Pathological gambling: a systematic review of biochemical, neuroimaging, and neuropsychological findings

Betting on Your Feelings: The Interplay between Emotion and Cognition in Gambling Affective Task

Background: Gambling Disorder (GD) is a bio-psycho-social disorder resulting from the interaction of clinical, cognitive, and affective factors. Impulsivity is a crucial factor in addiction studies, as it is closely linked to cognitive distortions in GD by encompassing impulsive choices, motor responses, decision-making, and cognitive biases. Also, emotions, mood, temperament, and affective state are crucial in developing and maintaining GD. Gambling can be used as a maladaptive coping strategy to avoid or escape problems and distress. Methods: The aim of the present study is to explore differences in personality traits and emotion regulation of people suffering from GD, substance-dependent gamblers (SDGs), and healthy controls (HCs). Additionally, the study proposes a new experimental task: the "Gambling Affective Task" (GAT) to investigate the influence of affective priming on risk-taking behaviors. Results: Our findings indicate that participants placed lower bets following positive priming. Additionally, SDGs wagered significantly higher amounts than HCs, regardless of priming type. In general, participants exhibited longer response times after positive priming trials, compared to negative and neutral priming trials. These findings suggest that experiencing positive emotions can act as a protective factor by delaying and lengthening gambling behaviors. By comparing gamblers with and without substance comorbidity, we can gain insight into the exclusive factors of GD and improve our understanding of this disorder. Conclusions: By elucidating the impact of emotional states on risk-taking, the research also provides new insights into the prevention and treatment of GD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Mediating Roles of Self-compassion and Emotion Regulation in the Relationship among Alexithymia, Gambling Frequency, Risky Decision-Making, and Gambling Severity in Online Gamblers

BACKGROUND

The research literature about the relationship between alexithymia, risky decision-making, and gambling severity has been contradictory and limited. Besides, there is no study on the mediating roles of self-compassion and emotion regulation in online gambling. Moreover, the role of these mediators in gambling frequency has not been studied. Thus, the present study aimed to investigate the relationship between alexithymia, risky decision-making, and gambling frequency by considering the mediating role of self-compassion and emotion regulation in online gamblers.

METHODS

A total of 319 Iranians who gambled online at least once a week in the past three months were investigated using an online survey including Farsi Toronto Alexithymia Scale-20 (FTAS-20), Difficulties in Emotion Regulation Scale (DERS), and Gambling Disorder Screening Questionnaire-Persian (GDSQ-P). Statistical analyses were conducted by SPSS 26.0 for Windows. The relationships between the variables were analyzed using correlation analysis. In cases where significant relationships were observed, the hypotheses of the regression model were tested.

FINDINGS

The mean age of the participants was 24.6±6.06 and 253 participants (73.9%) were male. Furthermore, no significant differences were observed between men and women in terms of risky decision-making (P=0.051), gambling severity (P=0.59), and age (P=0.293).

CONCLUSION

Alexithymia had both a direct and indirect relationship with gambling severity through the mediating roles of emotion regulation and self-compassion. Moreover, alexithymia was significantly associated with risky decision-making and gambling frequency, through the mediating role of difficulties in emotion regulation, both directly and indirectly.

Neural correlates of impulsive compulsive behaviors in Parkinson's disease: A Japanese retrospective study

BACKGROUND

Impulsive compulsive behaviors (ICBs) often disturb patients with Parkinson's Disease (PD), of which impulse control disorder (ICD) and dopamine dysregulation syndrome (DDS) are two major subsets. The nucleus accumbens (NAcc) is involved in ICB; however, it remains unclear how the NAcc affects cortical function and defines the different behavioral characteristics of ICD and DDS.

OBJECTIVES

To identify the cortico-striatal network primarily involved in ICB and the differences in these networks between patients with ICD and DDS using structural and resting-state functional magnetic resonance imaging.

METHODS

Patients with PD were recruited using data from a previous cohort study and divided into those with ICB (ICB group) and without ICB (non-ICB group) using the Japanese version of the Questionnaire for Impulsive Compulsive Disorders in Parkinson's Disease (J-QUIP). From these two groups, we extracted 37 pairs matched for age, sex, disease duration, and levodopa equivalent daily dose of dopamine agonists. Patients with ICB were further classified as having ICD or DDS based on the J-QUIP subscore. General linear models were used to compare gray matter volume and functional connectivity (FC) of the NAcc, caudate, and putamen between the ICB and non-ICB groups and between patients with ICD and those with DDS.

