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Uncovering the different subtypes of Problem Gamblers: An empirical testing of the Pathways Model and its clinical implications. Gupta, Blaszczynski, Nower, Derevensky, & Faregh. March 11, 2010 Sacramento, California. Context.

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Uncovering the different subtypes of Problem Gamblers: An empirical testing of the Pathways Model and its clinical implications

Gupta, Blaszczynski, Nower, Derevensky, & Faregh

March 11, 2010

Sacramento, California

context
Context

After many years of researching and working with teens, it became evident that not all were similar in their presentation and etiology.

Their gambling behaviors may have been similar, but distinct sub-types of people were emerging.

in order to better understand
In order to better understand…

Apply a theoretical framework to represent a complex phenomenon

Measure this phenomenon with identifiable and measurable units of information

A scientific approach will never reflect the true depth of human behavior, but it may reflect enough so that we may advance the current state of knowledge

background
Background

Jacobs’ General Theory of Addictions (1989) postulates that all addictions are a “…dependant state acquired over time by a predisposed person in an attempt to relieve a chronic stress condition”

Under/ Overactive physiological resting state

Psychological characteristics such as low self-esteem

pathways model
Pathwaysmodel

Blaszczynski’s model is based on the premise that there exist different typologies of gamblers and that it is counter productive to merge distinctly different types of people into a single heterogeneous group.

nower blaszczynski 2004
Nower & Blaszczynski (2004)

Proposed that the Pathways model can also serve as:

“…an effective template for the development of early intervention, prevention, & targeted clinical management strategies for adolescent and young adult gamblers.”

slide7
The Pathways model proposes that there are a minimum of three subgroups of problem and pathological gamblers with distinct clinical features and etiological processes.

This theoretical model is based on the premise that there exist different typologies of gamblers and that it is counter-productive to merge distinctly different types of people into a single heterogeneous group

pathway 1 behaviorally conditioned youth problem gamblers
Pathway 1- Behaviorally conditioned youth problem gamblers.

These youth develop gambling problems as a result of conditioning rather than impaired control. They are characterized by an absence of premorbid psychopathology. Anxiety can surface as a consequence of gambling problems.

pathway 2 emotionally vulnerable youth problem gamblers
Pathway 2- Emotionally-Vulnerable Youth Problem Gamblers

These young gamblers present with premorbid depression and/or anxiety, low self-esteem, poor coping, a history of familial neglect or abuse, and present with other adverse behaviors.

pathway 3 antisocial impulsivist youth problem gamblers
Pathway 3- Antisocial Impulsivist Youth Problem Gamblers

These young gamblers present with premorbid psychopathology suggestive of neurochemical dysfunctions. They share many things in common with Pathways 2 individuals, but they are distinct in their features of impulsivity and antisocial personality disorder which impair their overall psychosocial functioning.

science may be described as the art of systematic over simplification sir karl raymund popper
“Science may be described as the art of systematic over-simplification.”-Sir Karl Raymund Popper

Testing a model empirically is a very complex undertaking.

This study is the first to attempt to do so, and should be considered exploratory in nature.

This study is limited by its cross-sectional nature and needs replication.

the sample
The sample

1133 students from Ontario and Quebec schools

All English speaking

49.5% male, 50.5% female

Grades 7 through 12

gambling severity
Gambling severity

Non-gamblers 19.3% (n= 214)

Social gamblers 70.4% (n= 779)

At-Risk gamblers 7.2% (n= 80)

PPG 3% (n= 33)

instruments
Instruments

DSM-IV-MR-J

GAQ

Millon Adolescent Clinical Inventory (MACI)

Conners-Wells self report scale

Erroneous cognitions questions

maci description
MACI description

160 item self-report inventory designed specifically for assessing adolescent personality characteristics and clinical syndromes.

“It is useful in the evaluation of troubled adolescents, and it may be used for developing treatment plans and as an outcome measure.”

-p. 1 manual

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The MACI measures

12 personality patterns

8 expressed concerns

7 clinical syndromes

Reliability

Internal consistency alpha coefficients range from 0.73 to 0.91

Test-retest obtained a median stability coefficient of 0.82

slide18
An empirical classification of homogeneous subgroups by distinctive traits through 8 MACI variables*, making use of Latent Class Analysis (LCA)

* 9 variables selected based on Pathways Model postulates

slide19
Problem gamblers were composed of at-risk and ppg youth.
  • Step-wise mixture modelling technique in Mplus 5.21.
  • Global fit indices for model parsimony and fit (BIC and AIC), overall classification soundness (entropy), the Vuong-Lo-Mendell-Rubin Likelihood ratio, the Lo-Mendell-Rubin Adjusted LRT test, and the bootstrapped parametric likelihood ratio tests for the K-1 models.
a 4 class solution optimal
A 4 class solution: optimal

* Sample size adjusted

classes and control group for 8 maci variables mean scores
Classes and control group for 8 MACI variables (mean scores*)

Variable C1 C2 C3 C4 Control group (N=924)

