Pathological gambling and obsessive-compulsive disorder: towards a spectrum of disorders of volition

Correlates of Problematic Gambling in Emerging Adult University Students in Ireland

INTRODUCTION

Understanding the correlates of problematic gambling among emerging adult university students is crucial for developing effective approaches to minimise harm.

METHODS

This cross-sectional survey study reports on 397 18-25 year old emerging adults studying at Irish universities who completed an online survey about problematic gambling and a range of biopsychosocial variables. Chi-square and binary logistic regression analyses explored the relationships between problematic gambling and the biopsychosocial variables measured.

RESULTS

Chi-square analyses showed that being male, having an online gambling account, having a mobile gambling app, novelty seeking (impulsivity), harm avoidance (fear of uncertainty), and high alcohol volume consumption were significantly associated with problematic gambling. Regression analyses showed that individuals were more likely to report problematic gambling if they were male (OR = 9.57 times), had an online gambling account (OR = 17.05 times), had a mobile gambling app (OR = 20.37 times), scored high in impulsivity (OR = 7.79 times), and reported high alcohol volume consumption (OR = 4.66 times). Individuals were less likely to report problematic gambling if they scored high in fear of uncertainty (OR = 0.26 times).

CONCLUSIONS

A high rate of problematic gambling was observed among the current study sample. Participants were more likely to reported problematic gambling if they were male, had online gambling accounts, mobile gambling apps, scored high in impulsivity, scored low in fear of uncertainty, or consumed high volumes of alcohol in typical drinking sessions. These findings have implications for Irish legislation and policy-makers, Irish higher education institutions, and young adult Irish university students.

Impulsivity and compulsivity in gambling disorder and bulimic spectrum eating disorders: Analysis of neuropsychological profiles and sex differences

BACKGROUND

Gambling disorder (GD) and bulimic spectrum eating disorders (BSDs) not only share numerous psychopathological, neurobiological, and comorbidity features but also are distinguished by the presence of inappropriate behaviours related to impulsivity and compulsivity. This study aimed to emphasise the differences and similarities in the main impulsivity and compulsivity features between GD and BSD patients, and to analyse the potential influence of sex in these domains.

METHODS

Using self-reported and neurocognitive measures, we assessed different impulsive-compulsive components in a sample of 218 female and male patients (59 with BSD and 159 with GD) and 150 healthy controls.

RESULTS

We observed that GD and BSDs exhibited elevated levels of impulsivity and compulsivity in all the dimensions compared to healthy controls. Moreover, these disorders showed differences in several personality traits, such as high novelty seeking in GD, and low persistence and high harm avoidance in BSDs. In addition, patients with BSDs also displayed a trend towards greater impulsive choice than GD patients. Regarding sex effects, GD women presented higher overall impulsivity and compulsivity than GD men. Nevertheless, no sex differences were found in BSDs.

CONCLUSIONS

Clinical interventions should consider these deficits to enhance their effectiveness, including adjunctive treatment to target these difficulties. Our findings also provide support to the relevance of sex in GD, which should also be considered in clinical interventions.

Online Gambling in Iranian Social Media Users: Prevalence, Related Variables and Psychiatric Correlations

The exponential increase in Internet use has been associated with dangers and harms. Recently, the prevalence of online gambling is increasing in various countries. Online gambling can be a prelude to gambling disorder. No study has been conducted in this field in Iran yet. The aim of this study was to investigate the prevalence of online gambling (without disorder and pathological), and its relationship with demographic variables and psychiatric symptoms. 3252 people participated in this study online. Research tools included gambling disorder screening questionnaire-Persian (GDSQ-P), brief symptom inventory (BSI), Young's addiction questionnaire, and Demographic questionnaire. The prevalence of online gambling was 8.9%. 26.6% of online gamblers experience moderate to severe degrees of pathological gambling. 74.7% of online gamblers were male. Online gamblers have a lower mean age than non-online gamblers (p < 0.001). Online gamblers were equally from all economic classes. The most common methods of gambling were CRASH game and sports betting. Online gamblers had no significant difference in the rate of face-to-face (physical) gambling history, compared to non-online gamblers (6.9% vs 5.6%), (p > 0.05). In BSI-assessed psychiatric symptoms, online gamblers showed higher scores on anxiety and obsession, and lower scores on paranoid ideation, compared to the control group (p < 0.05). Also, Internet addiction and daily use of the Internet as entertainment were significantly higher in online gamblers than non-online gamblers (p < 0.05). Also, a positive and significant correlation was found between the severity of gambling and the severity of Internet addiction, severity of depression, severity of anxiety, and severity of obsession in online gamblers (p < 0.05). Overall, online gambling is common in Iran and is associated with psychiatric problems. Health professionals and the government should pay special attention to online gambling and its related problems.

Gambling disorder seeking treatment patients and tobacco use in relation to clinical profiles

OBJECTIVES

Tobacco smoking and gambling disorder (GD) often co-occur. However, few studies have assessed the extent to which cigarette smoking may serve to classify and/or better define GD behaviour profiles.

METHODS

Among a large sample of n = 3,652 consecutive treatment-seeking patients with GD (91% men). Smokers were compared to non-smokers across different sociodemographic, clinical, psychopathological and personality variables. The effect sizes for the means and the proportion differences between the groups were estimated. An evaluation of the smoking changes over the last 15 years was also performed.