RESULTS

We found no significant differences in gray matter volumebetween the ICB and non-ICB groups or between patients with ICD and those with DDS. Compared with the non-ICB group, the FC of the right NAcc in the ICB group was lower in the bilateral ventromedial prefrontal cortex and higher in the left middle occipital gyrus. Furthermore, patients with DDS showed higher FC between the right putamen and left superior temporal gyrus and higher FC between the left caudate and bilateral middle occipital gyrus than patients with ICD. In contrast, patients with ICD exhibited higher FC between the left NAcc and the right posterior cingulate cortex than patients with DDS.

CONCLUSIONS

The functionally altered network between the right NAcc and ventromedial prefrontal cortex was associated with ICB in PD. In addition, the surrounding cortico-striatal networks may differentiate the behavioral characteristics of patients with ICD and those with DDS.

Neural cue-reactivity in pathological gambling as evidence for behavioral addiction: a systematic review

Increasing incidence of problem gambling has led to prioritizing the problem from the point of view of public health. Additionally, gambling disorder has been recently classified as a behavioral addiction, with implications for both its diagnosis and treatment. However, the shared neural substrate of addictions, to substances and behavioral, is still discussed. Thus, this systematic review aims to provide up-to-date knowledge from the past five years (2017-2022) concerning the neural correlates of gambling related stimuli (cue-reactivity) on the basis of a previous review (Brevers et al., Cognitive, Affective and Behavioral Neuroscience 18:718-729, 2019). A total of five studies were included in the review. Activation of brain areas related to memory, reward and executive functions could be the underlying mechanism of this behavioral addiction. Specifically, nucleus accumbens and striatum (ventral and dorsal), parahippocampal regions, the right amygdala and several prefrontal cortex regions have systematically been found more active in those subjects exposed to gambling-related cues. Also, the insula could play a pivotal role connecting these three systems in a highly integrated neural network with several implications for reward processing modulation, associative learning and top-down attentional regulation to improve saliency of addiction-related cues. These results are consistent with previous findings on other substance addictions, such as alcohol, tobacco, marijuana or cocaine. The study of neural reactivity to stimuli related to addiction could be useful as a biomarker of the severity of the disorder, the efficacy of the treatment, the risk of relapse, in addition to being an objective criterion to measure the effectiveness of prevention campaigns.

Language processing in Internet use disorder: Task-based fMRI study

Internet use disorder (IUD) is generally conceptualized as a fast-growing behavioral addiction. Several structural and functional brain alterations have been revealed in this condition, but previous behavioral studies indicated that language systems may also be impaired. We used a silent word generation task to induce brain activation in Broca’s area and other parts of the language system. Blood-oxygen-level-dependent activation analysis and psychophysiological interaction analysis were applied to assess functional brain changes. IUD was measured by the Problematic Internet Use Questionnaire and two additional questions concerning usage time and subjective rating of addiction. According to our key findings, areas strongly related to the default mode network were altered in IUD during the task. Moreover, Broca’s area showed altered functional connectivity with other language network and occipital areas in IUD. These findings may address the neural background of decreased verbal fluency performance previously reported in the literature, and we emphasize that beside the brain’s reward and inhibitory control systems, the language system is the next candidate to be involved in the pathogenesis of IUD.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Prefrontal cortical activation in Internet Gaming Disorder Scale high scorers during actual real-time internet gaming: A preliminary study using fNIRS

Background

Observation of real-time neural characteristics during gameplay would provide distinct evidence for discriminating the currently controversial diagnosis of internet gaming disorder (IGD), and elucidate neural mechanisms that may be involved in addiction. We aimed to provide preliminary findings on possible neural features of IGD during real-time internet gaming using functional near-infrared spectroscopy (fNIRS).

Methods

Prefrontal cortical activations accompanying positive and negative in-game events were investigated. Positive events: (1) participant's champion slays or assists in slaying an opponent without being slain. (2) the opposing team's nexus is destroyed. Negative events: (1) participant's champion is slain without slaying or assisting in slaying any opponent. (2) the team's nexus is destroyed. Collected data were compared between the IGD group and control group, each with 15 participants.

Results

The IGD group scored significantly higher than the CTRL group on the craving scale. Following positive events, the IGD group displayed significantly stronger activation in the DLPFC. Following negative events, the IGD group displayed significantly weaker activation in the lateral OFC.

