Conference Report From the Addiction Psychiatry Meeting
Conference Report From the Addiction Psychiatry Meeting
What defines gambling? Simply stated, gambling amounts to risking something of value on the outcome of an event when the probability of that outcome is less than certain. According to Marc Potenza, MD, PhD, of Yale University, Howard Shaffer, PhD, of Harvard Medical School, and Nancy Petry, PhD, of the University of Connecticut Health Center, presenters at a symposium at the 13th Annual Meeting of the American Association for Addiction Psychiatry, gamblers have variable awareness that they are putting something of value at risk. Gamblers who do poorly seem even to lack the awareness, in some cases, that the bet is irreversible and that the outcome is determined by chance. They tend to overestimate their gambling skill (as most of us do, to some extent).
Pathologic gambling is considered a major psychiatric disorder characterized by an uncontrollable impulse to gamble that, like other addictive behavior, tends to be progressive and chronic. Our capacity to find therapeutic interventions will be greatly enhanced by our ability to understand neural mechanisms of (1) the brain state prior to engagement of self-destructive behavior, and (2) pharmacotherapies (and even psychotherapies) directed at specific conditions.
The problem gambler experiences adverse consequences in personal, social, and occupational functioning, and he or she continues to gamble despite the clearly negative outcomes and even loss of enjoyment of the activity. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition defines pathologic gambling as "persistent and recurrent maladaptive gambling behavior that is not better accounted for by a manic episode." Three elements are central to the diagnosis: loss of control; increasing investment in frequency, amount gambled, time spent gambling, and obtaining money with which to gamble; and continued gambling despite negative repercussions.
The neurobiology of impulse control involves complex arrays of prefrontal and frontal cortical activity. Emotion, decision, and impulse control have been linked to decreased activity in these areas. However, no neuroimaging studies of problem gamblers have been published.
Gambling is common in virtually all societies, and in the United States 80% to 90% of respondents state that they have some experience with gambling. Pathologic gambling represents a significant public health problem, and problem gambling is clearly associated with crime, incarceration, financial ruin, alcohol and drug addiction, suicide, and psychiatric disturbance. The gambler who has legal problems is likely to be male, unemployed, single, and abusing drugs or alcohol. An interesting finding, however, is that pathologic gamblers who have not been arrested tend to be female, and they tend to be involved in what are called nonstrategic forms of gambling such as lotteries or slot machines. Among troubled gamblers, there is a high degree of comorbidity not only with substance abuse and antisocial traits, but also with mood disorders and attention deficit/hyperactivity disorder (ADHD).
Problem gambling is important, therefore, because it may serve as a model for impaired impulse control. Suicide attempts, self-mutilating behavior, and syndromes of disinhibition may have common neurobiologic mechanisms that are also central to gamblers who are out of control.
The prevalence of problem gambling is estimated at less than 3% of the general population, with a male to female ratio of 2:1. The group with the highest prevalence of gambling problems is the 18- to 25-year-old age group, and among adolescents, the percentage approaches 6% in some studies and almost 15% in others. The diagnosis of pathologic gambling generally occurs as the gambler gets older, because gambling skill often deteriorates over time -- perhaps as long as 2 or 3 decades. Females tend to get involved later in life, in their thirties or forties, whereas males often begin during adolescence. Women seem to deteriorate more rapidly and seek help after only a few years; whereas with men, the problem may persist for many years, characterized by uncontrolled gambling related to significant loss, life stress, or increased exposure to gambling.
Studies show that about half of pathologic gamblers are alcohol or substance abusers, and this is particularly true among adolescents. Teen gamblers have higher rates of alcohol, tobacco, and marijuana use than nongambling peers, and among teen substance abusers, the rates of problem gambling have been estimated as high as 10% to 30% in different studies.
Although one would intuitively assume that problem gamblers have mood problems, most of us are surprised to learn just how high the rates of depression (32% to 76%), mania and hypomania (46%), and suicide attempts (12%) are within this population. The co-occurrence of ADHD is estimated at about 20%; when adult problem gamblers are compared with controls, the gamblers are significantly more likely to have childhood behavior problems.
What are the roles played by neurotransmitters? What are the differences between problem gamblers and control subjects who do not gamble? At this point, there are more questions than answers. In response to gambling cues (like viewing a videotape), problem gamblers show relatively decreased brain activities in cortical and subcortical structures. Also of interest is the finding that both groups, gamblers and controls, differ from patients in treatment for cocaine dependency.
These discrete differences may show us the way to more effective treatments. Limitations in what we know are related to the complexity of treating patients with 2 or more comorbid conditions, the nature of short-term trials, the limited number of sites suitable and available for research, and limited sample sizes. Both paroxetine and naltrexone seem to have some benefit in the treatment of pathologic gambling, but studies suffer from all of these limitations.
In summary, problem and pathologic gambling are serious public health concerns and offer us a window into the way the brain manages impulse control problems, compulsive behavior, and decision-making. Screening, education of the public, help lines, and continuing research are all parts of the future of this fascinating world of study and learning.
