pathological gambling impulse compulsion or addiction the addiction perspective n.
Download
Skip this Video
Download Presentation
PATHOLOGICAL GAMBLING: IMPULSE, COMPULSION, OR ADDICTION? THE ADDICTION PERSPECTIVE

Loading in 2 Seconds...

play fullscreen
1 / 14

PATHOLOGICAL GAMBLING: IMPULSE, COMPULSION, OR ADDICTION? THE ADDICTION PERSPECTIVE - PowerPoint PPT Presentation


  • 221 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'PATHOLOGICAL GAMBLING: IMPULSE, COMPULSION, OR ADDICTION? THE ADDICTION PERSPECTIVE' - bree-kemp


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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…
slide7
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