Discussion and Conclusions

Individuals scoring high on the IGD scale may crave for more internet gaming after encountering desired events during the game. Such observations are supported by the correlation between the craving scale and DLPFC activation. The IGD group may also show diminished punishment sensitivity to negative in-game experiences rendering them to continue playing the game. The present study provides preliminary evidence that IGD may demonstrate neural characteristics observed in other addictive disorders and suggests the use of fNIRS in behavioral addiction studies.

What game we are playing: the psychosocial context of problem gambling, problem gaming and poor well-being among Italian high school students

Gambling and gaming are not infrequent among adolescents and preventing low-risk youth from becoming at-risk appears to be a priority of public health strategies. Greater scrutiny of the risk and protective factors in the relationships and community of young people appears crucial in steering prevention initiatives adequately. This study aimed to explore the role of the qualities of relational networks (i.e. family functioning, perceived social and class support), family and peer approval and view of the social environment in predicting problem gambling, problem gaming and overall well-being among adolescents. High-school students aged 14-18 years (N: 595; female: 68,7%) completed a survey including the target variables. A multivariate multiple regression analysis was performed to examine the role of socio-demographic characteristics and psychosocial predictors on gaming, gambling, and well-being. Multivariate multiple regressions identify a common core underpinning problem gambling, gaming and poor well-being but also the distinct roles of psychosocial variables: being male, with low parental monitoring, and an anomic view of the social environment all predict problem gambling and gaming, which were also found to be associated. Low social support predicts problem gambling but not problem gaming; poor family functioning predicts problem gaming but not problem gambling. All the target psychosocial variables, except approval of gambling, predict poor well-being. On the whole the findings suggest the need to look more closely at the way adolescents, their system of activity and their culture participate in constructing the meaning of gambling and gaming activities and their impact on adolescents' well-being, so that future studies and strategies can more effectively examine the relational dynamics in which problem gambling and gaming develop.

COVID-19 Related Distress in Gambling Disorder

The COVID-19 pandemic has exerted a dramatic impact on everyday life globally. In this context, it has been reported that the lockdown and social distancing may have exerted an impact even on gambling behavior, not only by increasing gambling behavior in those affected by this disorder but even contributing to the occurrence of new cases. To explore such a possibility, we designed a cross-sectional web survey addressing a general population sample that lasted 3 weeks (March 23-April 20). Participants completed a survey including a demographic information section, a question regarding the presence of pathological gambling in the past and several questionnaires. These included the Perceived Stress Scale (PSS), the Kellner's Symptom Questionnaire (SQ), and the version of The Yale Brown Obsessive Compulsive Scale adapted for Pathological Gambling (PG-YBOCS) that investigated the presence of gambling behaviors in the last week. The final sample was composed by 254 subjects (112 males, 44.1%; 142 females, 55.9%). According to PG-YBOCS total score, pathological gambling has been found in 23.6% (n = 60) of the sample (53 males, 88.3%; 7 females, 11.7%), which is a high frequency compared to that reported by the existing literature. Among gamblers, 20.9% (n = 53) reported both past and current problem gambling (they have been defined as "chronic gamblers"), whereas 2.8% (n = 7) did not report to use gambling platforms in the past but only in the last week (defined as "new gamblers"). Data analysis showed a statistically significant difference between gamblers and people who do not gamble in age but not in education, and higher level of perceived stress, distress, and hostility in both chronic and new gamblers compared to those who did not report gambling behavior. A consistent proportion of business owners and unemployed individuals reported problem gambling during the lockdown period.

Brain Network Underlying Executive Functions in Gambling and Alcohol Use Disorders: An Activation Likelihood Estimation Meta-Analysis of fMRI Studies

BACKGROUND

Neuroimaging and neuropsychological studies have suggested that common features characterize both Gambling Disorder (GD) and Alcohol Use Disorder (AUD), but these conditions have rarely been compared.

METHODS

We provide evidence for the similarities and differences between GD and AUD in neural correlates of executive functions by performing an activation likelihood estimation meta-analysis of 34 functional magnetic resonance imaging studies involving executive function processes in individuals diagnosed with GD and AUD and healthy controls (HC).

RESULTS

GD showed greater bilateral clusters of activation compared with HC, mainly located in the head and body of the caudate, right middle frontal gyrus, right putamen, and hypothalamus. Differently, AUD showed enhanced activation compared with HC in the right lentiform nucleus, right middle frontal gyrus, and the precuneus; it also showed clusters of deactivation in the bilateral middle frontal gyrus, left middle cingulate cortex, and inferior portion of the left putamen.

