Gambling severity, impulsivity, and psychopathology: comparison of treatment- and community-recruited pathological gamblers

A Psychophysiological and Behavioural Study of Slot Machine Near-Misses Using Immersive Virtual Reality

During slot machine gambling, near-miss outcomes occur when the final winning icon lands one position off the pay-line. To understand how near-misses promote gambling behaviour in healthy populations, autonomic arousal is often used to index outcome response valence. Findings remain equivocal, possibly owing to the limited ecological validity of computer simulations. Relevant psychological traits, such as impulsivity, which increase the risk of problem gambling, are often not examined. Here, we used immersive virtual reality (VR) to investigate near-miss-induced changes in physiological arousal and VR gambling behaviour. Sixty adult participants with no history of problem gambling were immersed in a VR casino-bar where they engaged with a self-selected slot machine. Real-time heart rate (HR) data were acquired during immersion. Within-subjects analyses were conducted on HR and post-reinforcement pauses (PRPs; i.e., time taken to initiate next-spin) across wins, losses and near-misses. Significant HR acceleration occurred for both near-misses and losses compared to wins, indexing an initial orientation response. Both types of losses were associated with faster next-spin responses. Near-misses did not apparently have unique HR or PRP profiles from losses, although this may reflect our loss control condition, which in itself may have been a subtler near-miss outcome. Impulsivity measured by the SUPPS-P was not associated with near-miss responses. Losses may encourage gambling as participants experience more immediate HR acceleration (indexing arousal unique to losing) and initiate faster responses. Future studies should clarify this effect by investigating problem gambling cohorts and develop VR paradigms taking into consideration the current findings and limitations.

Where Do Gambling Problems Fit in the Structure of Psychopathology During Emerging Adulthood?

Research suggests major mental disorders co-occur at higher than chance levels. In adult samples, a two factor structure emerges when modeling the higher order structure of psychopathology. Specifically, disorders tend to co-aggregate into two dimensions: Internalizing (depression and anxiety) and Externalizing (acting out, impulsive, and addictive) disorders. Despite this large body of evidence, few studies have integrated problem gambling into this overall model. We used confirmatory factor analysis to model how the symptom count of gambling fits into the structure of psychopathology in a large, community based young adult twin sample of men and women (age 24; N=1329). Twins were assessed via in-person, structured diagnostic interviews on disorders including: Major Depression, Phobias, Post-Traumatic Stress Disorder and Anxiety Disorders (internalizing) and Substance Use Disorders, Gambling Problems (self-report), and Antisocial Behaviors (externalizing). The data were fit to a two-factor structure, with gambling symptoms loading most highly on externalizing, rather than internalizing. The problem gambling loadings did not differ by sex. Implications of these findings suggest that during emerging adulthood gambling problems are best classified and conceptualized in the realm of externalizing disorders for both males and females. Results also suggest prevention and intervention efforts be aimed at young adults who exhibit commonly co-occurring psychopathology.

Predicting Gambling Situations: The Roles of Impulsivity, Substance Use, and Post-Traumatic Stress

Gambling disorder and symptoms of post-traumatic stress are highly comorbid. Numerous studies suggest that the presence of one (either disordered gambling or post-traumatic stress) substantially increases the odds of later developing the other. However, little is known about the etiological links between these two domains or the nuances of the comorbidity. Past research has suggested that symptoms of post-traumatic stress might be related to unique motivations for and beliefs about gambling. The present work sought to examine whether or not symptoms of post-traumatic stress might also be related to specific situational vulnerabilities to gambling behaviors. Using a large cross-sectional sample of Internet-using adults in the United States who were primarily recreational gamblers (N = 743; 46% men, M_age = 36.0, SD = 11.1), as well as an inpatient sample of US Armed Forces veterans seeking treatment for gambling disorder (N = 332, 80% men, M_age = 53.5, SD = 11.5), the present work tested whether or not symptoms of post-traumatic stress were uniquely related to a variety of gambling situations. Results in both samples revealed that even when controlling for potentially confounding variables (eg, substance use and trait impulsivity), symptoms of post-traumatic stress were uniquely related to gambling in response to negative affect, gambling in response to social pressure, and gambling due to a need for excitement. These findings are consistent with recent work suggesting that individuals with post-traumatic stress symptoms are more likely to engage in gambling behaviors for unique reasons that differ from gamblers without such symptoms.