RESULTS

From the total sample, 62.4% of gamblers reported tobacco use. A decreasing linear trend in tobacco use was observed within the studied period, women having a more irregular pattern. The use of tobacco was linked to the use of alcohol and other illegal drugs. Gamblers who smoke, as compared to those who don't, presented lower education levels, lower social position indexes and active employment. They were younger, with an earlier age of onset, shorter duration of the gambling behavior, higher GD severity, more psychological symptoms, higher scores in novelty seeking and lower scores in reward dependence, self-directedness and self-transcendence.

CONCLUSIONS

Gamblers seeking treatment who smoke display particular social, clinical, psychological, temperamental and character features different from non-smoking gamblers, suggesting that the presence or absence of comorbid smoking condition in GD should always be considered when developing an optimal treatment, as gamblers who smoke might need treatment strategies different from non-smoking gamblers.

Discrete Roles for Impulsivity and Compulsivity in Gambling Disorder

Background and Objective: Complex associations between gambling disorder (GD) and impulsivity have been identified. However, little is known regarding how compulsivity associates with different impulsivity domains in GD. In this study, we examined associations between self-reported and behavioral measures of impulsivity-assessed through the Barratt Impulsiveness Scale (BIS-11) and the Experiential Discounting Task (EDT), respectively- and compulsivity-measured using the Padua Inventory and the Wisconsin Card Sorting Test (WCST), respectively-, in an adult sample with GD (N = 132, 94 men and 38 women, ages ranging from 18 to 69 years). GD severity was assessed using the South Oaks Gambling Screen. Methods: Structural Equation Modeling was used to examine relationships between impulsivity and compulsivity measures, age, and GD severity. Results: BIS-11 non-planning and BIS-11 total scores positively correlated with GD severity. The standardized coefficients for the SEM showed direct positive contributions of BIS-11 non-planning, Padua and EDT scores to GD severity. Only participants' ages directly contributed to WCST perseverative errors, and no direct or indirect effects were found with respect to GD severity. Conclusion: The findings suggest that specific aspects of impulsivity and compulsivity contribute to GD severity. Interventions specifically targeting domains that are most relevant to GD severity may improve treatment outcomes.

"Should've known better": Counterfactual processing in disordered gambling

Counterfactual thinking is a component of human decision-making that entails "if only" thinking about unselected choices and outcomes. It is associated with strong emotional responses of regret (when the obtained outcome is inferior to the counterfactual) and relief (vice versa). Counterfactual thinking may play a role in various cognitive phenomena in disordered gambling, such as the effects of near-misses. This study compared individuals with gambling disorder (n = 46) and healthy controls (n = 25) on a behavioural economic choice task that entailed choosing between two gambles, designed to measure counterfactual thinking. Participants provided affect ratings following both the obtained and the non-obtained outcomes. Choices were analyzed using a computational model that derived parameters reflecting sensitivity to expected value, risk variance, and anticipated regret. In the computational choice model, the group with gambling disorder showed increased sensitivity to anticipated regret, reduced sensitivity to expected value, and increased preference for high risk-variance gambles. On the affect ratings, the group with gambling disorder displayed blunted emotional sensitivity to obtained and counterfactual outcomes. Effect sizes of the group differences were modest. Participants with gambling disorder show wide-ranging alterations in decision-making processes and emotional reactivity to choice outcomes. Altered sensitivity to anticipatory regret in gambling disorder may contribute to the development of gambling-related cognitive distortions, and the influences of gambling marketing.

Giving a Voice to Gambling Addiction: Analysis of Personal Narratives

Gambling addiction (GA) is now considered a worldwide health issue. Although the topic of disorder awareness is a central issue in clinical practice, there are few studies examining this dimension in relation to GA. To bridge this gap, we conducted a qualitative study, administering interviews focused on awareness of GA and eliciting narratives of both the disorder and the whole life of participants. We adopted both qualitative and quantitative methods of research, using computer-aided content analysis. We administered to a sample of 15 treatment-seeking gamblers the Psychiatric Interview for Gambling Addiction and performed a qualitative analysis of the text using the T-Lab software. Five main thematic domains and four factors emerged, shedding light on specific aspects underlying the development of and recovery from GA. Specifically, the results suggested that dissociation processes, materialistic thinking and difficulties in social achievement underlie the subjective experience of GA. Moreover, closeness in interpersonal relationships and awareness of the disorder emerged as core features in the process of change. As a whole, the results highlight the specificities of disorder awareness in addicted gamblers. We discuss these results within the context of previous research and suggest clinical implications for the treatment of GA.

Transdiagnostic variations in impulsivity and compulsivity in obsessive-compulsive disorder and gambling disorder correlate with effective connectivity in cortical-striatal-thalamic-cortical circuits

