Disordered Gambling and Its Treatment

Pathological gambling is an increasing concern with the growth of legalized gambling opportunities, and clinicians who provide general psychotherapy, as well as those specializing in some disorders, are likely to encounter patients with gambling problems. This review article describes the diagnostic criteria for pathological gambling and screening methods for identifying individuals with gambling problems. Problem and pathological gambling are more likely to occur in certain populations, such as among individuals with substance use, mood and anxiety disorders, and medical problems. However, few pathological gamblers seek specialized gambling treatment. This paper reviews different forms of treatments that have been applied to gamblers, along with evidence of their efficacy. Clinical guidelines for identifying and treating gambling problems are outlined as well.     

Pathologisches Glücksspielen: Persönlichkeitsmerkmale und forensische Aspekte

Causes and psychological characteristics of pathological gambling are reviewed. Neither the addiction model nor the conception of a “disorder of impulse control” is fitting to comprehend the peculiarity of these hardened conduct disorders. Pathological gambling is a learned pattern of behaviour with a variety of etiological backgrounds. There is no uniform type of “the” pathological gambler. Some kinds of gambling like roulette or horse betting are used to experience arousal and thrill; other forms like german slot machines on the contrary are used to relax and to find relief from depression and boredom. There is a broad spectrum of comorbid disorders, e.g. mood disorders and personality disorders. The paper delineates the overlap with antisocial patterns and the juridical consequences.     

Cognitive treatment of pathological gamblers

This study evaluates the efficacy of a cognitive treatment for pathological gambling. Five pathological gamblers were treated in a multiple baseline across subjects design. Cognitive correction targeted the erroneous perceptions towards the notion of randomness. Four subjects reported a clinically significant decrease in the urge to gamble, an increase in their perception of control, and no longer met the DSM-IV criteria for pathological gambling. Therapeutic gains were maintained at the 6 month follow-up. Results suggest that cognitive therapy targeting the misconception of the notion of randomness is a promising treatment for pathological gambling, a refractory disorder to most therapeutic interventions.     

Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample.

The comorbidity of current and lifetime DSM-IV anxiety and mood disorders was examined in 1,127 outpatients who were assessed with the Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L). The current and lifetime prevalence of additional Axis I disorders in principal anxiety and mood disorders was found to be 57% and 81%, respectively. The principal diagnostic categories associated with the highest comorbidity rates were mood disorders, posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). A high rate of lifetime comorbidity was found between the anxiety and mood disorders; the lifetime association with mood disorders was particularly strong for PTSD, GAD, obsessive-compulsive disorder, and social phobia. The findings are discussed in regard to their implications for the classification of emotional disorders.     

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

Psychological Factors that Promote and Inhibit Pathological Gambling

This paper describes qualitative data regarding psychological factors that may affect gambling behavior among treatment-seeking pathological gamblers. Participants (n = 84) diagnosed with pathological gambling were treated in a clinical trial examining the efficacy of cognitive behavioral therapy (CBT). Qualitative data were collected from participants during each of 8 structured CBT sessions. Specific gambling-related psychological factors that were assessed include triggers, consequences, high-risk situations, craving experiences, assertiveness skills, cognitive distortions, and coping strategies. The most commonly reported triggers for gambling were lack of structured time and negative emotional state, which were similar to the high-risk times for gambling. The most frequently listed positive consequences of gambling were enjoyment associated with winning and use of gambling as an escape. Negative consequences of gambling included depressed mood, financial problems, and conflict with family. Coping strategies changed during treatment, as participants reported relying less upon avoidance and distraction, and became better able to utilize support networks and cognitive coping skills. These data are important to better understand the factors associated with the development, maintenance, and cessation of pathological gambling.     