CONCLUSIONS

Going beyond the limitations of a single study approach, these findings provide evidence, for the first time, that both disorders are associated with specific neural alterations in the neural network for executive functions.

Effects of 5-HT2C, 5-HT1A receptor challenges and modafinil on the initiation and persistence of gambling behaviours

RATIONALE

Problematic patterns of gambling are characterised by loss of control and persistent gambling often to recover losses. However, little is known about the mechanisms that mediate initial choices to begin gambling and then continue to gamble in the face of losing outcomes.

OBJECTIVES

These experiments first assessed gambling and loss-chasing performance under different win/lose probabilities in C57Bl/6 mice, and then investigated the effects of antagonism of 5-HT_2CR with SB242084, 5-HT_1AR agonism with 8-OH-DPAT and modafinil, a putative cognitive enhancer.

RESULTS

As seen in humans and other species, mice demonstrated the expected patterns of behaviour as the odds for winning were altered increasing gambling and loss-chasing when winning was more likely. SB242084 decreased the likelihood to initially gamble, but had no effects on subsequent gambling choices in the face of repeated losses. In contrast, 8-OH-DPAT had no effects on choosing to gamble in the first place, but once started 8-OH-DPAT increased gambling choices in a dose-sensitive manner. Modafinil effects were different to the serotonergic drugs in both decreasing the propensity to initiate gambling and chase losses.

CONCLUSIONS

We present evidence for dissociable effects of systemic drug administration on different aspects of gambling behaviour. These data extend and reinforce the importance of serotonergic mechanisms in mediating discrete components of gambling behaviour. They further demonstrate the ability of modafinil to reduce gambling behaviour. Our work using a novel mouse paradigm may be of utility in modelling the complex psychological and neurobiological underpinnings of gambling problems, including the analysis of genetic and environmental factors.

Excessive bodybuilding as pathology? A first neurophysiological classification

Objectives: Excessive bodybuilding as a pathological syndrome has been classified based on two different theories: bodybuilding as dependency or as muscle dysmorphic disorder (MDD). This study is a first attempt to find psychophysiological data supporting one of these classifications.Methods: Twenty-four participants (bodybuilders vs healthy controls) were presented with pictures of bodies, exercise equipment or general reward stimuli in a control or experimental condition, and were measured with functional near-infrared spectroscopy (fNIRS). Higher activation in the dorsolateral prefrontal cortex (DLPFC) and the orbitofrontal cortex (OFC) while watching bodies and training equipment in the experimental condition (muscular bodies and bodybuilding-typical equipment) would be an indicator for the addiction theory. Higher activation in motion-related areas would be an indicator for the MDD theory.Results: We found no task-related differences between the groups in the DLPFC and OFC, but a significantly higher activation in bodybuilders in the primary somatosensory cortex (PSC) and left-hemispheric supplementary motor area (SMA) while watching body pictures (across conditions) as compared to the control group.Conclusions: These neurophysiological results could be interpreted as a first evidence for the MDD theory of excessive bodybuilding.

Reactive and proactive control mechanisms of response inhibition in gambling disorder

Response inhibition, one component of cognitive control, refers to the ability to inhibit automatic responses and has been found to be impaired in gambling disorder. Recent models of cognitive control distinguish between two mechanisms: reactive control, the ability to stop in response to a stop-stimulus, and proactive control, the ability to anticipate and prepare for a stop. Previous studies have primarily focused on reactive modes of control in gambling disorder. The aim of the current study was to assess both reactive and proactive modes of response inhibition in individuals with gambling disorder (n = 27) and community controls (n = 21) using a variant of the stop-signal task. Second, the relationship between trait impulsivity, and reactive and proactive control was examined. No group differences in reactive or proactive control were found. However, premeditation, one domain of trait impulsivity, was associated with worse proactive control in the gambling group. These results suggest that difficulties with response inhibition may not be a core deficit in all forms of gambling disorder. Future research should continue to develop and test tasks that involve cognitive control processes in different presentations of gambling disorder.