Individual differences in impulsivity and compulsivity is thought to underlie vulnerability to a broad range of disorders and are closely tied to cortical-striatal-thalamic-cortical function. However, whether impulsivity and compulsivity in clinical disorders is continuous with the healthy population and explains cortical-striatal-thalamic-cortical dysfunction across different disorders remains unclear. Here, we characterized the relationship between cortical-striatal-thalamic-cortical effective connectivity, estimated using dynamic causal modelling of resting-state functional magnetic resonance imaging data, and dimensional phenotypes of impulsivity and compulsivity in two symptomatically distinct but phenotypically related disorders, obsessive-compulsive disorder and gambling disorder. 487 online participants provided data for modelling of dimensional phenotypes. These data were combined with 34 obsessive-compulsive disorder patients, 22 gambling disorder patients, and 39 healthy controls, who underwent functional magnetic resonance imaging. Three core dimensions were identified: disinhibition, impulsivity, and compulsivity. Patients' scores on these dimensions were continuously distributed with the healthy participants, supporting a continuum model of psychopathology. Across all participants, higher disinhibition correlated with lower bottom-up connectivity in the dorsal circuit and greater bottom-up connectivity in the ventral circuit, and higher compulsivity correlated with lower bottom-up connectivity in the dorsal circuit. In patients, higher clinical severity was also linked to lower bottom-up connectivity in the dorsal circuit, but these findings were independent of phenotypic variation, demonstrating convergence towards behaviourally and clinically relevant changes in brain dynamics. Effective connectivity did not differ as a function of traditional diagnostic labels and only weak associations were observed for functional connectivity measures. Together, our results demonstrate that cortical-striatal-thalamic-cortical dysfunction across obsessive-compulsive disorder and gambling disorder may be better characterized by dimensional phenotypes than diagnostic comparisons, supporting investigation of quantitative liability phenotypes.

Dual diagnosis of obsessive compulsive and compulsive buying disorders: Demographic, clinical, and psychiatric correlates

AIM

The present research assessed the rates as well as the demographic, clinical, and psychiatric correlates associated with comorbid obsessive-compulsive disorder (OCD) and compulsive buying disorder (CBD).

METHOD

Participants were drawn from a large (N = 993) multi-center study of people seeking treatment for their OCD. The diagnoses of psychiatric disorders were made using the Structured Clinical Interview for DSM by registered psychologists and psychiatrists. The clinical correlates, including the severity and presence of OCD symptoms and dimensions were assessed using psychometrically sound measures.

RESULTS

75 (7.5%) participants met criteria for comorbid CBD. The results of binary logistic regression found that women were more likely to present with comorbid CBD, whereas being a student was a protective factor. The presence of hoarding dimension, poorer insight, social phobia, binge eating disorder, internet use disorder and kleptomania were significantly associated with comorbid CBD.

CONCLUSION

The results suggest that individuals with a dual diagnosis of OCD and CBD may represent a unique clinical population that warrants tailored interventions. Specifically, they were more likely to present with other psychiatric disorders characterized by high levels of impulsivity and compulsivity. Targeting psychological mechanisms common to impulsivity-compulsivity disorders may enhance treatment utility in this dual-diagnosis population.

Assessing the Relationship between Disordered Gamblers with Psychosis and Increased Gambling Severity: The Mediating Role of Impulsivity

OBJECTIVE

Recent research suggests that disordered gambling and psychosis co-occur at higher rates than expected in the general population. Gamblers with psychosis also report greater psychological distress and increased gambling severity. However, the mechanism by which psychosis leads to greater gambling symptomology remains unknown. The objective of the present research was to test whether impulsivity mediated the relationship between comorbid psychosis and gambling severity.

METHOD

The sample consisted of 394 disordered gamblers voluntarily seeking treatment at a large university hospital in São Paulo, Brazil. A semistructured clinical interview (Mini-International Neuropsychiatric Interview) was used to diagnosis the presence of psychosis by registered psychiatrists. Severity of gambling symptoms was assessed using the Gambling Symptom Assessment Scale, and the Barratt Impulsiveness Scale-11 provided a measure of impulsivity.

RESULTS

Of the sample, 7.2% met diagnostic criteria for psychosis. Individuals with a dual diagnosis of psychosis did not report greater gambling severity. Conversely, dual diagnoses of psychosis were associated with greater levels of impulsivity. Higher levels of impulsivity were also associated with greater gambling severity. Importantly, support for our hypothesised mediation model was found such that impulsivity mediated the association between disordered gambling and psychosis and gambling severity.

CONCLUSION

Impulsivity appears to be a transdiagnostic process that may be targeted in treatment among disordered gamblers with a dual diagnosis of psychosis to reduce problematic gambling behaviours.

Demographic, psychiatric, and personality correlates of adults seeking treatment for disordered gambling with a comorbid binge/purge type eating disorder

Preliminary evidence suggests that binge/purge type eating disorders and gambling disorder may commonly co-occur. However, this dual-diagnosis population remains understudied. The present research examined the prevalence rates and correlates of binge/purge type eating disorders (i.e., bulimia nervosa, binge-eating disorder, and anorexia nervosa binge/purge type) among adults seeking treatment for their gambling (N = 349). In total, 11.5% of the sample (n = 40) met criteria for a binge/purge type eating disorder, most commonly bulimia nervosa (n = 33). There was a higher preponderance of binge/purge type eating disorders in women. People with a comorbid binge/purge type eating disorder reported more days gambling, gambling-related cognitive distortions, impulsivity, suicidality, and other current psychiatric comorbidities including addictive behaviours. These findings suggest that binge/purge type eating disorders in people seeking treatment for gambling may be more common than previously believed. Furthermore, the increased psychopathology among people with binge/purge type eating disorder and gambling disorder identify vulnerabilities of this dual-diagnosed population that may require clinical attention.

Unpacking the role of self-reported compulsivity and impulsivity in obsessive-compulsive disorder

OBJECTIVE

We aimed to determine whether individuals with obsessive-compulsive disorder (OCD) and demographically matched healthy individuals can be clustered into distinct clinical subtypes based on dimensional measures of their self-reported compulsivity (OBQ-44 and IUS-12) and impulsivity (UPPS-P).