Neuroimaging of reward mechanisms in Gambling disorder: an integrative review

Gambling disorder (GD) was reclassified as a behavioral addiction in the DSM-5 and shares clinical and behavioral features with substance use disorders (SUDs). Neuroimaging studies of GD hold promise in isolating core features of the addiction syndrome, avoiding confounding effects of drug neurotoxicity. At the same time, a neurobiologically-grounded theory of how behaviors like gambling can become addictive remains lacking, posing a significant hurdle for ongoing decisions in addiction nosology. This article integrates research on reward-related brain activity (functional MRI) and neurotransmitter function (PET) in GD, alongside the consideration of structural MRI data as to whether these signals more likely reflect pre-existing vulnerability or neuroadaptive change. Where possible, we point to qualitative similarities and differences with established markers for SUDs. Structural MRI studies indicate modest changes in regional gray matter volume and diffuse reductions in white matter integrity in GD, contrasting with clear structural deterioration in SUDs. Functional MRI studies consistently identify dysregulation in reward-related circuitry (primarily ventral striatum and medial prefrontal cortex), but evidence is mixed as to the direction of these effects. The need for further parsing of reward sub-processes is emphasized, including anticipation vs outcome, gains vs. losses, and disorder-relevant cues vs natural rewards. Neurotransmitter PET studies indicate amplified dopamine (DA) release in GD, in the context of minimal differences in baseline DA D2 receptor binding, highlighting a distinct profile from SUDs. Preliminary work has investigated further contributions of opioids, GABA and serotonin. Neuroimaging data increasingly highlight divergent profiles in GD vs. SUDs. The ability of gambling to perpetually activate DA (via maximal uncertainty) may contribute to neuroimaging similarities between GD and SUDs, whereas the supra-physiological DA effects of drugs may partly explain differences in the neuroimaging profile of the two syndromes. Coupled with consistent observations of correlations with gambling severity and related clinical variables within GD samples, the overall pattern of effects is interpreted as a likely combination of shared vulnerability markers across GD and SUDs, but with further experience-dependent neuroadaptive processes in GD.

Clinical and Personality Characteristics of Problem and Pathological Gamblers With and Without Symptoms of Adult ADHD

The study examined the differential clinical and personality characteristics of problem and pathological gamblers (PPGs) with and without clinically significant symptoms of adult attention deficit hyperactive disorder (ADHD). Adults (N = 150, n = 75 women) with PPG were assessed by the SCID-IV, Conners' Adult ADHD Rating Scales, Multidimensional Personality Questionnaire, Gambling Motivation Questionnaire, and the Barratt Impulsiveness Scale. PPGs who reported symptoms of ADHD were more likely to be male, endorse psychiatric comorbidities (i.e., alcohol dependence, anxiety disorders, and antisocial personality disorder), report maladaptive personality traits (i.e., higher negative emotionality and lower positive emotionality), as well as higher impulsivity (attention impulsiveness, motor impulsiveness, and nonplanning impulsiveness). PPGs with symptoms of ADHD reported gambling for social, coping, and enhancement reasons. A multivariate binary logistic regression revealed that sex, higher scores on social reasons for gambling, and lack of premeditation were associated with an increased likelihood of reporting ADHD symptoms. The findings demonstrate important differences of PPGs with symptoms of ADHD and provide information for treatment consideration.

Subtyping Non-treatment-seeking Problem Gamblers Using the Pathways Model

This study examined whether distinct subgroups could be identified among a sample of non-treatment-seeking problem and pathological/disordered gamblers (PG) using Blaszczynski and Nower's (Addiction 97:487-499, 2002) pathways model (N = 150, 50% female). We examined coping motives for gambling, childhood trauma, boredom proneness, risk-taking, impulsivity, attention-deficit/hyperactivity disorder (ADHD), and antisocial personality disorder as defining variables in a hierarchical cluster analysis to identify subgroups. Subgroup differences in gambling, psychiatric, and demographic variables were also assessed to establish concurrent validity. Consistent with the pathways model, our analyses identified three gambling subgroups: (1) behaviorally conditioned (BC), (2) emotionally vulnerable (EV), and (3) antisocial-impulsivist (AI) gamblers. BC gamblers (n = 47) reported the lowest levels of lifetime depression, anxiety, gambling severity, and interest in problem gambling treatment. EV gamblers (n = 53) reported the highest levels of childhood trauma, motivation to gamble to cope with negative emotions, gambling-related suicidal ideation, and family history of gambling problems. AI gamblers (n = 50) reported the highest levels of antisocial personality disorder and ADHD symptoms, as well as higher rates of impulsivity and risk-taking than EV gamblers. The findings provide evidence for the validity of the pathways model as a framework for conceptualizing PG subtypes in a non-treatment-seeking sample, and underscore the importance of tailoring treatment approaches to meet the respective clinical needs of these subtypes.

