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Università degli Studi di CataniaDIPARTIMENTO DI MEDICINA CLINICA E SPERIMENTALE

AOU “ Policlinico-vittorio emanuele “ Catania”

U.O.P.I. di Psichiatria

E. AGUGLIA

GIOCO D’AZZARDO PATOLOGICO E COMORBIDITÀ PSICHIATRICHE

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The DSM 5 chapter “Addictive Disorders” includes gambling disorder as the solecondition in a new category on behavioral addictions. DSM-IV listed pathologicalgambling but in a different chapter. This new term and its location in the new manualreflect research findings that gambling disorder is similar to substance-relateddisorders in clinical expression, brain origin, comorbidity, physiology, and treatment.

Recognition of these commonalities will help people with gambling disorder get thetreatment and services they need, and others may better understand the challengesthat individuals face in overcoming this disorder.

Pathological Gambling (PG) isan impulse-control disordercharacterized by “persistentand recurrent maladaptivegambling behavior” withdeleterious effects onindividuals’ personal, home,and work lives (AmericanPsychiatric Association).

J Psychiatr Res. 2013 Apr;47(4):534-41.

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Prevalence rates varyamong jurisdictionsaccording to availabilityand accessibility ofgambling as well asdefinitional, measurementand other research designfactors.

In this research were recruited 9282 English-speaking respondents ages 18 and olderbetween February 2001 and April 2003:

• Nearly four of every five respondents (78.4%) reported gambling at least once in theirlife;

• while 54.5% gambled more than ten times;

• 27.1% more than 100 times;

• 10.1% more than 1000 times.


A dose-response relationship exists betweennumber of times gambled and probability ofproblem gambling (i.e., at least oneCriterion A symptom of PG) and PG, withthe highest conditional probability ofproblem gambling (12.2%) and PG (4.3%)both occurring among respondents whogambled more than 1000 times.

In the total sample, the lifetime prevalenceestimate of problem gambling is 2.3%, whilethe lifetime prevalence estimate of PG is0.6%.


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In addition, rates of comorbid mental healthdisorders are higher than expected.

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With the elevated comorbidity rates for other mental health problems evidenced in a widerange of studies it is prudent to screen people who present with gambling problems for othermental health problems. There is sound research evidence that problem gambling is associatedwith elevated risk of:

• bipolar disorder;• personality disorders;• other impulse control disorders;• alcohol/drug dependence;• anxiety disorders;• depression/suicide;• family violence.

GAMBLING PROBLEMS MAY PREDATE THE ONSET OF PSYCHOPATHOLOGY

In a cross-sectional study where theage of onset for disorders was self-reported, problem gambling wasassociated with the subsequent onsetof bipolar disorder, PTSD, alcohol ordrug dependence, and nicotinedependence.

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Mental illness may contribute to the development of gambling problems

Gambling problems may contribute to the development of mental illness.

In this model, a subset of problem gamblers are “emotionally vulnerable” and havepsychological and personality profiles marked by premorbid depression, poor copingskills, and negative life events.


Furthermore, pathological gamblers reported experiencing a greater number of recentstressful life events and higher levels of anxiety.

The life events common among this population are:

•the death of a spouse/partner;•increasing social isolation;•role confusion following retirement;•relocation to assisted living facility or retirement community;•financial strain;•onset of chronic illness.


This algorithm is an attempt to explain how gamblers could group together in relation to their preferred gambling activity

This study highlights the importance of

considering the pair gambler-game rather than one or the other

separately

Three characteristics could explain thisgrouping: the search for a thrill, the search forcontrol over the game and the atmosphere ofthe game.

THE PREFERENCE FOR ONE PARTICULAR GAMBLING ACTIVITY MAY CONCERN DIFFERENT PROFILES OF GAMBLERS

CLASS 1 (Electronic Gaming Machines gamblers) showed high cooperativeness, a lower level of gambling-related cognitions (GRC) about strategy andmore depressive disorders;

CLASS 2 (games with deferred results gamblers) were high novelty seekers and showed a higher level of GRC about strategy and more addictivedisorders;

CLASS 3 (roulette gamblers) were more often high rollers and showed a higher level of GRC about strategy and more manic or hypomanic episodesand more obsessive–compulsive disorders;

CLASS 4 (instant lottery gamblers) showed a lower tendency to suicide attempts;

CLASS 5 (scratch cards gamblers) were high harm avoiders and showed a lower overall level of GRC and more panic attacks and eating disorders.

628 non-problem and problem gamblers were assessed with a structured interview including‘‘healthy’’ and ‘‘pathological’’ and psychiatric variables. The obtained classes weredescribed using both ‘‘healthy’’ and ‘‘pathological’’ variables, by comparing each class tothe rest of the sample.

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BD patients frequently reportco-occurring substance usedisorders (SUDs) and behavioraladdictions, including gamblingdisorder (GD).