METHODS

Participants (n=217) were 103 patients with a clinical diagnosis of OCD; 79 individuals from the community who were "OCD-likely" according to self-report (Obsessive-Compulsive Inventory-Revised scores equal or greater than 21); and 35 healthy controls. All data were collected between 2013 and 2015 using self-report measures that assessed different aspects of compulsivity and impulsivity. Principal component analysis revealed two components broadly representing an individual's level of compulsivity and impulsivity. Unsupervised clustering grouped participants into four subgroups, each representing one part of an orthogonal compulsive-impulsive phenotype.

RESULTS

Clustering converged to yield four subgroups: one group low on both compulsivity and impulsivity, comprised mostly of healthy controls and demonstrating the lowest OCD symptom severity; two groups showing roughly equal clinical severity, but with opposing drivers (i.e., high compulsivity and low impulsivity, and vice versa); and a final group high on both compulsivity and impulsivity and recording the highest clinical severity. Notably, the largest cluster of individuals with OCD was characterized by high impulsivity and low compulsivity. Our results suggest that both impulsivity and compulsivity mediate obsessive-compulsive symptomatology.

CONCLUSIONS

Individuals with OCD can be clustered into distinct subtypes based on measures of compulsivity and impulsivity, with the latter being found to be one of the more defining characteristics of the disorder. These dimensions may serve as viable and novel treatment targets.

A psychometric validation study of the Impulsive-Compulsive Behaviours Checklist: A transdiagnostic tool for addictive and compulsive behaviours

The occurrence of repetitive behaviours that are often harmful has been attributed to traits traditionally described as "impulsive" or "compulsive" e.g. substance dependence, excessive gambling, and hoarding. These behaviours are common and often co-occur in both the general population and psychiatric populations. The lack of measures to concurrently index a range of such behaviours led to the development of the Impulsive-Compulsive Behaviours (ICB) Checklist. This study aims to validate the ICB Checklist in a general community sample. Factor analyses revealed a two-factor structure, demonstrating good model fit in two independent samples. These were labelled Impulsive-Compulsions and Compulsive-Impulsions, comprising of classically compulsive and impulsive behaviours respectively. Reliability and construct validity were further confirmed using correlations with existing measures of impulsivity and compulsivity. Results suggest that the ICB Checklist is a valid and practical assessment that can be used to monitor behavioural clusters characterised by deficits in inhibition.

Effect of amphetamine on behavioral patterns of obsessive-compulsive and addictive gambling in a rat marble test

A rodent marble test can be qualified as the most informative test of evaluation of obsessive-compulsive disorder as a neurobiological component of pathological gambling. Several behavioral components of obsession (obsessive and anxious ideas) and compulsions (obsessive actions) directed to anxiety reduction are modeled in this test. The effect of psychostimulant amphetamine on the rat behavior was studied in a marble test, anxiety-phobic model (scale), open field (evaluation of motor and emotional activity) and resident-intruder test (Intraspecies behavior). Amphetamine 0.5 and 1.5 mg/kg increased a number of burying bolls and elevated anxiety level in dose dependent manner. This accompanied with reduction of explorative activity, elevation of motor activity and number of individual behavioral patterns. Therefore, dopaminergic system of the brain activated with amphetamine is involved in obsessive-compulsive behavior and pathological gambling.

Behavioral Impulsivity in Obsessive-Compulsive Disorder

Background Grassi et al. (2015) collected data to examine impulsivity in individuals with obsessive-compulsive disorder (OCD) compared to nonpsychiatric controls. Their aim was to examine whether OCD may be fully captured by the behavioral addiction model, using the prototypical mechanism underlying drug addiction as their framework. Based on their findings, Grassi et al. concluded that OCD shares behavioral components with addictions, particularly behavioral impulsivity and risky decision making. Furthermore, the authors suggested that this model may be superior to the prevailing psychological model of OCD. Findings We argue that based on the nature of their data as well as the current dominant conceptualization of OCD in the literature, this conclusion is untenable. The authors inferred behavioral impulsivity, whereas their main finding was concerning cognitive impulsivity or difficulties in planning. Such items on the Barratt impulsiveness scale have been shown in other research to overpredict behavioral impulsive tendencies in OCD, where the nature of the condition involves doubting of action and a conservative estimate of how one's cognitions may impact behavior. Conclusions We conclude that similar to drug addiction, compulsive rituals in OCD may be governed by a negative reinforcement mechanism; the available data indicate that OCD does not share the two main components seen in addiction, namely, behavioral impulsivity and risky decision making.

Premature responding is associated with approach to a food cue in male and female heterogeneous stock rats

RATIONALE

Disorders of behavioral regulation, including attention deficit hyperactivity disorder (ADHD) and drug addiction, are in part due to poor inhibitory control, attentional deficits, and hyper-responsivity to reward-associated cues.

OBJECTIVES

To determine whether these traits are related, we tested genetically variable male and female heterogeneous stock rats in the choice reaction time (CRT) task and Pavlovian conditioned approach (PavCA). Sex differences in the response to methylphenidate during the CRT were also assessed.

METHODS

In the CRT task, rats were required to withhold responding until one of two lights indicated whether responses into a left or right port would be reinforced with water. Reaction time on correct trials and premature responses were the operational definitions of attention and response inhibition, respectively. Rats were also pretreated with oral methylphenidate (0, 2, 4 mg/kg) during the CRT task to determine whether this drug would improve performance. Subsequently, during PavCA, presentation of an illuminated lever predicted the delivery of a food pellet into a food-cup. Lever-directed approach (sign-tracking) and food-cup approach (goal-tracking) were the primary measures, and rats were categorized as "sign-trackers" and "goal-trackers" using an index based on these measures.

