Neuropsychiatric Aspects of Impulse Control Disorders

Impulse control disorders (ICDs) are neuropsychiatric conditions characterized by the repeated inability to resist an impulse, drive, or temptation to perform an act that is harmful to the person or others. Although classification approaches to ICDs vary both diachronically and synchronically, this group of conditions encompasses a wide range of syndromes, including pathologic gambling, kleptomania, trichotillomania, excoriation (skin picking) disorder, intermittent explosive disorder, pyromania, oppositional defiant, conduct, and antisocial personality disorders. ICDs can play a significant role as comorbidities in both neurodevelopmental (eg, attention-deficit/hyperactivity disorder, Tourette syndrome) and neurodegenerative (eg, Parkinson disease) disorders.

The effect of online gambling on gambling problems and resulting economic health costs in Germany

Problematic and pathological gambling have emerged as substantial problems in many countries. One potential accelerating factor for this phenomenon during recent years is the Internet, which offers different kinds of games and online applications for gambling that are faster, more attractive due to a variety of design and marketing options, less costly and potentially more addictive than terrestrial gambling opportunities. However, the contributing role of the Internet for problematic gambling has not been analyzed sufficiently so far and remains inconclusive. The current study is based on a representative sample with 15,023 individuals from Germany. With a new concept of assessing online gambling with its relative fraction of total gambling activities and a control-function approach to account for possible endogeneity of online gambling, we estimate the impact of online gambling on gambling behavior while additionally controlling for a rich set of important covariates, like education, employment situation and family status. The results show that, on average, replacing 10% of offline gambling with online gambling increases the likelihood of being a problematic gambler by 8.8-12.6%. This increase is equivalent to 139,322 problematic gamblers and 27.24 million € per year of additional expenditures in the German health sector. Our findings underpin the necessity to keep online gambling restricted to prevent further developments of problematic and pathological gambling in Germany.

Daily Fantasy Football and Self-Reported Problem Behavior in the United States

Traditional, season-long fantasy sport participation has grown considerably since the late 1990s, and in an attempt to capitalize on this growing demand, daily fantasy sports (DFS) providers have created a new game where money changes hands instantly. This change has led some legal commentators and state agencies to believe the game is a form of Internet gambling similar to online poker, blackjack, and sports wagering, and thus, it requires increased regulation or even prohibition. Little is known, however, about the gambling behavior associated with DFS participation. Thus, the purpose of the current study was to examine problem gambling severity in conjunction with DFS participant motives, perceptions, and consumption behavior. Over 500 DFS participants were surveyed, and the results suggest DFS participants behave similarly with participants in other forms of gambling activities. In addition, the findings suggest additional consumer protections may be needed to prevent further problem behavior such as chasing.

An analysis of problem gambling among the Finnish working-age population: a population survey

Background

Gambling problems currently affect approximately 100 000 Finns. In order to prevent and reduce gambling-related harms it is crucial for the Finnish public health authorities to gain a stronger understanding of the association between gambling problems and related socio-demographic factors, other commonly co-occurring dependencies (e.g. alcohol and nicotine) and the type of games gambled. In this article the prevalence of problem gambling in Finland and the socio-demographic profiles of problem gamblers are studied.

Method

An annual postal survey entitled Health Behaviour and Health among the Finnish Adult Population AVTK was sent to a random sample of Finnish adults (N=5000) aged between 15 and 64. The sample was derived from the Finnish Population Register. The survey was mailed to the participants in April 2010. Gender differences in socio-demographic variables and Problem Gambling Severity Index PGSI were assessed. A multinomial regression model was created in order to explore the association between socio-demographic factors and the severity of gambling.

Results

A total of 2826 individuals (1243 males and 1583 females) replied to the survey. Of the respondents, 1.1% (2.1% of males, 0.3% of females) were identified as problem gamblers. Those who were of younger age, gender, had less than twelve years of education, consumed alcohol at risk level and smoked had higher odds of having low or moderate levels of gambling problems. Whereas, unemployment and smoking predicted significantly for problem gambling. Females gambled Lotto and slot machines less frequently than males and had more low level gambling problems. Males gambled more with a higher frequency and had a more severe level of gambling problems. Females were more attracted to scratch card gambling and daily Keno lotteries compared to males. In comparison, males gambled more on internet poker sites than females. Overall, a high frequency of gambling in Lotto, daily lotteries, slot machines, horse race betting and internet gambling was significantly associated with a more severe level of problem gambling.