Glücksspielsucht in der Rechtsprechung des Bundesgerichtshofs

Among the non-substance-related addictions, pathological gambling is the only one that has gained noteworthy forensic relevance. There are numerous parallels to substance-related addictions and not only in the symptomatology. A high proportion of pathological gamblers commit criminal offences to enable them to continue gambling or to pay gambling debts. According to the jurisdiction of the Federal Court of Justice (BGH) pathological gambling in itself cannot be considered as a pathological mental disorder or other serious mental abnormality that substantially diminishes the responsibility of the offender (German Penal Code § 21 StGB); however, the BGH recognizes that in serious cases of pathological gambling mental changes and personality defects can evolve that show similar structure and severity to substance-related addictions and severe withdrawal symptoms might also develop. As with substance-related addictions a substantial diminution of the offender’s responsibility can be assumed, therefore, also with pathological gambling if it has led to most severe personality changes or if the offender suffered from severe withdrawal symptoms while committing an addiction-related crime. According to these criteria a substantial diminution of the offender’s responsibility can be stated only in very rare cases. A custodial addiction treatment order (§ 64 StGB), which is also possible for fully responsible delinquents, is not applicable to cases of mere pathological gambling because the order requires an addiction to alcohol or other drugs. A mental hospital commitment order (§ 63 StGB) can be issued by the court under the same strict conditions that are applied to cases of substance-related addictions. Based on these principles this can only be issued if the defendant is addicted to gambling due to a mental defect that can be distinguished from the addiction itself or if the dependence has already been manifested in very severe personality changes. Pathological gambling can cause a propensity to commit serious offences and therefore, under the further conditions of §§ 66, 66a StGB justify detention for the purpose of incapacitation or a deferred incapacitation order. Even during imprisonment, detainees must be offered a suitable therapy (§ 66c para 2 StGB); however, penitentiaries do not offer the best environment for the treatment of pathological gamblers. The treatment in an addiction therapeutic setting appears to be more promising. Criminal political demands to make custodial addiction treatment orders also applicable to pathological gamblers have, however, very little chance of success.     

Personality disorders and dimensions in pathological gambling

Comorbid DSM-IV Axis II personality disorders appear to be common in pathological gambling (PG) and may contribute to the chronic problems often associated with the disorder. This study sought to examine the relationship between PG, personality disorders, and impulsivity in a sample of pathological gamblers. Personality assessments included the SCID-II, Eysenck Impulsiveness Questionnaire, Tridimensional Personality Questionnaire, and Barratt Impulsiveness Scale. A total of 77 individuals with DSM-IV PG were included in this study, of which 35 (45.5%) met criteria for at least one personality disorder. Specific aspects of impulsivity were associated with certain personality disorders in PG when grouped by cluster, yet the presence of a personality disorder was not positively correlated with gambling severity. It remains unclear how the presence of a personality disorder and aspects of impulsivity may affect treatment outcome. Further exploration of these disorders and dimensions of personality may encourage a more inclusively global treatment approach.     

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."     

Discounting of probabilistic rewards is associated with gambling abstinence in treatment-seeking pathological gamblers

Individuals with addictive disorders, including substance abusers and pathological gamblers, discount or devalue rewards delayed in time more than controls. Theoretically, preference for probabilistic rewards is directly related to gambling, but limited empirical research has examined probabilistic discounting in individuals with pathological gambling. This study evaluated probability and delay discounting in treatment-seeking pathological gamblers and their association with gambling treatment outcomes during and after treatment. At time of treatment entry, 226 pathological gamblers completed probability and delay discounting tasks. They were then randomized to one of three treatment conditions, and gambling behavior was measured throughout treatment and at a 1-year follow-up assessment. After controlling for possibly confounding variables and treatment condition, more shallow probability discounting was associated with greater reductions in amounts wagered during treatment and likelihood of gambling abstinence at the end of treatment and throughout the follow-up period. No associations were noted between delay discounting and gambling treatment outcomes. These data suggest that probability discounting may be an important construct in understanding pathological gambling and its treatment.     