What defines gambling? Simply stated, gambling amounts to risking something of value on the outcome of an event when the probability of that outcome is less than certain. According to Marc Potenza, MD, PhD, of Yale University, Howard Shaffer, PhD, of Harvard Medical School, and Nancy Petry, PhD, of the University of Connecticut Health Center, presenters at a symposium at the 13th Annual Meeting of the American Association for Addiction Psychiatry, gamblers have variable awareness that they are putting something of value at risk. Gamblers who do poorly seem even to lack the awareness, in some cases, that the bet is irreversible and that the outcome is determined by chance. They tend to overestimate their gambling skill (as most of us do, to some extent).
Pathologic gambling is considered a major psychiatric disorder characterized by an uncontrollable impulse to gamble that, like other addictive behavior, tends to be progressive and chronic. Our capacity to find therapeutic interventions will be greatly enhanced by our ability to understand neural mechanisms of (1) the brain state prior to engagement of self-destructive behavior, and (2) pharmacotherapies (and even psychotherapies) directed at specific conditions.
The problem gambler experiences adverse consequences in personal, social, and occupational functioning, and he or she continues to gamble despite the clearly negative outcomes and even loss of enjoyment of the activity. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition defines pathologic gambling as "persistent and recurrent maladaptive gambling behavior that is not better accounted for by a manic episode." Three elements are central to the diagnosis: loss of control; increasing investment in frequency, amount gambled, time spent gambling, and obtaining money with which to gamble; and continued gambling despite negative repercussions.
The neurobiology of impulse control involves complex arrays of prefrontal and frontal cortical activity. Emotion, decision, and impulse control have been linked to decreased activity in these areas. However, no neuroimaging studies of problem gamblers have been published.
Gambling is common in virtually all societies, and in the United States 80% to 90% of respondents state that they have some experience with gambling. Pathologic gambling represents a significant public health problem, and problem gambling is clearly associated with crime, incarceration, financial ruin, alcohol and drug addiction, suicide, and psychiatric disturbance. The gambler who has legal problems is likely to be male, unemployed, single, and abusing drugs or alcohol. An interesting finding, however, is that pathologic gamblers who have not been arrested tend to be female, and they tend to be involved in what are called nonstrategic forms of gambling such as lotteries or slot machines. Among troubled gamblers, there is a high degree of comorbidity not only with substance abuse and antisocial traits, but also with mood disorders and attention deficit/hyperactivity disorder (ADHD).
Problem gambling is important, therefore, because it may serve as a model for impaired impulse control. Suicide attempts, self-mutilating behavior, and syndromes of disinhibition may have common neurobiologic mechanisms that are also central to gamblers who are out of control.
The prevalence of problem gambling is estimated at less than 3% of the general population, with a male to female ratio of 2:1. The group with the highest prevalence of gambling problems is the 18- to 25-year-old age group, and among adolescents, the percentage approaches 6% in some studies and almost 15% in others. The diagnosis of pathologic gambling generally occurs as the gambler gets older, because gambling skill often deteriorates over time -- perhaps as long as 2 or 3 decades. Females tend to get involved later in life, in their thirties or forties, whereas males often begin during adolescence. Women seem to deteriorate more rapidly and seek help after only a few years; whereas with men, the problem may persist for many years, characterized by uncontrolled gambling related to significant loss, life stress, or increased exposure to gambling.
Studies show that about half of pathologic gamblers are alcohol or substance abusers, and this is particularly true among adolescents. Teen gamblers have higher rates of alcohol, tobacco, and marijuana use than nongambling peers, and among teen substance abusers, the rates of problem gambling have been estimated as high as 10% to 30% in different studies.
Although one would intuitively assume that problem gamblers have mood problems, most of us are surprised to learn just how high the rates of depression (32% to 76%), mania and hypomania (46%), and suicide attempts (12%) are within this population. The co-occurrence of ADHD is estimated at about 20%; when adult problem gamblers are compared with controls, the gamblers are significantly more likely to have childhood behavior problems.
What are the roles played by neurotransmitters? What are the differences between problem gamblers and control subjects who do not gamble? At this point, there are more questions than answers. In response to gambling cues (like viewing a videotape), problem gamblers show relatively decreased brain activities in cortical and subcortical structures. Also of interest is the finding that both groups, gamblers and controls, differ from patients in treatment for cocaine dependency.
These discrete differences may show us the way to more effective treatments. Limitations in what we know are related to the complexity of treating patients with 2 or more comorbid conditions, the nature of short-term trials, the limited number of sites suitable and available for research, and limited sample sizes. Both paroxetine and naltrexone seem to have some benefit in the treatment of pathologic gambling, but studies suffer from all of these limitations.
In summary, problem and pathologic gambling are serious public health concerns and offer us a window into the way the brain manages impulse control problems, compulsive behavior, and decision-making. Screening, education of the public, help lines, and continuing research are all parts of the future of this fascinating world of study and learning.