Conclusion

Gambling problems affect tens of thousands of individuals annually, therefore certain vulnerabilities should be noted. Comorbid dependencies, smoking in particular, ought to be screened for and recognised in the public health sector. Regulating the availability of slot machine gambling and enforcement of the age limit should be acknowledged. In establishing new gambling venues, prevalence rates in those particular areas should be actively monitored.

Illicit drug use and problem gambling

Problem gambling, substance use disorders, and their cooccurrence are serious public health concerns. We conducted a comprehensive review of the literature to understand the present state of the evidence on these coaddictions. Our main focus was illicit drug use rather than misuse of legal substances. The review covers issues related to gambling as a hidden problem in the illicit drug use community; prevalence, problem gambling, and substance use disorders as kindred afflictions; problem gambling as an addiction similar to illicit drug use; risk factors and problems associated with comorbidity, and gender issues. We end with some suggestions for future research.

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.

Correlates of gambling-related problems among older adults in Ontario

Although the literature suggests that gambling among older adults is influenced by unique age-related factors, there is little information on the factors associated with the experience of gambling-related problems among older adults. The purpose of this study was to identify the sociodemographic health determinants and mental health-related problems, including alcohol and drug dependence, that are associated with the experience of gambling problems among older adults in Ontario. The research was an exploratory analysis of data from Ontario adults, aged 55 and over, who completed the Canadian Community Health Survey -Mental Health and Well-being, Cycle 1.2 (1,904 males and 2,622 females). Logistic regression analyses were conducted to identify sociodemographic, gambling behaviour, and mental health correlates of the experience of any gambling-related problems, as identified by responses to the Canadian Problem Gambling Index. Being married or living common law and having a higher education level were associated with reduced risk of gambling problems. Among mental health variables, alcohol dependence and any substance dependence significantly increased the odds of reporting a gambling problem. Gambling behaviour measures, such as more frequent gambling, participating in more types of gambling, and spending more on gambling were significant correlates of gambling problems.

The dimensional assessment of personality in pathologic and social gamblers: the role of novelty seeking and self-transcendence

OBJECTIVE

A few personality traits are characteristic of pathologic gamblers (PGs), but it is not clear if and how their personality profile differs from that of non-pathologic gamblers (non-PGs).

METHODS

Sixty-five non-clinical subjects, differentiated into non-PGs and PGs with the means of the South Oak Gambling Screen (SOGS) and Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR) criteria, were administered with the Temperament and Character Inventory; their values were compared with those of control subjects (CS).

RESULTS

Novelty seeking (NS) and self-transcendence (ST) values were higher whereas self-directedness and cooperativeness values were lower in PGs with respect to both non-PGs and CS. A positive correlation was noted between SOGS score and NS (r = 0.40) and ST (r = 0.50) values, as well as a significant positive dependence between SOGS score and a family history of gambling (t = 2.816; P = .007). The subsamples of PGs reporting a parental involvement in gambling showed higher NS than the remaining PGs.

CONCLUSIONS

Specific temperamental and character dimensions, especially NS and ST, differentiated PGs from both non-PGs and CS; the identification of a personality profile at risk for problem gambling may represent an important predictor of outcome and constitute a possible target for specific treatment approaches.

Heart rate arousal and excitement in gambling: Winners versus losers

People sometimes claim they gamble for excitement rather than money. The authors examined in a laboratory analog whether excitement is generated by the expectancy of winning money. Eighty male undergraduate students watched a videotaped horse race with an exciting neck-to-neck finish. Half bet $1 for a chance of winning $7 if they picked the winning horse; the other half predicted the winning horse without wagering. Winning and losing were experimentally manipulated. Participants with a chance to win money showed greater heart rate (HR) elevations and reported more subjective excitement while watching the race compared with those who did not wager. Of students who wagered, the winners showed higher HRs after the end of the race than did those who lost, even though differences in subjective excitement were not statistically significant. The findings suggest that the expectancy of winning money is an important contributing factor to the excitement associated with gambling.