Pathological gambling as an insanity defense

Recognition of pathological gambling as a diagnostic and clinical entity has been paralleled by its use as an insanity defense by gamblers engaged in criminal behavior. The societal ramifications of exculpation for crimes committed by volitionally impaired defendants require a critical analysis of the relationship between mental illness and criminal acts. Following a summary of current knowledge about pathological gambling as a clinical disorder, case law relevant to its use as an insanity defense is reviewed. It is argued that pathological gambling is not a serious mental illness for the purposes of the criminal law and that it bears no causal relationship to criminal activity. Legal and societal interests dictate that pathological gambling be excluded as a potential insanity defense.     

Measurement and structure of pathological gambling behavior

The serious effects of pathological gambling on both gamblers and their families warrants research on the disorder. This study aimed at identifying components of pathological gambling with the goal of developing methods for early detection and preventive strategies. A factor analysis of behaviors hypothesized to relate to pathological gambling resulted in a multidimensional model of the disorder. Eight factors were identified, including distinct neurotic, psychopathic, and impulsive components, and used in a comparative analysis of 83 admitted compulsive gamblers and 61 nongamblers. Five of the factors differentiated the two groups even when sex, age, and education were controlled. Implications of these findings are discussed.     

Do patients with OCD and pathological gambling have similar dysfunctional cognitions?

The obsessive-compulsive spectrum disorder (OCSD) theory postulates that a wide range of disorders is closely related to OCD. Current cognitive models ascertain that certain beliefs leading to misinterpretation of the significance of intrusions are important in the etiology and maintenance of OCD. This study examined whether pathological gambling, a disorder belonging to the OC spectrum, is characterized by similar dysfunctional cognitions as OCD. Dysfunctional beliefs of OCD patients were compared to those of patients with pathological gambling, panic disorder and normal controls. These beliefs were measured by the Obsessive-compulsive Beliefs Questionnaire-87 (OBQ-87), which was developed by a group of leading OCD researchers [Behav. Res. Ther. 35 (1997) 667]. It was hypothesized that according to the OCSD theory, pathological gamblers would exhibit similar cognitions to OCD patients, as well as increased levels of OCD symptoms. Analysis showed that OCD patients exhibited higher OBQ-87 scores than both panic patients and normal controls, but equal to pathological gambling patients. Pathological gamblers exhibited, however, no increase in OCD symptoms. These mixed results do not seem to support the OC spectrum theory for pathological gambling, moreover being contradictory to contemporary cognitive OCD models.     

赌博障碍的认知功能缺陷及神经基础

赌博障碍是指持续且反复的赌博行为,给个人、家庭和社会都带来了严重后果,近年来受到越来越多研究者的关注。本研究总结了赌博障碍的认知功能缺陷及其神经基础,主要集中在如下四个方面：①认知扭曲、②奖赏和惩罚敏感性、③注意偏向和④决策。未来研究应多从认知神经科学角度深入探究赌博障碍的发生机制和发展过程,关注大脑结构变化及功能网络改变,并将其整合到一个统一的神经生物机制框架中,找到更加有效的干预和治疗手段。     

Temporal patterns of anxious and depressed mood in generalized anxiety disorder: a daily diary study

Research suggests that anxiety disorders tend to temporally precede depressive disorders, a finding potentially relevant to understanding comorbidity. The current study used diary methods to determine whether daily anxious mood also temporally precedes daily depressed mood. 55 participants with generalized anxiety disorder (GAD) and history of depressive symptoms completed a 21-day daily diary tracking anxious and depressed mood. Daily anxious and depressed moods were concurrently associated. Daily anxious mood predicted later depressed mood at a variety of time lags, with significance peaking at a two-day lag. Depressed mood generally did not predict later anxious mood. Results suggest that the temporal antecedence of anxiety over depression extends to daily symptoms in GAD. Implications for the refinement of comorbidity models, including causal theories, are discussed.     