RESULTS

Sign-trackers made more premature responses than goal-trackers but showed no differences in reaction time. There were sex differences in both tasks, with females having higher sign-tracking, completing more CRT trials, and making more premature responses after methylphenidate administration.

CONCLUSIONS

These results indicate that response inhibition is related to reward-cue responsivity, suggesting that these traits are influenced by common genetic factors.

Clinical Profile and Psychiatric Comorbidity of Treatment-Seeking Individuals with Pathological Gambling in South-Africa

Pathological gambling is a prevalent and disabling mental illness, which is frequently associated with mood, anxiety, and substance use disorders. However, there is relatively little data on comorbidity in individuals with pathological gambling from low and middle income countries such as South-Africa. The Mini-International Neuropsychiatric Interview was used to assess the frequency of DSM-IV-TR disorders among 100 male and 100 female treatment-seeking individuals with pathological gambling in South-Africa. The Sheehan Disability Scale was used to assess functional impairment. In a South-African sample of individuals with pathological gambling, the most frequent current comorbid psychiatric disorders were major depressive disorder (28%), anxiety disorders (25.5%) and substance use disorders (10.5 %). Almost half of the individuals had a lifetime diagnosis of major depressive disorder (46%). Female pathological gamblers were significantly more likely to be diagnosed with a comorbid major depressive disorder or generalised anxiety disorder than their male counterparts. Data from South-Africa are consistent with previously published data from high income countries. Psychiatric comorbidity is common among individuals with pathological gambling.

Components of Impulsivity in Gambling Disorder

This study examined the structure of impulsivity within gambling disorder. A group of 51 men and 53 women with gambling disorder completed self-report and behavioral measures of impulsivity. Principal component analyses found two factors. The first was interpreted as measuring trait impulsivity. This factor correlated with problem gambling severity, presence of comorbid mental health and substance use disorders, history of brain injury, and was higher in Aboriginal participants. The second factor had high loadings on the self-reported sensation-seeking scales and the behavioural measures of response impulsivity. This factor correlated with overall gambling involvement but not with indicators of pathology. Higher scores were associated with younger age. These results are consistent with an evolving model of the etiology of disordered gambling that suggests that sensation-seeking is related to gambling involvement but that trait impulsivity and mental health struggles are associated with the development of gambling disorder.

Prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers: A systematic review and meta-analysis

OBJECTIVE

The aim of this paper was to systematically review and meta-analyse the prevalence of co-morbid psychiatric disorders (DSM-IV Axis I disorders) among treatment-seeking problem gamblers.

METHODS

A systematic search was conducted for peer-reviewed studies that provided prevalence estimates of Axis I psychiatric disorders in individuals seeking psychological or pharmacological treatment for problem gambling (including pathological gambling). Meta-analytic techniques were performed to estimate the weighted mean effect size and heterogeneity across studies.

RESULTS

Results from 36 studies identified high rates of co-morbid current (74.8%, 95% CI 36.5-93.9) and lifetime (75.5%, 95% CI 46.5-91.8) Axis I disorders. There were high rates of current mood disorders (23.1%, 95% CI 14.9-34.0), alcohol use disorders (21.2%, 95% CI 15.6-28.1), anxiety disorders (17.6%, 95% CI 10.8-27.3) and substance (non-alcohol) use disorders (7.0%, 95% CI 1.7-24.9). Specifically, the highest mean prevalence of current psychiatric disorders was for nicotine dependence (56.4%, 95% CI 35.7-75.2) and major depressive disorder (29.9%, 95% CI 20.5-41.3), with smaller estimates for alcohol abuse (18.2%, 95% CI 13.4-24.2), alcohol dependence (15.2%, 95% CI 10.2-22.0), social phobia (14.9%, 95% CI 2.0-59.8), generalised anxiety disorder (14.4%, 95% CI 3.9-40.8), panic disorder (13.7%, 95% CI 6.7-26.0), post-traumatic stress disorder (12.3%, 95% CI 3.4-35.7), cannabis use disorder (11.5%, 95% CI 4.8-25.0), attention-deficit hyperactivity disorder (9.3%, 95% CI 4.1-19.6), adjustment disorder (9.2%, 95% CI 4.8-17.2), bipolar disorder (8.8%, 95% CI 4.4-17.1) and obsessive-compulsive disorder (8.2%, 95% CI 3.4-18.6). There were no consistent patterns according to gambling problem severity, type of treatment facility and study jurisdiction. Although these estimates were robust to the inclusion of studies with non-representative sampling biases, they should be interpreted with caution as they were highly variable across studies.

CONCLUSIONS

The findings highlight the need for gambling treatment services to undertake routine screening and assessment of psychiatric co-morbidity and provide treatment approaches that adequately manage these co-morbid disorders. Further research is required to explore the reasons for the variability observed in the prevalence estimates.