Gamblers Anonymous: A critical review of the literature

This study surveys existing literature on Gamblers Anonymous (GA) and issues that help to contextualise our understanding of this mutual aid association. While GA has been the subject of investigation by social scientists, it is still understudied, with a notable shortage of research on issues facing women and ethnic minorities. A need exists for large-scale assessments of GA's effectiveness, more detailed accounts of GA beliefs and practices, increased knowledge of the ways in which GA attendance interacts with both formal treatment and attendance at other mutual aid organisations, and a better understanding of the profiles of gamblers best (and least) suited to GA, along with a clearer grasp of what GA was able to offer those gamblers that it seems to have helped. This assessment of the current state of knowledge underscores the embryonic state of our collective inquiry into the nature of GA, and the authors emphasise that significant advances have been made. Notably, important targets for study are being identified.

Obsessive-compulsive spectrum disorders

The obsessive-compulsive spectrum is an important concept referring to a number of disorders drawn from several diagnostic categories that share core obsessive-compulsive features. These disorders can be grouped by the focus of their symptoms: bodily preoccupation, impulse control, or neurological disorders. Although the disorders are clearly distinct from one another, they have intriguing similarities in phenomenology, etiology, pathophysiology, patient characteristics, and treatment response. In combination with the knowledge gained through many years of research on obsessive-compulsive disorder (OCD), the concept of a spectrum has generated much fruitful research on the spectrum disorders. It has become apparent that these disorders can also be viewed as being on a continuum of compulsivity to impulsivity, characterized by harm avoidance at the compulsive end and risk seeking at the impulsive end. The compulsive and impulsive disorders differ in systematic ways that are just beginning to be understood. Here, we review these concepts and several representative obsessive-compulsive spectrum disorders including both compulsive and impulsive disorders, as well as the three different symptom clusters: OCD, body dysmorphic disorder, pathological gambling, sexual compulsivity, and autism spectrum disorders.

A population-based study of the association between pathological gambling and attempted suicide

The association between pathological gambling and attempted suicide was examined using data from a prevalence study conducted in Edmonton, Alberta, Canada. The sample size was 7,214, the questionnaire was the Diagnostic Interview Schedule, and diagnoses were made on a lifetime basis according to DSM-III criteria. Logistic regression analysis was performed, with attempted suicide as the dependent variable. The odds ratio for pathological gambling was statistically significant (odds ratio = 4.91; 95% confidence interval = [1.41,17.1]) when major depression was the only comorbid mental disorder in the model. As terms for additional mental disorders were included, pathological gambling ceased to be statistically significant. It was concluded that a history of pathological gambling is associated with previous attempted suicide, and that the association may be due to a common factor--"mental illness."

Differences in cognitive distortions between problem and social gamblers

The cognitive model of gambling argues that irrational beliefs and erroneous perceptions including illusions of control, superstitious beliefs, expectancies of winning, attributional biases, selective memory, and entrapment play a pivotal role in the development and maintenance of impaired control over patterns of gambling behaviours. Assessment strategies using self-report, behavioural inferences, and verbalizations produced by 'thinking aloud' techniques, and the effectiveness of treatment interventions designed to correct cognitive distortions have provided substantive empirical evidence supporting this model. However, research has yet to measure such differences between the quality, intensity, or conviction of specific dysfunctional beliefs held by problem in contrast to social gamblers. At the theoretical level, the absence of such demonstrable differences would undermine the validity of the cognitive explanatory model. Based on a review of the available literature, a preliminary measure to assess differences in irrational gambling beliefs was constructed and administered to a convenience sample of 56 problem gamblers and 52 social gamblers. In support of the cognitive model, analysis indicated that, compared to social gamblers, problem gamblers endorsed more irrational beliefs across all domains except for the variable of 'denial'. Implications for research issues relevant to the identification of irrational beliefs that may be subjected to challenge within a cognitive therapy paradigm are mentioned.

Problem-solving skills in male and female problem gamblers

The current study was designed to compare the self-reported problem-solving skills of male and female gamblers. In total, 148 females and 112 males (mean age = 43.6 years, SD = 12.0), responding to an advertisement for people concerned about their gambling, completed the Problem Solving Inventory (Heppner, 1988). The PSI consists of three factors related to self-perception of problem-solving: confidence, personal control and approach-avoidance style. Gamblers were categorized into three subgroups according to their DSM-IV scores: Asymptomatic, Problem, and Pathological. Results from a series of analyses of co-variance (co-varying for the confounding effects of current emotional distress) revealed that gender had no significant effect, but problem severity on appraisal of problem-solving confidence and sense of personal control had a significant effect. Pathological gamblers were less confident and felt less in control than the other subgroups while engaging in problem-solving activities. Problem gamblers tended to have more negative appraisals of control than Asymptomatic gamblers. Problem-solving skills were also a significant predictor of DSM-IV scores for pathological gambling (i.e., negative appraisals were associated with higher DSM-IV scores). The results suggest that problem-solving skills are deficient in pathological gamblers and problem gamblers, but are not related to gender.