The co-occurrence of other psychiatric disorders in bipolarpatients is associated with several indices of illnessseverity, a low probability of recovery as well as anunfavorable course and outcome.

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BD–GD patients experience a more severecourse of illness and poorer treatmentoutcome, due to a range of clinical andpsychosocial factors that collectively impederemission and recovery.

This frequent comorbidity is not surprising ifone focuses on some of thepsychopathological core features of GD:impulsivity, urges, anxiety and affectiveinstability, pleasure seeking, and decreasedjudgment.

BD AND GD OFTEN CO-OCCUR, AND THIS HAS IMPORTANT CLINICAL IMPLICATIONS

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Research has shown that PG is associated with ahigh prevalence of co-occurring personalitydisorders.

The Cluster B (“dramatic”) disorders are themost frequent, particularly the antisocial andborderline personality disorders.

The presence of a personality disorder has beenassociated with more severe gamblingsymptoms and a greater frequency of co-occurring psychiatric disorders.

Antisocial personality disorder is thought tohave a special relationship with PG perhapsbecause of their mutual connection with crimeand irresponsible behavior.

J Gambl Stud. 2014 Nov 26. [Epub ahead of print]

https://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=https://showard76.wordpress.com/2011/12/26/mental-health-monday-christmas-with-the-cluster-b-personality-disorders/&ei=eQXSVJbOIsv7Us7tgZAL&bvm=bv.85076809,d.d24&psig=AFQjCNFM1sbAi8g-moKiZGiL1sHdyvIllg&ust=1423136498621255

While relatively few PG researchers haveexamined the personality dimensions describedby Cloninger et al., those who have report highscores for novelty seeking.

Cloninger et al. describe persons with high levelsof novelty seeking as impulsive, extravagant, anddisorderly, and have linked this trait to low basaldopamine activity.


Among dimensionally measured personality traits, people with PG are reported to haveelevated levels of impulsivity (or impulsiveness) that could indicate impaired executivefunctioning.

Interestingly, impulsivity increases as gambling behavior worsens; high levels in normalgamblers have been correlated with the subsequent development of PG.

• PG probands had a significantlygreater prevalence of personalitydisorders, and this findingextended to the three personalitydisorder clusters, with Cluster Bdisorders having the greatest oddsratio (OR = 17.2, P

Shin et al. reported that an higher novelty seeking scores has been linked withsubstance use disorders, impulsivity, and sensation seeking.

PG probands also scored much higher on impulsiveness and novelty seeking

Elevated scores in peoplewith PG suggest a linkbetween impulse controldisorders and the bipolarspectrum of mental illnessand disturbed dopamineactivity.


THE FIRST-DEGREE RELATIVES OF PG AND CONTROL PROBANDS ALSODIFFERED WITH RESPECT TO THE PREVALENCE OF PERSONALITYDISORDER AND IMPULSIVENESS

The relatives had a much greater prevalence of personality disorders overall and for eachof the three clusters, particularly Cluster C which achieved an odds ratio of nearly twenty.

PG relatives also scored significantly higher on impulsiveness, but not novelty seeking.

Personality disorders and trait impulsiveness may also share a common familial etiologywith PG and serve as an alternate expression of the same underlying vulnerability thatcould be genetic, but non-genetic causes cannot be excluded.


Consequently, given that substance usedisorders are prevalent among pathologicalgamblers, the question arises as to whetherit is PG, substance abuse or a combinationof these conditions (dual diagnosis) that ismost strongly associated with the range ofpsychiatric conditions documented instudies of pathological gamblers.

The co-incidence of PG and alcoholproblems has been reported from 10–15%to 9-33%.

Like PG, substance use disorder (and in particular, excessive alcohol use) isrecognised as a significant predictor of a range of co-morbid psychiatricconditions significantly overlapping with those identified for PG.

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.pwcgov.org/government/dept/cs/pages/adult-substance-abuse-services.aspx&ei=lQfSVKG6Lon4UNelhIAJ&bvm=bv.85076809,d.d24&psig=AFQjCNGFgTw8tRZDg2nX9AWXLIyQ-dppNg&ust=1423137027137003

1) Alcohol problems may contribute to PG: when gambling under the influence ofalcohol people are generally less inhibited, and display greater risk-taking andpersistence; drinking may increase the risk of the likelihood of people spending morethan they intended.

2) PG causes alcohol problems: gambling exposes people to environments where alcoholis readily available, and that stress associated with gambling-related losses mightencourage excessive drinking as a coping mechanism.

3) There are some underlying factors (or “third variables”) that explain why some peopleare more likely to display both disorders: current neurological, genetic and otherpsychiatric evidence in the literature provide the most conceptual support for the thirdargument.