A naturalistic study of recovering gamblers: What gets better and when they get better

Gambling recovery has typically been assessed through the lens of gambling behavior and its consequences. Little attention has been given to less obvious features of gambling disorder, such as negative affectivity, gambling cognitive distortions, impulsivity, cognitive flexibility, planning, inhibitory control, and decision-making. The current study investigates how gambling treatment affected these variables and if any are related to gambling recovery. One hundred and thirteen patients were assigned to psycho-education and psychiatric treatment. A subset of 48 patients was additionally assigned to cognitive behavioral therapy (CBT). Seventy-two patients were reassessed 6 months after treatment onset. Recovered and non-recovered gamblers did not differ in pre-treatment demographic, gambling, and psychiatric profiles. Three outcome variables were strongly related with gambling recovery: negative affectivity, cognitive distortions and decision-making. Logistic regression identified reduction of gambling cognitive distortions and better performance on decision-making as the best predictors of gambling recovery, regardless of the type of treatment received. Beyond the standard outcome measures for gambling treatment, increased sensitivity to loss and decreased positive expectancies towards gambling are key targets to promote recovery in gambling treatment.

Gambling in Brazil: a call for an open debate

AIMS

To provide an overview of gambling in Brazil, including historical background, past and current legislation, gamblers' profile, treatment and research initiatives.

METHODS

Review of the published literature and research reports.

RESULTS

Gambling is deeply rooted in Brazilian history and culture, but gambling regulation historically alternates between legalization and banning. Currently, only state lotteries, horse betting and poker-playing are allowed. There is pressure to widen the games repertoire, but efforts at full legalization and commercial exploration of gambling have receded. Despite the barriers to gambling access, Brazil has prevalence rates similar to other countries: 1.0 and 1.3% life-time prevalence for pathological and problem gambling. A faster progression from regular to problem gambling was found among middle-aged women in clinical samples and for adolescent male gamblers in a population-based sample. Youth gambling is associated with severe forms of gambling and other risk-taking behaviours. Treatment options are scarce, and the public health system is unprepared to support gambling patients. Ongoing incipient efforts are being made to establish a treatment model combining psychotherapy and psychiatric comorbidity treatment with promotion of quality of life.

CONCLUSION

Life-time incidence of pathological gambling in Brazil appears similar to many other countries, at approximately 1%. Arguably, there is a need to develop a more coherent regulatory and treatment response to this societal problem.

The neural bases of cognitive processes in gambling disorder

Functional imaging is offering powerful new tools to investigate the neurobiology of cognitive functioning in people with and without psychiatric conditions like gambling disorder. Based on similarities between gambling and substance-use disorders in neurocognitive and other domains, gambling disorder has recently been classified in the Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5) as a behavioral addiction. Despite the advances in understanding, there exist multiple unanswered questions about the pathophysiology underlying gambling disorder and the promise for translating the neurobiological understanding into treatment advances remains largely unrealized. Here we review the neurocognitive underpinnings of gambling disorder with a view to improving prevention, treatment, and policy efforts.

Shared psychological characteristics that are linked to aggression between patients with Internet addiction and those with alcohol dependence

BACKGROUND

Internet addiction (IA) is considered as one of behavioral addictions. Although common neurobiological mechanisms have been suggested to underlie behavioral addiction and substance dependence, few studies have directly compared IA with substance dependence, such as alcohol dependence (AD).

METHODS

We compared patients with IA, AD, and healthy controls (HC) in terms of the Five Factor Model of personality and with regard to impulsiveness, anger expression, and mood to explore psychological factors that are linked to aggression. All patients were treatment-seeking and had moderate-to-severe symptoms.

RESULTS

The IA and AD groups showed a lower level of agreeableness and higher levels of neuroticism, impulsivity, and anger expression compared with the HC group, which are characteristics related to aggression. The addiction groups showed lower levels of extraversion, openness to experience, and conscientiousness and were more depressive and anxious than the HCs, and the severity of IA and AD symptoms was positively correlated with these types of psychopathology.

CONCLUSIONS

IA and AD are similar in terms of personality, temperament, and emotion, and they share common characteristics that may lead to aggression. Our findings suggest that strategies to reduce aggression in patients with IA are necessary and that IA and AD are closely related and should be dealt with as having a close nosological relationship.

Heterogeneity of compulsive buyers based on impulsivity and compulsivity dimensions: a latent profile analytic approach

Despite the recognition that compulsive buyers are not one homogenous group, there is a dearth of theory-guided empirical investigation. Furthermore, although compulsivity and impulsivity are used as major psychiatric criteria for diagnosing compulsive buyers, these dimensions have rarely been considered in assessing the heterogeneity issue. We fill this gap by applying the motivation shift model of addiction to compulsive buying and empirically assessing the heterogeneity issue in the bi-dimensional space represented by the buying impulsivity and compulsivity dimensions. These hypotheses were tested with latent profile analysis based on survey data (N=445). Consistent with the hypothesis, we identified the cluster of buyers with high buying compulsivity and impulsivity ("compulsive-impulsive buyers"), the cluster of buyers with low buying compulsivity and high impulsivity ("impulsive excessive buyers"), and the cluster of ordinary buyers. Furthermore, it was found that disparate clusters of buyers exhibit unique dispositional tendencies. Theoretical contributions and policy implications of the findings are discussed as well.