Pathological gambling in women: a review

Pathological gambling was only recently recognized as a psychiatric disorder (DSM-III, APA, 1980). Most studies of pathological gambling include only male subjects. Despite the paucity of information, it is likely that at least one-third of pathological gamblers are women. The objective of this article is to review clinical and epidemiological characteristics of female gamblers as compared to their male counterparts. MEDLINE and PsycINFO were searched for investigational studies and reviews of the past 10 years on clinical (sociodemographic, course and progression, psychiatric comorbidities, genetics, and personality) and epidemiological aspects of female gamblers. Other relevant articles were also selected from reference lists. It is concluded that the current literature indicates some common characteristics in female and male gamblers, but it also indicates the possibility that each gender may carry etiopathogenic differences that when better understood should lead to improved treatment and prevention strategies.

A pathways model of problem and pathological gambling

At the moment, there is no single conceptual theoretical model of gambling that adequately accounts for the multiple biological, psychological and ecological variables contributing to the development of pathological gambling. Advances in this area are hampered by imprecise definitions of pathological gambling, failure to distinguish between gambling problems and problem gamblers and a tendency to assume that pathological gamblers form one, homogeneous population with similar psychological principles applying equally to all members of the class. The purpose of this paper is to advance a pathways model that integrates the complex array of biological, personality, developmental, cognitive, learning theory and ecological determinants of problem and pathological gambling. It is proposed that three distinct subgroups of gamblers manifesting impaired control over their behaviour can be identified. These groups include (a) behaviourally conditioned problem gamblers, (b) emotionally vulnerable problem gamblers and (c) antisocial, impulsivist problem gamblers. The implications for clinical management are discussed.

Reliability, validity, and classification accuracy of the South Oaks Gambling Screen (SOGS)

The South Oaks Gambling Screen (SOGS) was originally developed to screen for pathological gambling in clinical settings; however, its use has expanded to other purposes, settings, and populations, including prevalence studies of pathological gambling in the general population. Questions have been raised about the accuracy of the SOGS with its use in these new settings and populations. The purpose of this study is to examine current estimates of the reliability, validity, and classification accuracy of the SOGS in two different samples: (a) a general population sample (N= 803) and (b) a gambling treatment sample (N = 1,589). DSM-IV diagnostic criteria served as the standard against which to measure the SOGS classification accuracy and both the SOGS and DSM-IV diagnostic criteria were administered to participants. The SOGS was found to have satisfactory reliability with coefficient alphas of .69 and .86 in the general population and gambling treatment samples, respectively. The SOGS demonstrated satisfactory validity by differentiating between the general population and the gambling treatment sample and by exhibiting high correlations with DSM-IV diagnostic criteria and moderate correlations with other measures of gambling problem severity. The SOGS demonstrated good to excellent classification accuracy in the gambling treatment sample, but had poorer accuracy in the general population sample with a 50% false positive rate. The SOGS overestimated the number of pathological gamblers in the general population, as compared to DSM-IV diagnostic criteria.

The additive effect of neurotransmitter genes in pathological gambling

As access to gambling increases there is a corresponding increase in the frequency of addiction to gambling, known as pathological gambling. Studies have shown that a number of different neurotransmitters are affected in pathological gamblers and that genetic factors play a role. Polymorphisms at 31 different genes involved in dopamine, serotonin, norepinephrine, GABA and neurotransmitters were genotyped in 139 pathological gamblers and 139 age, race, and sex-matched controls. Multivariate regression analysis was used with the presence or absence of pathological gambling as the dependent variable, and the 31 coded genes as the independent variables. Fifteen genes were included in the regression equation. The most significant were the DRD2, DRD4, DAT1, TPH, ADRA2C, NMDA1, and PS1 genes. The r(2) or fraction of the variance was less than 0.02 for most genes. Dopamine, serotonin, and norepinephrine genes contributed approximately equally to the risk for pathological gambling. These results indicate that genes influencing a range of brain functions play an additive role as risk factors for pathological gambling. Multi-gene profiles in specific individuals may be of assistance in choosing the appropriate treatment.