Gambling involvement among Native Americans, Blacks, and Whites in the United States

BACKGROUND AND OBJECTIVES

This paper examines risk factors of gambling and problem gambling among racial subgroups in the U.S. population, namely Native Americans and blacks, for whom research data are lacking.

METHODS

Findings are based on a large representative general population survey (n = 3,474) of gambling in the U.S. with an oversample of Native Americans (n = 549). Multiple domains were assessed including sociodemographic factors; ecological factors (census-defined neighborhood disadvantage, geocoded density of casinos within 30 miles of respondents' homes, and perceived gambling convenience); impulsivity; and alcohol abuse.

RESULTS

After controlling for all variables in the study, neighborhood disadvantage has a significantly greater effect on overall gambling, frequent gambling, and problem gambling for Native Americans than for the rest of the U.S.

POPULATION

In addition, the relationship between frequent gambling and heavier drinking is much stronger for blacks than for the rest of the U.S.

POPULATION

DISCUSSION AND CONCLUSIONS

There is a lack of research on gambling involvement among minority groups in the U.S. Blacks and Native Americans are at a higher risk for problem gambling as compared with the rest of the population. Furthermore, social factors and alcohol abuse may show a stronger co-occurrence with gambling involvement among minority groups than among whites.

SCIENTIFIC SIGNIFICANCE

This study is a large representative U.S. sample with sizeable numbers of Native Americans and blacks. Thus, prevalence rates and risk factors can be assessed for these important population subgroups. This will allow for targeted intervention programs for Native Americans and blacks with problem gambling and alcohol abuse. (Am J Addict 2017;26:713-721).

Neuroscience in gambling policy and treatment: an interdisciplinary perspective

Neuroscientific explanations of gambling disorder can help people make sense of their experiences and guide the development of psychosocial interventions. However, the societal perceptions and implications of these explanations are not always clear or helpful. Two workshops in 2013 and 2014 brought together multidisciplinary researchers aiming to improve the clinical and policy-related effects of neuroscience research on gambling. The workshops revealed that neuroscience can be used to improve identification of the dangers of products used in gambling. Additionally, there was optimism associated with the diagnostic and prognostic uses of neuroscience in problem gambling and the provision of novel tools (eg, virtual reality) to assess the effectiveness of new policy interventions before their implementation. Other messages from these workshops were that neuroscientific models of decision making could provide a strong rationale for precommitment strategies and that interdisciplinary collaborations are needed to reduce the harms of gambling.

A Longitudinal Study of the Temporal Relation Between Problem Gambling and Mental and Substance Use Disorders Among Young Adults

OBJECTIVE

Relatively little is known about the temporal relation between at-risk gambling or problem gambling (PG) and mental and substance use disorders (SUDs) in young adulthood. Our study aimed to examine whether past-year, at-risk, or PG is associated with incident mental disorders and SUDs (that is, depression, generalized anxiety disorder, obsessive-compulsive disorder [OCD], or alcohol dependence) and illegal drug use, and whether past-year mental disorders and SUDs and illegal drug use is associated with incident at-risk or PG.

METHOD

Data for this longitudinal study were drawn from the Manitoba Longitudinal Study of Young Adults (MLSYA). Respondents aged 18 to 20 years in 2007 were followed prospectively for 5 years.

RESULTS

In cross-sectional analyses, at-risk or PG was associated with increased odds of depression, OCD, alcohol dependence, and illegal drug use. In longitudinal analysis at-risk or PG at cycle 1 was associated with incident major depressive disorder, alcohol dependence, and illegal drug use in the follow-up period. Only illegal drug use at cycle 1 was associated with incident at-risk or PG during follow-up.

CONCLUSIONS

At-risk or PG was associated with more new onset mental disorders and SUDs (depression, alcohol dependence, and illegal drug use), compared with the reverse (illegal drug use was the only association with new onset at-risk or PG). Preventing at-risk or PG from developing early in adulthood may correspond with decreases in new onset mental disorders and SUDs later in adulthood.

Pharmacotherapy and group cognitive behavioral therapy enhance follow-up treatment duration in gambling disorder patients

BACKGROUND

Longer treatment duration is important for the successful treatment of gambling disorder (GD). This retrospective study investigated the factors and interventions that might enhance treatment duration in GD patients in South Korea.

METHODS

A total of 758 outpatients with a primary diagnosis of GD, who were treated in a clinical practice from 2002 to 2011, were assessed by retrospective chart review. We compared the treatment duration according to pharmacotherapy and group cognitive behavioral therapy (CBT).