Neuropsychological performance, impulsivity, ADHD symptoms, and novelty seeking in compulsive buying disorder

We examined the neuropsychological performance of people with compulsive buying disorder (CBD) and control subjects, along with trait impulsivity, symptoms of attention deficit hyperactivity disorder (ADHD), and selected personality characteristics. Subjects received a comprehensive neuropsychological test battery, depression and ADHD symptom assessment, the Barratt Impulsiveness Scale, and a version of the Temperament and Character Inventory. Persons with CBD (n=26) and controls (n=32) were comparable in terms of age, sex, and years of education. Subjects with CBD had a mean age of 36.3 years (S.D.=15.7) and an age at onset of 19.7 years (S.D.=7.0). Compulsive buyers had more lifetime mood, anxiety, and impulse control disorders. People with Compulsive buying performed significantly better on the Wechsler Abbreviated Scale of Intelligence Picture Completion task, a test of visual perception; otherwise, there were no consistent differences in neuropsychological measures. They also had elevated levels of self-reported depression, ADHD symptoms, trait impulsivity, and novelty seeking. In conclusion, compulsive buyers have greater lifetime psychiatric comorbidity than controls, and higher levels of self-rated depression, ADHD symptoms, trait impulsivity, and novelty seeking. The present study does not support the notion that there is a pattern of neuropsychological deficits associated with CBD.

Compulsive features in behavioural addictions: the case of pathological gambling

AIMS

To describe, in the context of DSM-V, how a focus on addiction and compulsion is emerging in the consideration of pathological gambling (PG).

METHODS

A systematic literature review of evidence for the proposed re-classification of PG as an addiction.

RESULTS

Findings include: (i) phenomenological models of addiction highlighting a motivational shift from impulsivity to compulsivity associated with a protracted withdrawal syndrome and blurring of the ego-syntonic/ego-dystonic dichotomy; (ii) common neurotransmitter (dopamine, serotonin) contributions to PG and substance use disorders (SUDs); (iii) neuroimaging support for shared neurocircuitries between 'behavioural' and substance addictions and differences between obsessive-compulsive disorder (OCD), impulse control disorders (ICDs) and SUDs; (iv) genetic findings more closely related to endophenotypic constructs such as compulsivity and impulsivity than to psychiatric disorders; (v) psychological measures such as harm avoidance identifying a closer association between SUDs and PG than with OCD; (vi) community and pharmacotherapeutic trials data supporting a closer association between SUDs and PG than with OCD. Adapted behavioural therapies, such as exposure therapy, appear applicable to OCD, PG or SUDs, suggesting some commonalities across disorders.

CONCLUSIONS

PG shares more similarities with SUDs than with OCD. Similar to the investigation of impulsivity, studies of compulsivity hold promising insights concerning the course, differential diagnosis and treatment of PG, SUDs, and OCD.

'Impulsive compulsivity' in obsessive-compulsive disorder: a phenotypic marker of patients with poor clinical outcome

Although traditionally obsessive-compulsive disorder (OCD) and impulse control disorders (ICD) have represented opposing ends of a continuum, recent research has demonstrated a frequent co-occurrence of impulsive and compulsive behaviours, which may contribute to a worse clinical picture of some psychiatric disorders. We hypothesize that individuals with 'impulsive' OCD as characterized by poor insight, low resistance, and reduced control towards their compulsions will have a deteriorative course, greater severity of hoarding and/or symmetry/ordering symptoms, and comorbid ICD and/or substance use disorders (SUD). The sample consisted of 869 individuals with a minimum score of 16 on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Of these, 65 had poor insight, low resistance, and reduced control towards compulsions ('poor IRC') and 444 had preserved insight, greater resistance and better control over compulsions ('good IRC'). These two groups were compared on a number of clinical and demographic variables. Individuals with poor IRC were significantly more likely to have a deteriorative course (p < 0.001), longer duration of obsessions (p = 0.017), greater severity of symmetry/ordering (p < 0.001), contamination/cleaning (p < 0.001) and hoarding (p = 0.002) symptoms, and comorbid intermittent explosive disorder (p = 0.026), trichotillomania (p = 0.014) and compulsive buying (p = 0.040). Regression analysis revealed that duration of obsessions (p = 0.037) and hoarding severity (p = 0.005) were significant predictors of poor IRC. In the absence of specific measures for impulsivity in OCD, the study highlights the utility of simple measures such as insight, resistance and control over compulsions as a phenotypic marker of a subgroup of OCD with impulsive features demonstrating poor clinical outcome.

Neither bipolar nor obsessive-compulsive disorder: compulsive buyers are impulsive acquirers

INTRODUCTION

Compulsive buying (CB) is currently classified as an impulse control disorder (ICD) not otherwise classified. Compulsive buying prevalence is estimated at around 5% of the general population. There is controversy about whether CB should be classified as an ICD, a subsyndromal bipolar disorder (BD), or an obsessive-compulsive disorder (OCD) akin to a hoarding syndrome. To further investigate the appropriate classification of CB, we compared patients with CB, BD, and OCD for impulsivity, affective instability, hoarding, and other OCD symptoms.

METHOD

Eighty outpatients (24 CB, 21 BD, and 35 OCD) who were neither manic nor hypomanic were asked to fill out self-report questionnaires.

RESULTS

Compulsive buying patients scored significantly higher on all impulsivity measures and on acquisition but not on the hoarding subdimensions of clutter and "difficulty discarding." Patients with BD scored higher on the mania dimension from the Structured Clinical Interview for Mood Spectrum scale. Patients with OCD scored higher on obsessive-compulsive symptoms and, particularly, higher on the contamination/washing and checking dimensions from the Padua Inventory; however, they did not score higher on any hoarding dimension. A discriminant model built with these variables correctly classified patients with CB (79%), BD (71%), and OCD (77%).

CONCLUSION

Patients with CB came out as impulsive acquirers, resembling ICD- rather than BD- or OCD-related disorders. Manic symptoms were distinctive of patients with BD. Hoarding symptoms other than acquisition were not particularly associated with any diagnostic group.

