Pathological gambling impulse compulsion or addiction the addiction perspective
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PATHOLOGICAL GAMBLING: IMPULSE, COMPULSION, OR ADDICTION? THE ADDICTION PERSPECTIVE PowerPoint PPT Presentation


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Addiction. PATHOLOGICAL GAMBLING: IMPULSE, COMPULSION, OR ADDICTION? THE ADDICTION PERSPECTIVE. Nady el-Guebaly, MD*, Heidi Friesen BSR (OT)C, Jennifer Corbiell MSW. *Prof & Head, Addiction Division, U of Calgary Consultant, Addiction Centre & Program, Alberta Health Services

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PATHOLOGICAL GAMBLING: IMPULSE, COMPULSION, OR ADDICTION? THE ADDICTION PERSPECTIVE

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Pathological gambling impulse compulsion or addiction the addiction perspective

Addiction

PATHOLOGICAL GAMBLING:IMPULSE, COMPULSION, OR ADDICTION?THE ADDICTION PERSPECTIVE

Nady el-Guebaly, MD*, Heidi Friesen BSR (OT)C, Jennifer Corbiell MSW.

*Prof & Head, Addiction Division, U of Calgary

Consultant, Addiction Centre & Program, Alberta Health Services

Chair, Alberta Gaming Research Institute [AGRI]

Program

Network

AGRI: www.abgaminginstitute.ualberta.ca


Burden of history

BURDEN OF HISTORY

  • 1952 DSM: Sociopathic Personality Disorder

    (Addiction – alcoholism & drugs)

  • 1968 DSM II: Personality Disorders

  • 1980 DSM III:Substance Use Disorders:Dependence > Addiction by 1 vote

    (criteria for abuse & dependence; Tolerance & Withdrawal)

    Disorders of Impulse Control: Pathological Gambling

  • 1987 DSM III-R:Psychoactive Substance Use Disorders

    (T & W now 2 among any 3);

    Impulse Control Disorders

  • 1994 DSM IV: Substance Related Disorders

    (criteria reduced to 7, with any 3 for diagnosis.

    Neither T or W necessary)

    Impulse Control Disorders, incl Pathological Gambling

  • 2010 DSM-V ?Addiction & Related Disorders with Pathological Gambling


Overlapping constructs

Overlapping Constructs

  • Impulse Control Disorders NOT ELSEWHERE CLASSIFIED (SUD, Cluster B PD, eating dis)

    “Recurrent failure to resist impulse, drive, or temptation to perform an act harmful to the person / others”

    Motivation: Increasing tension/arousal Pleasure/relief “Ego-syntonic” ± Regret/Guilt

  • Obsessive-Compulsive Disorders ”Ego-dystonic” products of one’s mind!

    “Persistent ideas, thoughts, impulses, or images EXPERIENCED AS INTRUSIVE & INAPPROPRIATE”

    Motivation: Suppress/neutralize thoughts’ tension Compulsions(wash, lock, gambling rituals?)

  • Addictions

    ASAM: A primary disease characterized by behaviors, including one or more of 4 C’s

Act


Why am i confused

WHY AM I CONFUSED?

  • IMPULSIVE/COMPULSIVE SPECTRUM ALONG HARM AVOIDANCE (HA)

    High HALow HA

    OCD ICD

    BUT DIFFERENCE IS NOT CONSTANT

    • In OCD & PG , Mix of impulsivity & harm avoidance vary

      i.e., suicidality (despair), course severity, appreciation of consequences

    • Gender differences

  • WHAT ABOUT ADDICTION’S MOTIVATION in HA?

    • Varied “impaired control” i.e., initial caution disappears;apprecofconsequences

  • WHAT ABOUT DENIAL? Unconscious disclaimer of intolerable thoughts / feelings / realities to allay anxiety.

  • Scarce investigation of triad OCT, ICD, & Addiction

  • Cultural differences?


P g addiction vs icd nec a

P G “ADDICTION vs. ICD NEC” - A

  • Addiction “without a drug”

  • Similarities to substance dependence

    • Epidemiology M2 : F1 (OCD 1:1)

    • Course

      • Lifecycle: low in childhood, high in adolesc. & young adult, lower in seniors (OCD & Impulsivity common in childhood)

      • Telescoping course among women

    • Criteria (DSM IV borrowed terminology?)

      • Tolerance & Withdrawal

      • Unsuccessful attempts to cutback/quit

      • Interference with life functioning


P g addiction vs icd nec b

P G “ADDICTION vs. ICD NEC” - B

  • Clinical differences

    • Low salience of physical manifestations

    • High salience of financial problems

    • No biological tests or urine monitoring

  • PG is not always welcome as an Addiction?!