RESULTS

Pharmacotherapy contributed to a longer duration of treatment maintenance, despite the patients' gambling severity (p < 0.001). Participation in group CBT (p < 0.001) and antidepressants (p = 0.009) were associated with a longer treatment duration after adjusting for age, depression, and gambling severity. The treatment maintenance duration was the longest in those receiving combined antidepressant pharmacotherapy and group CBT (F = 35.79, p < 0.001).

CONCLUSIONS

Group CBT and antidepressants seem to enhance treatment follow-up duration in GD patients. Additional studies are needed to advance GD prevention and treatment strategies.

Contribution of illegal acts to pathological gambling diagnosis: DSM-5 implications

The purposes of this study were to examine the specific contribution of illegal acts to the diagnostic criteria of pathological gambling, to assess the possibility of differential item functioning across patients' sex and age, and to explore the existence of different clinical phenotypes based on the presence of illegal acts. The sample consisted of 2,155 patients seeking treatment for pathological gambling at the University Hospital of Bellvitge in Barcelona, Spain. The illegal acts item did not show different item functioning, and younger patients presented higher latent means than middle-aged and older patients, whereas no differences were found across sex. This item also showed the lowest discrimination coefficient; its exclusion would maintain satisfactory internal consistency for the remaining 9 symptoms and was poorly related to psychopathology and the severity of the gambling behavior. The relevance of the illegal acts as a diagnostic criterion appears to be limited, and its elimination from the Diagnostic and Statistical Manual for Mental Disorders, 5th edition, seems justified. However, illegal acts have implications for both the clinical and legal domains and contribute to increase the patients' impairment.

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.

Pathological gambling subtypes: A comparison of treatment-seeking and non-treatment-seeking samples from Brazil and Canada

BACKGROUND

Pathological gambling (PG) is a heterogeneous disorder. The identification and characterization of PG subtypes could lead to tailored treatment approaches, which may, in turn, improve treatment outcomes.

OBJECTIVE

To investigate PG subtypes based on personality traits across two different cultural and clinical settings. Consistent with the Pathways Model, we hypothesized the presence of three subtypes (behaviorally conditioned - BC, emotionally vulnerable - EV, and antisocial impulsivist - AI).

METHODS

140 PG adults from São Paulo, Brazil (SP sample) and 352 adults with PG (n=214) or sub-clinical PG (n=138) from Toronto, Canada (TO sample) completed the Temperament and Character Inventory (TCI). Latent-class analysis was used to investigate subtypes.

RESULTS

A 2-class solution was the best model for the pooled SP and TO samples. Class 1 presented a normative personality profile and was composed exclusively of participants from Toronto (BC subtype). Class 2 was characterized by high novelty seeking, high harm avoidance, and low self-directedness, and included participants from both SP and TO (EV subtype). When sub-clinical PGs were excluded from the analysis, a single-class solution better characterized the SP and TO samples.

CONCLUSIONS

Our results suggest that PG severity, rather than community or clinical settings, may have an effect on PG subtypes. The generalizability of the results is limited by the demographic and clinical features of the selected samples. Future neurobiological studies may contribute to the categorization of subjects into PG subtypes based on different underlying biological pathways.

Getting a grip on problem gambling: what can neuroscience tell us?

In problem gamblers, diminished cognitive control and increased impulsivity is present compared to healthy controls. Moreover, impulsivity has been found to be a vulnerability marker for the development of pathological gambling (PG) and problem gambling (PrG) and to be a predictor of relapse. In this review, the most recent findings on functioning of the brain circuitry relating to impulsivity and cognitive control in PG and PrG are discussed. Diminished functioning of several prefrontal areas and of the anterior cingulate cortex (ACC) indicate that cognitive-control related brain circuitry functions are diminished in PG and PrG compared to healthy controls. From the available cue reactivity studies on PG and PrG, increased responsiveness towards gambling stimuli in fronto-striatal reward circuitry and brain areas related to attentional processing is present compared to healthy controls. At this point it is unresolved whether PG is associated with hyper- or hypo-activity in the reward circuitry in response to monetary cues. More research is needed to elucidate the complex interactions for reward responsivity in different stages of gambling and across different types of reward. Conflicting findings from basic neuroscience studies are integrated in the context of recent neurobiological addiction models. Neuroscience studies on the interface between cognitive control and motivational processing are discussed in light of current addiction theories.

Clinical implications: We suggest that innovation in PG therapy should focus on improvement of dysfunctional cognitive control and/or motivational functions. The implementation of novel treatment methods like neuromodulation, cognitive training and pharmacological interventions as add-on therapies to standard treatment in PG and PrG, in combination with the study of their effects on brain-behavior mechanisms could prove an important clinical step forward towards personalizing and improving treatment results in PG.