Gambling in Brazil: lifetime prevalences and socio-demographic correlates

Gambling has experienced world-wide growth. The current study is the first national survey into household gambling conducted in a developing country. The sample was a three-stage probabilistic one designed to cover individuals 14 years old or older, of both genders and from all regions of the national territory; 325 census sectors were visited, including rural areas. DSM-IV-based instruments were used to assess problem and pathological gambling; individuals were asked to estimate their monthly gambling expenditure. The lifetime prevalences were: pathological gambling 1.0%, and problem gambling 1.3%. Maximum gambling expenditure corresponded to 5.4% of the household income for social gamblers, 16.9% for problem gamblers and 20.0% for pathological gamblers. The male:female ratio among adults for pathological gambling was 3.2:1. The data suggest the existence of two subgroups of pathological gamblers, one younger (33.9±4.19) and severe (7 or more DSM-IV criteria), another older (47.8±6.01) and less severe (5-6 criteria). In a multinomial logistic regression, problematic gambling was associated with gender, age, education, employment, region of origin and living in metropolitan areas. The data suggest that feeling active and socially inserted protects against problematic gambling. Individuals who are young, male, unemployed or not currently pursuing further education may be at special risk for severe pathological gambling.

Introduction to behavioral addictions

BACKGROUND

Several behaviors, besides psychoactive substance ingestion, produce short-term reward that may engender persistent behavior, despite knowledge of adverse consequences, i.e., diminished control over the behavior. These disorders have historically been conceptualized in several ways. One view posits these disorders as lying along an impulsive-compulsive spectrum, with some classified as impulse control disorders. An alternate, but not mutually exclusive, conceptualization considers the disorders as non-substance or "behavioral" addictions.

OBJECTIVES

Inform the discussion on the relationship between psychoactive substance and behavioral addictions.

METHODS

We review data illustrating similarities and differences between impulse control disorders or behavioral addictions and substance addictions. This topic is particularly relevant to the optimal classification of these disorders in the forthcoming fifth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

RESULTS

Growing evidence suggests that behavioral addictions resemble substance addictions in many domains, including natural history, phenomenology, tolerance, comorbidity, overlapping genetic contribution, neurobiological mechanisms, and response to treatment, supporting the DSM-V Task Force proposed new category of Addiction and Related Disorders encompassing both substance use disorders and non-substance addictions. Current data suggest that this combined category may be appropriate for pathological gambling and a few other better studied behavioral addictions, e.g., Internet addiction. There is currently insufficient data to justify any classification of other proposed behavioral addictions.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Proper categorization of behavioral addictions or impulse control disorders has substantial implications for the development of improved prevention and treatment strategies.

Pathological gambling and substance use disorders

BACKGROUND

Pathological gambling (CPG) has been considered as a behavioral addiction having similarities with substance use disorders (SUDs).

OBJECTIVES AND METHODS

Current conceptualizations of addiction, as well as experimental studies of PG and SUDs, are reviewed in order to provide a perspective on tbe areas of convergence between addictive behaviors in PG and SUDs.

RESULTS

Shared features exist in diagnostic, clinical, physiological, and behavioral domains. CONCLUSIONS AND SCIELLTIFIC SIGNIFICANCE: Similarities between PG and SUDs have important implicatiol1s for categorizing, assessing, preventing and treating both PO and SUDs.

Pathological gambling and compulsive buying: do they fall within an obsessive-compulsive spectrum?

Both compulsive buying (CB) and pathological gambling (PG) have been proposed as members of a spectrum of disorders related to obsessive-compulsive disorder (OCD). The spectrum hypothesis originated in the early 1990s and has gained considerable support, despite the lack of empirical evidence. Interest in this hypothesis has become critical because some investigators have recommended the creation of a new category that includes these disorders in DSM-5, now under development. In this article, the authors describe the origin of the obsessive-compulsive (OC) spectrum and its theoretical underpinnings, review both CB and PG, and discuss the data both in support of and against an OC spectrum. Both disorders are described in terms of their history, definition, classification, phenomenology family history, pathophysiology, and clinical management. The authors conclude that: (i) CB and PG are probably not related to OCD, and there is insufficient evidence to place them within an OC spectrum in DSM-V; (ii) PG should stay with the impulse-control disorders (ICDs); and (iii) a new diagnosis of CB should be created and be classified as an ICD.

Volitional disorders: a proposal for DSM-V

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

Pathological love: impulsivity, personality, and romantic relationship

INTRODUCTION

Pathological love (PL)--behavior characterized by providing repetitive and uncontrolled care and attention to the partner in a romantic relationship--is a rarely studied condition, despite not being rare and causing suffering. This study aims at investigating impulsivity, personality, and characteristics related to the romantic relationship in this population.

METHODS

Eighty-nine individuals (50 with PL; 39 individuals with no psychiatric disorder) were compared regarding impulsivity, personality, type of attachment, satisfaction with romantic relationship, and love style.

RESULTS

Individuals with PL have higher levels of impulsivity (P<.001; Barratt Impulsiveness Scale), higher self-transcendence, that is, are more unconventional and hold sense of communion with a wider reality (P<.001; Temperament and Character Inventory) and keep dissatisfactory romantic relationships (P<.001; Adapted Relationship Assessment Scale).

CONCLUSION

Individuals with PL present personality traits and relationship aspects that must be taken into account in devising assessment and therapeutic strategies for this population.