赌博障碍的认知功能缺陷及神经基础

赌博障碍是指持续且反复的赌博行为,给个人、家庭和社会都带来了严重后果,近年来受到越来越多研究者的关注。本研究总结了赌博障碍的认知功能缺陷及其神经基础,主要集中在如下四个方面：①认知扭曲、②奖赏和惩罚敏感性、③注意偏向和④决策。未来研究应多从认知神经科学角度深入探究赌博障碍的发生机制和发展过程,关注大脑结构变化及功能网络改变,并将其整合到一个统一的神经生物机制框架中,找到更加有效的干预和治疗手段。     

Integrating neurobiology and psychopathology into evidence-based treatment of social anxiety disorder

Social anxiety disorder (SAD) is a common, chronic psychiatric disorder characterized by a persistent fear of social or performance situations in which embarrassment can occur. This disorder typically appears during the mid-adolescent years and is unremitting throughout life if not properly treated. SAD presents as two subtypes: the more common and debilitating generalized form, and the nongeneralized form, which consists predominantly of performance anxiety. The majority of patients with SAD have comorbid mental disorders, including mood, anxiety, and substance abuse. No single development theory has been proposed to account for the origins of SAD, although current understanding of the etiology of SAD posits an interaction between psychological and biological factors. Risk factors include environmental and parenting influences and dysfunctional cognitive and conditioning events in early childhood. The neurobiology of SAD appears to involve neurochemical dysfunction, as evidenced by studies of neuroreceptor imaging, neuroendocrine function, and profiles of response to specific medications. Clinical trials have demonstrated that benzodiazepines and antidepressants are effective in the treatment of SAD. The selective serotonin reuptake inhibitors are emerging as the first-line treatment for SAD, based on their proven safety, tolerability, and efficacy. Goals for ongoing future research include development of approaches to achieve remission, to convert nonresponders and partial responders to full responders, and to prevent relapse and maintain long-term efficacy. This monograph explores the epidemiology, clinical presentation, and differential diagnosis of SAD, with a focus on neural circuitry of social relationships and neurochemical dysfunction. The prevalence, rates of recognition and treatment, patterns of comorbidity, quality-of-life issues, and natural history of SAD are discussed as well as pharmacologic and psychosocial treatment strategies for SAD.     

人格与病理性赌博研究述评

人格障碍是病理性赌博的定论之一。与病理性赌博有关的人格特质包括神经质、精神质、感觉寻求特质、专注特质等,这在跨文化的研究中都找到了证据。现有的研究结论存在疑问,未来研究需注意被试取样代表性,人格特质与赌博行为之间的关系有待于进一步研究,本土化研究需要加强     

Why are psychological treatments prolonged? Predictors of a longer duration of treatment and analysis of the differences between long- and short-term cases

The purpose of this study was to identify variables that may explain a longer psychological treatment and to analyze differences between short- and long-term cases. Data from 419 patients of the University Clinic of Psychology at the Complutense University of Madrid were analyzed. Number of intervention techniques, comorbidity, previous treatments, and a primary diagnosis of mood disorder or eating disorder were the factors that explained longer treatment duration. Significant differences were observed between short- and long-term cases in number of intervention techniques, number of therapeutic objectives, and also in some clinical variables (diagnostic group, comorbidity, previous treatment) and demographics (age and educational level). Results are discussed and some lines of intervention and/ or reflection are proposed.     

BEHAVIORAL TREATMENT FOR PATHOLOGICAL GAMBLING IN PERSONS WITH ACQUIRED BRAIN INJURY

The present investigation examined a behavior‐analytic clinical treatment package designed to reduce the pathological gambling of 3 individuals with acquired brain injury. A prior history of pathological gambling of each patient was assessed via caregiver report, psychological testing, and direct observation of gambling behavior. Using an 8‐week one‐on‐one client—patient format, a treatment program was developed in which the patient learned about the antecedents, consequences, and motivating operations that controlled the emission of gambling behavior. Data were collected on both self‐report of gambling urges and behavior following therapy and during in situ gambling opportunities. The therapy program reduced urges to gamble and actual gambling for all patients. The potential of behavior‐analytic therapy for reducing the pathological gambling of patients with and without brain injury is discussed.