Pathological gambling

With increasing access to gambling facilities through casinos, the Internet, and other venues, PG is a rapidly emerging mental health concern. This impulse-control disorder tends to be comorbid with a wide range of other disorders and is reportedly associated with a high rate of suicide. For most gamblers, gambling is a form of entertainment, but for many individuals, the activity leads to far-reaching disruption of family and work. The personal and societal financial ramifications are severe, and many individuals with PG end up in the criminal justice system. An understanding of the neurobiology of PG is beginning to surface. 5-HT is linked to behavioral initiation and disinhibition, which are important in the onset of the gambling cycle and the difficulty in ceasing the behavior. Norepinephrine is associated with the arousal and risk taking in patients with PG. Dopamine is linked to positive and negative reward, the addictive component of this disorder. Effective treatment strategies for pathological gamblers are emerging. Potentially useful pharmacologic agents include SRIs (clomipramine and fluvoxamine), mood stabilizers for pathological gamblers with comorbid bipolar disorders (lithium), and naltrexone. Cognitive-behavioral psychotherapies offer promising results in the treatment of patients with this disorder. To devise prevention and early-intervention programs, research is needed to identify specific features of the individuals at risk for gambling problems. Education targeting vulnerable youth that show early signs of gambling behavior may be worthwhile and should be investigated further. Funding is necessary to support these endeavors, so perhaps a portion of tax revenues generated from the gambling industry should go toward specialized treatment facilities, educational efforts, and research into the neurobiology and treatment of PG.

Pathways to Pathological Gambling: Identifying Typologies

The majority of explanatory models of pathological gambling fail to differentiate specific typologies of gamblers despite recognition of the multi-factorial causal pathways to its development. All models inherently assume that gamblers are a homogenous population; therefore theoretically derived treatments can be effectively applied to all pathological gamblers. This article describes a comprehensive and alternative conceptual-pathway model that identifies three main subgroups: "normal," emotionally vulnerable and biologically based impulsive pathological gamblers. All three groups are exposed to common influences related to ecological factors, cognitive processes and contingencies of reinforcement. However, predisposing emotional stresses and affective disturbances for one group, and biological impulsivity for another, are additional risk factors of aetiological significance in identifying separate subtypes. The implications for treatment are discussed with particular reference to the need to match client subtype with specific treatment interventions.

Treatment approaches for pathological gamblers

Outcome literature on the treatment of pathological gambling is reviewed, encompassing psychodynamic, behavioral, cognitive, cognitive-behavioral, multimodal, pharmacotherapeutic, and 12-step approaches. No properly controlled research has been conducted with psychodynamic or 12-step methods, and pharmacotherapies require replications with larger samples to determine their efficacy. Multimodal approaches have been tested most often in inpatient settings, and given the range of methods combined it is difficult to infer specific efficacy for treatment components. The largest volume of outcome research has focused on behavioral, cognitive, and combined cognitive-behavioral treatment methods, and findings from controlled and uncontrolled trials provide support for efficacy of these approaches. As a whole, the literature indicates that pathological gambling can be treated with highly successful outcomes. Needs for further research are considered.

Gambling among methadone patients

In this paper we assess participation in various forms of gambling activities and establish the prevalence of pathological gambling in a sample of patients (N = 117) enrolled in a large methadone maintenance treatment program in New York City. Respondents were interviewed with a protocol that incorporates the South Oaks Gambling Screen. We found that gambling was a common part of the regular activities of many patients, that 15% of the patients had some problem with gambling, and that an additional 16% were probable pathological gamblers. The implications of our findings are discussed.

Insights about pathological gamblers. 'Chasing losses' in spite of the consequences

In the United States, a small but growing portion of the adult population are pathological gamblers. The majority are men (about one third are women). Although the Diagnostic and Statistical Manual of Mental Disorders, third revised edition, defines pathological gambling as a disorder of impulse control, diagnostic criteria and treatment are modeled after psychoactive substance dependence. About half of pathological gamblers have a history of alcoholism or substance abuse, and accompanying mood disorders (eg, major depression, bipolar disorder) are common. Once diagnosed, pathological gambling is highly treatable.