    • Stigma of term

    • Trivialization of hard-fought recognition of SUD

    • Turf: research funding…


Pathological gambling impulse compulsion or addiction the addiction perspective

CO-OCCURING DISORDERS “BIRDS OF A FEATHER!”NESARC (Nat Epid Survey Alc & Related Conditions) N=43000 – Petry ‘05


Genes neurobiology

Genes / Neurobiology

  • THE REWARD SYSTEM: MRI & PET Contributions to SUD & PG

    Limbic – pre frontal cortex with “reward deficiency syndrome”; “reward circuit disorders; some differences

  • ROLE OF SEROTONIN (5HT1B) - risk taking behaviors

    - prefrontal cortex  impulse

  • ROLE OF DOPAMINE - translates drive into action – the “go” signal

    - release in nucleus acumbens

    - surge with uncertain rewards: “it is not about money; it is about the hunt”

  • NOREPINEPHRINE - mediation of arousal & attention; “heart race”

  • OPIOID SYSTEM - “cravings”

    - endorphin linked with dopamine via GABA

    Genetic 35-54% liability  link with alcohol, antisocial PD & major depression ’05

    OCD? Other 5HT genes in some; Orbito-frontal Cortex – Caudate nucleus circuitry


Academic debate or management implications

ACADEMIC DEBATE OR MANAGEMENT IMPLICATIONS

  • PHARMACEUTICAL TRIALS – SHORT TERM

    • SSRIs: OCD, Anxiety / mood

    • MOOD STABILIZERS: Impulsivity

    • Opioid antagonist “Naltrexone” / Nalmefene, most robust data (like alcohol & opioids but worsens OCD)

    • Dopamine & Parkinson meds; antagonist olanzepine n.s.; haloperidol primes motivation

    • N-Acetyl cysteine – glutamate modulator

      No FDA approved medication for PG

  • PSYCHOTHERAPIES – LONGER TERM

    • CBT – ROBUST targeting of cognitive distortions, cravings & coping strategies

    • Motivational therapies

  • MUTUAL HELP / 12 STEPS

    • GA is the most widely available intervention in N. America

    • OC-A? IC-A?


Linda impulsivity

“Linda” – Impulsivity

  • 49 y/o; married 10 years; press technician;

    - son has schizophreniform disorder & a mgt challenge

  • GAMBLING- 2 y ago “X-mas gift” of a cell phone

    “quickly addicted” to poker game & opening cash account

    Two initial wins at casino, now $20,000 in debt

    - “Excitement, fun, due to win, lucky, strong urges”

    Now stays up gambling online, purchases scratch tickets & plays VLTs with sister in law “an escape”

  • DRUG USE– “Whatever was around” as teenager but no longer

  • “SEX ADDICTION”issues in the past with STDs

  • PSYCHIATRIC HISTORY– “Conduct disorder” as child


Cindy compulsivity

“Cindy” - Compulsivity

  • 45 y/o, spinster, living alone most of her life,

    customer rep in bank for 15 yrs; interpersonal difficulties at work

  • GAMBLING- 2 y ago began regular gambling, accompanying her sister to casino whose husband had cancer

    • Casino Gambling 10 days/mt; no substantial win; loss $2,000/mt

    • Power of attorney & spending her mother’s $45,000; “her dirty little secret!”; relieved to talk to someone because of distress

    • “Preoccupied with gambling & losses”, which leads to “significant anxiety, guilt, shame, & sleeping problems”

      “Trying to put limits on spending or abstinence 1 mt max; self-disgust; secretive about amounts incl sister”

  • DRUG USE– Some social experimentation as teenager; 2 alcohol drinks/mt

  • PSYCHIATRIC HISTORY– Shy – Social Phobia


  • Mary addictions

    “Mary” - Addictions

    • 54 y/o married; LPN & Rec Therapist;

      Osteoporosis with pain in neck, spine, & knees

    • GAMBLING

      • Bingo & Scratch ticket for 25 y; problem for 7 yrs since “supportive” mother died; takes care of “abusive” father

      • Initially slot machine $200, twice/wk; then “extreme problem” $1,000 daily;

        maxing Credit Cards

      • Declared bankruptcy 5 yrs ago $36,000; 1 yr ago, charged with theft of $87,000 in financial trust of a cousin with MS; jail term & now on Pre-release

      • “Oh to be alone with the machine, not thinking of anything else”, “restless when trying to cut down”, “If not caught, I would have continued”,

        “certain machines were lucky”, “wore a guardian angel for luck”

  • ALCOHOL & DRUG USE

    • Non-user except half a pack/day cigs for yrs, assoc with gambling;

      but urine cannabis-positive; now computer video game 7 hrs

  • PSYCHIATRIC HISTORY

    • Overdose 2 mts ago on “mother’s grave”; Prior depressive episodes


  • Conclusions

    CONCLUSIONS

    • Evidence favors the Addiction Model, overall; DSM V?

    • Impulse control shapes some types of PG

    • OCD is also relevant but more distant

    • Patients should be assessed for all 3 with valid & reliable instruments;

    • Studies of their relative frequency (full/partial syndrome) ?

    • Distinctive Therapeutic trials could improve outcome


    Clinical red flags

    Clinical Red Flags

    • Ego syntonic / dystonic

    • Harm avoidance

    • Locus of Control: External for impulsive vs. less so for addiction & compulsion

    • Description of gambling: addiction & denial

    • Comorbidities

    • Family history?

    • Trt: Individualize


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