Self-demeaning 19.3 29.5 90.0 56.1 45.623

Family discord 36.8 76.5 77.8 61.3 59.15

Childhood abuse 9.9 25.9 70.6 32.6 28.51

SAP** 19.5 84.7 73.2 39.5 43.53

Impulsivity 31.5 73.7 72.3 46.9 47.67

Anxious feeling 63.9 30.4 55.8 64.5 59.76

Depressive affect 35.4 30.7 99.1 73.1 59.87

Suicidal tendency 8.4 13.9 78.5 30.7 26.19

*A mean MACI score of > 60 reflects clinical range

** Substance abuse propensity

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Class 1: Anxious feelings (minimally significant)

Class 2: Impulsive, prone to abusing substances (poor coping/ impulsive nature), reported family discord

Class 3: Impulsive, prone to abusing substances, reported family discord, childhood abuse*, self-demeaning (very significant), depressive affect (very significant), suicidal tendency

Class 4: Anxious feelings, depressive affect, family discord (minimally significant)

* Self-demeaning, suicidal tendencies, and high depressive affect linked to childhood abuse only

additional findings
Additionalfindings

Problem gamblers are more likely to fall into class 3 (distinguished by childhood abuse, and combination of impulsivity and mood disorder) than any other class

No significance in endorsement rates of DSM-IV-MR-J items between classes

No significant differences in types of gambling activities and rates of play between classes

slide27
Three of our classes align very nicely with the 3 proposed pathways in the PM

Pathway 1= latent class 1

Pathway 2= latent class 4. However, unlike those in PM, those experiencing childhood abuse are in a class of their own.

Pathway 3= latent class 3

there is one meaningful difference
There is one meaningful difference:
  • our data points to a 4th class of people who are impulsive, prone to other addictions, but do not experience depressive/anxious symptoms (our latent class 2).
  • Based on our clinical experience with youth, we often treated gamblers who were either primarily impulsive OR depressive/anxious, so the addition of the 4th class makes a lot of sense, as the Pathways \model does not account for a unique subset of problem gamblers who are primarily impulsive but not depressed.
what does this tell us
What does this tell us?

Blaszczynski was onto something.

Nower and Blaszczynski were also warranted in their belief that this pathways model could apply to youth.

should the theory be modified
Should the theory be modified?

Replication studies are necessary, with different methodologies and larger subject pools, before any modifications or additions to the Pathways Model are warranted.

Having said that, further exploration into the validity of a 4th pathway is warranted at this time.

conclusions
Conclusions
  • Strong support for the premise that not all problem gamblers are the same
implications
Implications

Assessment on intake of gamblers in treatment should be extensive (clinical syndromes, history of abuse, impulsivity, personality concerns).

Treatment should be tailored to these etiological factors and co-morbid disorders.

implications1
Implications
  • Treatment providers must be proficient in treating mood & impulse control disorders, and co-morbid addictions. Furthermore, it is important to be comfortable working with a family systems approach as well as in dealing with underlying contributing issues such as childhood abuse.
  • Therefore, an eclectic training is ideal so that treatment can be properly tailored to each of the 4 subgroups of problem gamblers.
therapy class 1
Therapy: Class 1
  • Cognitive restructuring of erroneous beliefs pertaining to gambling participation.
  • Financial counselling. Outcome excellent.
therapy class 2
Therapy: Class 2
  • Impulse control management is primary focus. Environmental and emotional triggers need to be identified and client is taught more effective ways of coping. Family systems approach would be helpful as well. Cognitive restructuring, financial counselling and management of budget skills. Anticipated outcome good, but relapse risk is high due to impulsive style.
therapy class 3
Therapy: Class 3
  • Primary focus on mood disorder and underlying cause of childhood abuse. Focus also on making them feel better about themselves and be less self-demeaning, self-destructive. Secondary focus on triggers and impulse control issues. Minimal focus on cognitive restructuring until primary mood and underlying issues dealt with. Anticipated outcome: guarded. Risk of relapse high.
slide37
Those experiencing childhood abuse are going to require a more comprehensive approach psycho-therapeutic approach and lengthy treatment protocol. Abuse leads to self-demeaning thought patterns, depression, and self-harming behaviours.
therapy class 4
Therapy: Class 4
  • Treatment of mood disorders is primary focus. Family systems approach, and financial counselling also useful. Cognitive restructuring may be necessary but minimal. Outcome good, lower risk of relapse if depression/anxiety under control.
slide39
Pharmacotherapy may be indicated for those experiencing underlying impulsivity, depression, and/or anxiety disorder. Grant et al. have proposed the benefits of SRIs, mood stabilizers, and Naltrexone for the treatment of problem gamblers.
common therapeutic threads across subtypes
Common therapeutic threads across subtypes
  • Focus on gradually cutting down gambling involvement (time, money, frequency). Requesting immediate abstinence will result in elevated treatment dropout rates. (Best achieved by establishing a baseline rate and working from there.)
slide41
Restructuring free time: Most temptation occurs when faced with free time. Help them plan and organize their time on a weekly basis.
slide42
Replace the gambling with other activities. Encourage a balanced lifestyle (i.e., exercise, taking on a hobby)
slide43
Involve others as supports, such as significant other, friends, relatives. (Support groups, such as GA can be useful in conjunction with therapy, especially when other supports are unavailable.)