examine whether sleep problems play a role in the development of alcohol use disorder or gambling disorder.

METHODS

One hundred and forty-one individuals who gamble and use alcohol, yet do not meet criteria for gambling disorder or alcohol use disorder, were assessed to determine the correlation between sleepiness, amount of sleep obtained, decision-making, and alcohol or gambling behaviors.

RESULTS

Our results suggest that inconsistent sleep patterns may be associated with increased frequency of alcohol use and gambling. We did not, however, find a significant correlation between sleep factors and decision-making.

DISCUSSION

Further research is needed to examine the specific relationship between sleep patterns and alcohol use and gambling frequency. Overall these data suggest that sleepiness or sleep and risky decision-making is not a significant factor in gambling and alcohol use behaviors in individuals not meeting criteria for alcohol use disorder or gambling disorder.

Addressing sleep disturbances: an opportunity to prevent cardiometabolic disease?

There is increasing awareness of the role of sleep disturbance as an important factor in health and disease. Although sub-clinical sleep disturbances (insufficient sleep duration or inadequate sleep quality) may be difficult to assess with conceptual and/or methodological clarity, this review attempts to summarize and synthesize these findings. First, the concept of sleep disturbance in a public health context is introduced, to provide context and rationale. Second, operational definitions of 'cardiometabolic disease' and 'sleep disturbance' are offered, to address many unclear operationalizations. Third, the extant literature is summarized regarding short or long sleep duration and/or insufficient sleep, insomnia and insomnia symptoms, general (non-specific sleep disturbances), circadian rhythm abnormalities that result in sleep disturbances, and, briefly, sleep-disordered breathing. Fourth, the review highlights the social/behavioural context of sleep, including discussions of sleep and race/ethnicity, socio-economic position, and other social/environmental factors, in order to place these findings in a social-environmental context relevant to public health. Fifth, the review highlights the issue of sleep as a domain of health behaviour and addresses issues regarding development of healthy sleep interventions. Finally, a research agenda of future directions is proposed.

Pathological gambling, problem gambling and sleep complaints: an analysis of the National Comorbidity Survey: Replication (NCS-R)

The purpose of this study is to investigate the relationship between sleep disturbances and gambling behavior. Data from the National Comorbidity Survey-Replication (NCS-R) was used to examine the relationship between three specific sleep complaints (difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS], and early morning awakening [EMA]) and gambling behavior. Bivariate logistic regression models were used to control for potentially confounding psychiatric disorders and age. Almost half of respondents with problem gambling behavior (45.9%) and two thirds (67.7%) of respondents with pathological gambling behavior reported at least one sleep compliant. Compared to respondents with no gambling pathology, respondents with pathological gambling were significantly more likely to report at least one sleep complaint (Adjusted Odds Ratio [AOR] = 3.444, 95% CI = 1.538-7.713), to report all sleep complaints (AOR = 3.449, 95% CI = 1.503-7.914), and to report any individual complaint (DIS: OR = 2.300, 95% CI = 1.069-4.946; DMS: AOR = 4.604, 95% CI = 2.093-10.129; EMA: AOR = 3.968, 95% CI = 1.856-8.481). The relationship between problem gambling and sleep complaints were more modest (any sleep complaint: AOR = 1.794, 95% CI = 1.142-2.818; all three sleep complaints: AOR = 2.144, 95% CI = 1.169-3.931; DIS: AOR = 1.961, 95% CI = 1.204-3.194; DMS: AOR = 1.551, 95% CI = 0.951-2.529; EMA: AOR = 1.796, 95% CI = 1.099-2.935). Given the individual and societal ramifications linked with the presence of sleep problems, this study presents another health-related repercussion associated with gambling pathology rarely discussed in the literature.

The Implementation of a Telephone-Delivered Intervention for Asian American Disordered Gamblers: A Pilot Study

This report will discuss the implementation and preliminary results of a community-based telephone-delivered gambling treatment program specifically designed for Asian Americans. The intervention was implemented by the NICOS Chinese Health Coalition, a nonprofit community organization based in Northern California, overseen by the UCLA (University of California, Los Angeles) Gambling Studies Program and the California Office of Problem Gambling, and launched in December 2010. It consisted of six 1-hr long telephone-delivered sessions conducted by a mental health provider using a translated version of the Freedom from Problem Gambling Self-Help Workbook. In the current study, 6 providers completed a 30-hr training program for gambling related disorders. One-hundred and 40 callers inquired about the intervention within the first 6 months of its launch, 19 clients expressed interest in participating, and 8 enrolled into the program. The results show that the majority of clients who enrolled into the program did not report any gambling behavior after baseline and improved on self-reported measures of overall life satisfaction, gambling urges, and self-control. This study suggests that the implementation of this type of intervention is feasible at a small community-based organization and may be effective in treating gambling-related disorders for Asian American populations. The low rate of clientele enrollment is addressed and potential remedies are discussed.

Behavioral addictions: where to draw the lines?

Behavioral addictions can present in a variety of subtle and deceptive patterns. Because of the intense shame, guilt, and embarrassment felt by patients, it may fall to providers to utilize screening tools and deeper interviewing techniques to uncover the extent of these behaviors. Identifying when the line is crossed from recreation/habit to psychopathology relies on understanding current diagnostic criteria and consideration of cultural, ethnic, and local community standards. Individuals are also likely to cross back and forth between this line of pathology and habit, further clouding provider’s opinions of diagnosis; therefore, tracking and monitoring these symptoms over time is critical to establishing patterns of use and documenting ongoing consequences. Treatment for these conditions is emerging slowly, and treatment outcomes for these conditions appear to be similar to those with other addictive disorders.