Shirt sponsorship by gambling companies in the English and Scottish Premier Leagues: global reach and public health concerns

While the nature of gambling practices is contested, a strong evidence base demonstrates that gambling can become a serious disorder and have a range of detrimental effects for individuals, communities and societies. Over the last decade, football in the UK has become visibly entwined with gambling marketing. To explore this apparent trend, we tracked shirt sponsors in both the English and Scottish Premier Leagues since 1992 and found a pronounced increase in the presence of sponsorship by gambling companies. This increase occurred at the same time the Gambling Act 2005, which liberalized rules, was introduced. We argue that current levels of gambling sponsorship in UK football, and the global visibility it provides to gambling brands, is a public health concern that needs to be debated and addressed. We recommend that legislators revisit the relationship between football in the UK and the sponsorship it receives from the gambling industry.

Distinct Response Inhibition Patterns in Obsessive Compulsive Disorder Patients and Pathological Gamblers

Background: Obsessive-compulsive disorder (OCD) and pathological gambling (PG) are common disorders. The cognitive models of OCD and PG focus on abnormalities in response inhibition. Although, these functions have been studied in different PG and OCD samples, no study has compared the response inhibition in both. Methods: Medication-naïve OCD (n = 61) and PG subjects (n = 109) and healthy controls (n = 131) performed CPT and Go/NoGo tasks. Results: Compared to healthy controls (HC), PG and OCD groups underperformed on speed and exhibited larger time variability on the CPT and Go/NoGo task. Only in OCD patients, a positive correlation between omission errors and response time (RT) was observed in the CPT. At the Go/NoGo task, a negative correlation between false alarms and RT (a fast-errors trade-off) was significant only in the PG group. The HC group had greater sensitivity values (d') than the OCD and PG groups in the Go/NoGo task. The PG group displayed lower d' values and more conservative response criterion in the CPT. In addition, only the OCD group expressed a high switching cost compared to both the PG and HC groups in terms of the RT and d' values. Conclusions: Both the PG and OCD groups demonstrated impaired response inhibition compared to the HC group. On several measures, the OCD and PG groups showed comparable impairments, and in others these were distinct. Thus, it appears that distinct neurocognitive patterns are involved in performance of the CPT and the Go/NoGo tasks among OCD and PG subjects whose cognitive status is currently under intensive investigation.

Gambling disorder: an integrative review of animal and human studies

Gambling disorder (GD), previously called pathological gambling and classified as an impulse control disorder in DSM-III and DSM-IV, has recently been reclassified as an addictive disorder in the DSM-5. It is widely recognized as an important public health problem associated with substantial personal and social costs, high rates of psychiatric comorbidity, poor physical health, and elevated suicide rates. A number of risk factors have been identified, including some genetic polymorphisms. Animal models have been developed in order to study the underlying neural basis of GD. Here, we discuss recent advances in our understanding of the risk factors, disease course, and pathophysiology. A focus on a phenotype-based dissection of the disorder is included in which known neural correlates from animal and human studies are reviewed. Finally, current treatment approaches are discussed, as well as future directions for GD research.

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

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

Stress vulnerability in male youth with Internet Gaming Disorder

Internet Gaming Disorder [IGD] was introduced as new behavioral addiction in DSM-5 Section 3. Vulnerability to stress is a potential predisposing factor for IGD. Given a lack of preexisting empirical data, the study investigated differences in the psychological and neurobiological response to acute stress in patients with IGD. 24 young men (mean age 18.38 years; range 13-25 years) fulfilling DSM-5 criteria for IGD and 25 matched controls underwent the Trier Social Stress Test [TSST]. Participants provided hair samples for the analysis of basal hypothalamic-pituitary-adrenal [HPA] axis activity and clinical interviews were conducted to assess psychopathology. During the experiment, participants reported on their subjective stress experience and momentary affect, provided samples of salivary cortisol and their heart rate was continuously recorded. Patients with IGD reported greater everyday and chronic stress, as well as psychopathological comorbidity. No differences were found on measures of hair cortisol. Compared to controls, IGD patients showed an attenuated cortisol response (χ²₍₇₎=25.75, p<0.001) and greater negative affect (χ²₍₇₎=17.25, p=0.016) in response to acute stress. Heart rate (χ²₍₁₎=5.49, p=0.019), negative affect (χ²₍₁₎=5.60, p=0.018) and subjective stress (χ²₍₁₎=5.55, p=0.019) were transiently increased in IGD patients. After adjusting for sportive activities, IGD patients showed transiently decreased cortisol (χ²₍₁₎=5.20, p=0.022), potentially indicating general HPA-axis dysfunction beyond altered reactivity. Stress reactivity showed correlations with IGD symptom severity. Findings illustrate differences in acute psychological and neurobiological stress reactivity in patients with IGD. Alterations of the stress response system may be involved in the development and maintenance of IGD.