There are at least three possible ways to explain the correlation between PG and AUD:

THE AIM OF OUR STUDY WAS TO IDENTIFY SUBTYPES OF GAMBLERS CURRENTLY IN TREATMENT

Group 1 (psychological distress) - higher scores of psychological distress and lower scoreson alcohol abuse:

1) Older age, female gender;2) Retirement or sick/disability pensions;3) Family member mental health issues and drug problems;4) Gambling on electronic gaming machines (EGMs);5) Using gambling as a means to cope with negative emotions.

Group 2 (low comorbidity) - lower scores on all three co-morbidities (psychologicaldistress; alcohol abuse; impulsivity):

1) Better general health, better quality of life, lower endorsement of having familymembers with mental health issues, lower gambling severity, higher rates of currentgambling abstinence, a lower likelihood of gambling to cope with negative emotions, andlower levels of hostility and aggressiveness.

Group 3 (alcohol abuse) - higher scores on alcohol abuse, lower scores on psychologicaldistress and impulsivity:

1) Younger age, male gender, working full-time, reporting better quality of life, lowerlevels of aggression and hostility, higher likelihood of being in a gaming venue self-exclusion programme but higher levels of stimulant drug use.

Group 4 (multimorbidity) - high levels of each comorbidity (psychological distress, alcoholabuse and impulsivity):

1) Male gender and a higher likelihood of reporting problems related to multiple lifedomains: general health, quality of life, cannabis use, gambling severity, hostility, andaggressiveness;

• Their most common form of gambling was horse/dog racing and they were least likelyto report current gambling abstinence.

Approximately 40% of outpatientswith PG may experience co-occurringADs In the National Co-morbiditySurvey Replication, it was found thatPG is often temporally preceded bypanic disorder (PD), generalizedanxiety disorder (GAD), and phobias;furthermore, 52% of participants withlifetime PG experienced phobias,21.9% experienced PD, and 16.6%experienced GAD.

Problem gambling and PG frequently co-occurs with other psychiatric conditions includinganxiety disorders (ADs).

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://thestressoflife.com/portfolio-item/vestibulum-ante-ipsum/&ei=egjSVNQUxe5S6IaEeA&bvm=bv.85076809,d.d24&psig=AFQjCNE3SOvlKnxJ-LpH8DvDqOj_LkYY2w&ust=1423137206770127

Both PG and ADs co-occur with otherpsychopathologies, including externalizingdisorders (e.g., alcohol dependence andantisocial personality disorder) andinternalizing disorders (e.g., depression anddysthymia).

In the modeling of date from large samples oftwins, PG has been found to share geneticcontributions with both externalizing disordersand internalizing disorders.

Externalizing disorders (e.g., alcoholabuse/dependence) have been found toinfluence the relationships between PG and abroad range of internalizing and externalizingdisorders.

https://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/psychological-disorders-18/anxiety-disorders-91/explaining-anxiety-disorders-348-12883/&ei=TAjSVJmlLMH9ULv1g9AP&bvm=bv.85076809,d.d24&psig=AFQjCNE3SOvlKnxJ-LpH8DvDqOj_LkYY2w&ust=1423137206770127

J Gambl Stud. 2014 Dec 27. [Epub ahead of print]

Problem and pathological gamblers have high rates of depression in comparison to the generalpopulation, with as many as 75% of compulsive gamblers endorsing major depressive symptoms.

Reasons for high rates of depressive symptomsamong those with gambling disorders may includea shared genetic predisposition for both agambling disorder and major depression,dysfunctional coping styles involvingavoidance/escapism, impulsiveness, and reactivenegative emotional states which are depleting andthe associated impact of negative consequencescommonly linked to problem gambling.

Clinically, the co-occurrence of major depression isrelevant in that it negatively impacts treatmentoutcomes including higher rates of attrition anddiminished response to therapeutic interventions.

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Mood symptoms may be a precipitating risk factor for gambling disorders predatinggambling behaviors which are subsequently used to alleviate depressive mood states.

A second theory postulates that gambling behavior and its consequences result indepressive symptoms.

Thus, depressive symptoms may stem from issues including difficulties at work, problemswith social and family relationships, and financial stress due to gambling losses.

Moreover, the shame and guilt the gambler may feel as a result of his/her behavior cancontribute to depressive symptoms.

J Gambl Stud. 2014 Dec 27. [Epub ahead of print]

THE AIM OF THIS STUDY WAS TO FURTHER INVESTIGATE THE NATURE OF DEPRESSION THROUGHOUT THE COURSE OF RESIDENTIAL GAMBLING TREATMENT.

TO THIS END, WE EXAMINED IN-TREATMENT DEPRESSION SYMPTOMS OVER 8 WEEKS IN A SAMPLE OF INDIVIDUALS WITH GAMBLING DISORDER IN RESIDENTIAL TREATMENT.