Treatment modalities for patients with gambling disorder

BACKGROUND

Gambling disorder (GD) is defined as persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress. The prevalence of GD has been shown to be 1.2-7.1% in the general population. GD can severely impact on personal and vocational wellbeing as well as lead to financial problems, and has been known to be difficult to treat. This review describes the available pharmacotherapy/psychosocial treatments for GD patients, and summarizes data on the effectiveness of these GD treatments.

METHODS

This review refers to newly as well as previously published studies and guidelines.

RESULTS

The description of pharmacotherapy mainly focuses on opioid receptor antagonists, selective serotonin reuptake inhibitors, and mood stabilizers. Psychosocial treatments/strategies mainly include cognitive behavioral therapy, motivational interviewing, and Gamblers Anonymous. We also introduce relatively novel treatment modalities.

CONCLUSIONS

This review can help clinicians to decide treatment plans for their GD patients. In addition, it can be used as a reference for designing future research.

Neural and psychological underpinnings of gambling disorder: A review

Gambling disorder affects 0.4 to 1.6% of adults worldwide, and is highly comorbid with other mental health disorders. This article provides a concise primer on the neural and psychological underpinnings of gambling disorder based on a selective review of the literature. Gambling disorder is associated with dysfunction across multiple cognitive domains which can be considered in terms of impulsivity and compulsivity. Neuroimaging data suggest structural and functional abnormalities of networks involved in reward processing and top-down control. Gambling disorder shows 50-60% heritability and it is likely that various neurochemical systems are implicated in the pathophysiology (including dopaminergic, glutamatergic, serotonergic, noradrenergic, and opioidergic). Elevated rates of certain personality traits (e.g. negative urgency, disinhibition), and personality disorders, are found. More research is required to evaluate whether cognitive dysfunction and personality aspects influence the longitudinal course and treatment outcome for gambling disorder. It is hoped that improved understanding of the biological and psychological components of gambling disorder, and their interactions, may lead to improved treatment approaches and raise the profile of this neglected condition.

The somatic marker theory in the context of addiction: contributions to understanding development and maintenance

Recent theoretical accounts of addiction have acknowledged that addiction to substances and behaviors share inherent similarities (eg, insensitivity to future consequences and self-regulatory deficits). This recognition is corroborated by inquiries into the neurobiological correlates of addiction, which has indicated that different manifestations of addictive pathology share common neural mechanisms. This review of the literature will explore the feasibility of the somatic marker hypothesis as a unifying explanatory framework of the decision-making deficits that are believed to be involved in addiction development and maintenance. The somatic marker hypothesis provides a neuroanatomical and cognitive framework of decision making, which posits that decisional processes are biased toward long-term prospects by emotional marker signals engendered by a neuronal architecture comprising both cortical and subcortical circuits. Addicts display markedly impulsive and compulsive behavioral patterns that might be understood as manifestations of decision-making processes that fail to take into account the long-term consequences of actions. Evidence demonstrates that substance dependence, pathological gambling, and Internet addiction are characterized by structural and functional abnormalities in neural regions, as outlined by the somatic marker hypothesis. Furthermore, both substance dependents and behavioral addicts show similar impairments on a measure of decision making that is sensitive to somatic marker functioning. The decision-making deficits that characterize addiction might exist a priori to addiction development; however, they may be worsened by ingestion of substances with neurotoxic properties. It is concluded that the somatic marker model of addiction contributes a plausible account of the underlying neurobiology of decision-making deficits in addictive disorders that is supported by the current neuroimaging and behavioral evidence. Implications for future research are outlined.

Behavioral addictions: a novel challenge for psychopharmacology

Although addictive syndromes have been traditionally related to substance-use disorders, during the last few decades a novel addictive group, including the so-called "behavioral or no-drug addictions," has been recognized and has attracted increasing attention for its relevant social impact. This group includes pathological gambling, compulsive shopping, TV/Internet/social network/videogame addictions, workaholism, sex and relationship addictions, orthorexia, and overtraining syndrome. Substance and behavioral addictions show similar phenomenological features, such as craving, dependence, tolerance, and abstinence, and perhaps they share a common possible pathophysiology. It is, however, controversial whether all or at least some of them should be considered real disorders or just normal, albeit extreme, behaviors. The aim of this article is to review current data on pharmacological treatment of behavioral addictions. As no specific and validated treatment algorithms are currently available, only an improved knowledge on their psychopathological, clinical, and neurobiological features may have relevant implications for more focused preventive and therapeutic strategies.

Prefrontal control and internet addiction: a theoretical model and review of neuropsychological and neuroimaging findings

Most people use the Internet as a functional tool to perform their personal goals in everyday-life such as making airline or hotel reservations. However, some individuals suffer from a loss of control over their Internet use resulting in personal distress, symptoms of psychological dependence, and diverse negative consequences. This phenomenon is often referred to as Internet addiction. Only Internet Gaming Disorder has been included in the appendix of the DSM-5, but it has already been argued that Internet addiction could also comprise problematic use of other applications with cybersex, online relations, shopping, and information search being Internet facets at risk for developing an addictive behavior. Neuropsychological investigations have pointed out that certain prefrontal functions in particular executive control functions are related to symptoms of Internet addiction, which is in line with recent theoretical models on the development and maintenance of the addictive use of the Internet. Control processes are particularly reduced when individuals with Internet addiction are confronted with Internet-related cues representing their first choice use. For example, processing Internet-related cues interferes with working memory performance and decision making. Consistent with this, results from functional neuroimaging and other neuropsychological studies demonstrate that cue-reactivity, craving, and decision making are important concepts for understanding Internet addiction. The findings on reductions in executive control are consistent with other behavioral addictions, such as pathological gambling. They also emphasize the classification of the phenomenon as an addiction, because there are also several similarities with findings in substance dependency. The neuropsychological and neuroimaging results have important clinical impact, as one therapy goal should enhance control over the Internet use by modifying specific cognitions and Internet use expectancies.

The latest achievements in the pharmacotherapy of gambling disorder

Gambling disorder (GD) is becoming increasingly prevalent both among adults and adolescents. Unfortunately, this disorder is largely underestimated, while it can still lead to serious social and personal consequences, including criminal behavior or suicide attempts. In the past, the only means of treating gambling were psychobehavioral therapies. Nowadays, this disorder could also respond to many drugs from different classes such as opioid antagonists, serotonin selective reuptake inhibitors, mood stabilizers, atypical antipsychotics or glutamatergic agents. This review presents current pharmacological strategies and the results of clinical trials evaluating the efficacy of pharmacotherapy for GD. It also discusses the importance of distinguishing different pathological gambler subtypes such as impulsive, obsessive-compulsive and addictive subtypes as this may have serious pharmacological implications.

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.

Endogenous cortisol levels are associated with an imbalanced striatal sensitivity to monetary versus non-monetary cues in pathological gamblers

Pathological gambling is a behavioral addiction characterized by a chronic failure to resist the urge to gamble. It shares many similarities with drug addiction. Glucocorticoid hormones including cortisol are thought to play a key role in the vulnerability to addictive behaviors, by acting on the mesolimbic reward pathway. Based on our previous report of an imbalanced sensitivity to monetary versus non-monetary incentives in the ventral striatum of pathological gamblers (PGs), we investigated whether this imbalance was mediated by individual differences in endogenous cortisol levels. We used functional magnetic resonance imaging (fMRI) and examined the relationship between cortisol levels and the neural responses to monetary versus non-monetary cues, while PGs and healthy controls were engaged in an incentive delay task manipulating both monetary and erotic rewards. We found a positive correlation between cortisol levels and ventral striatal responses to monetary versus erotic cues in PGs, but not in healthy controls. This indicates that the ventral striatum is a key region where cortisol modulates incentive motivation for gambling versus non-gambling related stimuli in PGs. Our results extend the proposed role of glucocorticoid hormones in drug addiction to behavioral addiction, and help understand the impact of cortisol on reward incentive processing in PGs.