Volume 225, Issue 3, 28 February 2015, Pages 413–419

Pathological gambling does not only result in severe social and financial problems withdevastating effects for patients and their families: additionally, international studiessuggest that suicidal events are frequent among pathological gamblers.

Recently, a large Austrian sample of 862 pathological gamblers undergoing treatmentshowed that 9.7% of the participants had a history of suicide attempts.

Various risk factors for suicidality were found ingeneral population: especially substance usedisorders, anxiety disorders, personalitydisorders, younger age, female gender andtreatment utilization are known to be high riskfactors for suicidal ideation and suicideattempts.

Pathological gambling has been found to be anindependent risk factor for suicidal events.

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://southcentralhealth.info/programs/injury-prevention/suicide-prevention-and-information/&ei=HgrSVPWTI4TsUrbdgNAN&bvm=bv.85076809,d.d24&psig=AFQjCNHuARrqb8C9AeKKbhHFIIXGSsSUPg&ust=1423137664666871

The present study is the first study that analyzes whether gambling disorder, comorbid Axis I disorders, and personality disorders are combined risk factors for suicidal events

In addition, an earlier onset of gamblingproblems was significantly associated withsuicidal ideation.

Group comparisons showed significantassociations of comorbidity of Axis I and IIdisorders with suicidal events inpathological gamblers in univariateanalyses.


Main findings are that comorbidity of mood disorders and Cluster B personality disordersare the predominant risk factors for suicidal events, independently from the severity ofthe gambling disorder.

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The multivariate comparison revealed pathological gamblers with suicidalideation to have a six-fold risk for a mood disorder and independently analmost two times higher risk for a substance use disorder compared togamblers without suicidal events.

Results underline that especially the strongly impulsive Cluster B personalitydisorders depict a serious risk factor for suicidal events.

Suicide attempters among pathological gamblers have a significantly higherrate of intense treatment utilization in comparison with participants with nosuicidal event.

Data revealed that especially being female is an independent risk factor forpathological gamblers to attempt suicide compared to individuals with outsuicidal events.


THERE IS GROWING EVIDENCE THAT SUGGESTS A SIGNIFICANT ASSOCIATION BETWEEN PROBLEM GAMBLING AND FAMILY VIOLENCE

There is also limited evidence that asignificant proportion (56%) of problemgamblers report past year IPVperpetration.

Findings relating to gender differencesindicate that women (100%) are morelikely to report lifetime abusevictimisation than men (69%).

Most of the studies in this area report past year or lifetime intimate partner violence (IPV)victimisation estimates ranging from 60% to 69%.

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://16days.thepixelproject.net/16-ways-to-stop-domestic-violence-in-your-community/&ei=_QrSVOPHPIn4UNelhIAJ&psig=AFQjCNEVGd3Ij0gzyduCsFG4M2oTxt_sjg&ust=1423137844457608

Problem gambling is likely over-representedin samples of IPV offenders, there arecurrently no prevalence estimates ofproblem gambling in samples of individualspresenting to treatment services for IPV orfamily violence victimisation experiences.

Given that alcohol and substance usedisorders and psychiatric disorders are highlycomorbid with both problem gambling andfamily violence, there are surprisingly fewstudies that explore their relationship inother treatment seeking samples.

THERE IS GROWING EVIDENCE THAT SUGGESTS A SIGNIFICANT ASSOCIATION BETWEEN PROBLEM GAMBLING AND FAMILY VIOLENCE

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://hart-legal.com/escaping-family-violence/&ei=VgvSVMvGGsuAU6OdgbgN&psig=AFQjCNEVGd3Ij0gzyduCsFG4M2oTxt_sjg&ust=1423137844457608

The prevalence of family violence in the gambling sample was 27.0% for victimisation,22.9% for perpetration, and 33.9% for any form of family violence.

Women were significantly more likely to report victimisation than men.

The alcohol and drug sample reported significantly higher rates of family violencevictimisation, perpetration and any form of family violence than the gambling sample.

The findings of this studyunderscore the need thatother services, such alcoholand drug services, mentalhealth services, and financialcounselling services, shoulddevelop screening, referraland management protocolsfor problem gambling andfamily violence.

http://www.google.it/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.familyviolencehumeregion.com.au/central-goldfields-strategy-to-tackle-family-violence/&ei=hQvSVMvpN4v1UKu2g_gB&psig=AFQjCNEVGd3Ij0gzyduCsFG4M2oTxt_sjg&ust=1423137844457608

In 2008, the NCPG commissioned this report as a first-step towardidentifying and, subsequently, funding a body of research that will finallyprovide comprehensive evidence to inform policymakers, legislators,treatment providers, program administrators, and gaming officials in futuredecision-making.

The purpose of this project was toidentify key topic areas for study, and,within those areas, to posit importantresearch questions that must beanswered to better serve the populationof problem gamblers and their familiesand communities in the future.

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