Chronic exposure to a gambling-like schedule of reward predictive stimuli can promote sensitization to amphetamine in rats

Addiction is considered to be a brain disease caused by chronic exposure to drugs. Sensitization of brain dopamine (DA) systems partly mediates this effect. Pathological gambling (PG) is considered to be a behavioral addiction. Therefore, PG may be caused by chronic exposure to gambling. Identifying a gambling-induced sensitization of DA systems would support this possibility. Gambling rewards evoke DA release. One episode of slot machine play shifts the DA response from reward delivery to onset of cues (spinning reels) for reward, in line with temporal difference learning principles. Thus, conditioned stimuli (CS) play a key role in DA responses to gambling. In primates, DA response to a CS is strongest when reward probability is 50%. Under this schedule the CS elicits an expectancy of reward but provides no information about whether it will occur on a given trial. During gambling, a 50% schedule should elicit maximal DA release. This closely matches reward frequency (46%) on a commercial slot machine. DA release can contribute to sensitization, especially for amphetamine. Chronic exposure to a CS that predicts reward 50% of the time could mimic this effect. We tested this hypothesis in three studies with rats. Animals received 15 × 45-min exposures to a CS that predicted reward with a probability of 0, 25, 50, 75, or 100%. The CS was a light; the reward was a 10% sucrose solution. After training, rats received a sensitizing regimen of five separate doses (1 mg/kg) of d-amphetamine. Lastly they received a 0.5 or 1 mg/kg amphetamine challenge prior to a 90-min locomotor activity test. In all three studies the 50% group displayed greater activity than the other groups in response to both challenge doses. Effect sizes were modest but consistent, as reflected by a significant group × rank association (ϕ = 0.986, p = 0.025). Chronic exposure to a gambling-like schedule of reward predictive stimuli can promote sensitization to amphetamine much like exposure to amphetamine itself.

Comorbid Axis I-disorders among subjects with pathological, problem, or at-risk gambling recruited from the general population in Germany: results of the PAGE study

The aim of the present study was to analyze comorbid Axis I-disorders in a sample of individuals with at-risk, problem, and pathological gambling. A number of 164 adult gamblers derived from a random sample of 15,023 individuals were compared with a general population sample. The lifetime prevalence of any psychiatric disorder was 93.6% among pathological (five-10 criteria), 83.5% among problem (three or four criteria), and 81.0% among at-risk gamblers (one or two criteria). Substance use disorders were the most common comorbid disorders in gamblers. Logistic regression analyses revealed elevated odds ratios for having a comorbid disorder in at-risk (Conditional Odds Ratio (COR) 3.5, Confidence Interval (CI) 2.6-4.6), problem (COR 4.9, CI 3.3-7.3), and pathological gamblers (COR 4.6, CI 3.0-6.9) compared to the general population. No significant differences were found between at-risk and problem gamblers or problem and pathological gamblers. Compared to at-risk gamblers, pathological gamblers showed elevated rates of comorbid substance use disorders. The data suggest a linear association between gambling disorder severity and comorbid Axis I-disorders. In conclusion, comorbid disorders are very prevalent in individuals with gambling problems. Even at-risk gamblers with one or two DSM-IV criteria show high rates of Axis I-disorders. Therefore, this group should be included in further studies on problematic gambling.

Gambling problems in young people: experience from the Asian region

PURPOSE OF REVIEW

To introduce the existing research conducted into gambling problems among young people in the Asian region.

RECENT FINDINGS

The prevalence rates of gambling-related problems of young people ranged from 32 to 60% for participation, from 1.5 to 5.0% for problem gambling and from 0.07 to 2.66% for pathological gambling in Asia; social gambling and lottery were the most popular gambling types. Psychiatric comorbidity is common among pathological gamblers, but the causal mechanisms are unclear. The psychological theories on youth gambling in Asia included diathesis, motivation, stress, coping, cognitive and positive youth development. The Positive Adolescent Training through Holistic Social Programmers has been developed; this aims to intervene and help those young people experiencing gambling problems in Hong Kong.

SUMMARY

Published gambling studies on young people in Asia are limited and have different definitions, research tools and diagnostic criteria. Therefore, the results vary and are incomparable. More work needs to be done in the near future, on comorbidity mechanisms, the neuropsychological and neurobiological mechanisms of youth gambling and, importantly, an increase in early intervention programmes.

Neurological soft signs in individuals with pathological gambling

Increased neurological soft signs (NSSs) have been found in a number of neuropsychiatric syndromes, including chemical addiction. The present study examined NSSs related to perceptual-motor and visuospatial processing in a behavioral addiction viz., pathological gambling (PG). As compared to mentally healthy individuals, pathological gamblers displayed significantly poorer ability to copy two- and three-dimensional figures, to recognize objects against a background noise, and to orient in space on a road-map test. Results indicated that PG is associated with subtle cerebral cortical abnormalities. Further prospective clinical research is needed to address the NSSs' origin and chronology (e.g., predate or follow the development of PG) as well as their response to therapeutic interventions and/or their ability to predict such a response.