Investigating Decision-Making under Risk in Pathological Gambling Using a Virtual Slot Machine: A Pilot Eye-Tracking Study

IntroductionThe relevance of behavioral addictions (like gambling or internet gaming disorder) is growing constantly - not only in clinical practice, but also as a topic in addiction research. Furthermore, behavioral addictions were found to share similar neurobiological mechanisms with substance-use disorders like alcohol or drug addiction. Cue reactivity is a well-established concept to study an important concept in addiction: craving, which denotes the strong desire to consume the addictive substance. For instance, images of alcoholic beverages can induce a strong desire to drink alcohol in patients with alcohol addiction, reflected in brain activation in parts of the reward system and regions specifically involved in craving.ObjectivesIn order to extend existing findings to the field of slot machine gambling, we focused on patients suffering from gambling disorder (GD) and who mainly played slot-machines. We investigated neural activation as a response to addiction-related cues (in comparison to neutral cues) using a cue reactivity paradigm.MethodsTo that end, participants with a diagnosis of GD (N = 10) and a group of healthy controls (N = 20) viewed pictures of gambling-related cues (slot machines) as well as neutral cues (ticket vending machines), while brain activation was recorded using functional magnetic resonance imaging (fMRI). Direct comparisons of patients suffering from GD with healthy controls were analyzed for the two different image types (gambling-related vs. neutral) separately.ResultsWe found stronger activation in the insular cortex for patients with GD only during presentation of the slot-machine images, but not for the neutral cues. Furthermore, for the slot-machine condition also stronger activation in the dorsal anterior cingulate cortex (dACC) and the supplementary motor area (SMA) was documented for the clinical population but not for the healthy controls.ConclusionsIn line with previous findings, the visual presentation of gambling cues led to stronger brain activations in parts of the reward system (dACC) and in the insula, which plays a crucial role in addictive disorders, especially in craving. Our results further add to the notion that brain areas involved in substance-use disorders might also play an important role in behavioral addictions. Specifically, our findings extend existing results to the research field of slot-machine gambling in the context of craving.Disclosure of InterestNone Declared

Although most people gamble occasionally for fun and pleasure, gambling brings with it inherent risks of personal and social harm. According to the most recent British Gambling Prevalence Survey there are ~350,000 problem gamblers in the UK which equates to just under 1% of the adult population (Wardle et al., 2011). Problem and pathological gambling can negatively affect significant areas of a person's life, including their physical and mental health, employment, finances, and interpersonal relationships (e.g., family members, financial dependents) (Griffiths, 2004). Furthermore, there are significant co-morbidities with problem gambling, including depression, alcoholism, and obsessive-compulsive behaviors (Petry et al., 2005; Desai and Potenza, 2008). These co-morbidities may exacerbate, or be exacerbated by, problem and pathological gambling. The availability of opportunities to gamble and the incidence of problem gambling within a community are also known to be linked (e.g., Pearce et al., 2008). Anyone coming into the gambling studies field from a psychological perspective would probably conclude from reading the literature that problem and pathological gambling is associated with particular game types. More specifically, there appears to be a line of thinking in the gambling studies field that casino-type games (and particularly slot machines) are more likely to be associated with problem gambling than lottery-type games (Griffiths, 1994; Meyer et al., 2009). In this opinion paper it is argued that when it comes to problem gambling, game-type is irrelevant and that the most important factors along with individual susceptibility and risk factors of the individual gambler (which are not discussed here and beyond this paper's remit), are the structural characteristics relating to the speed and frequency of the game (and more specifically event frequency, bet frequency, event duration, and payout interval) rather than the type of game. It is also argued that researchers in the gambling studies field need to think about game parameters rather than game type when it comes to any association with problem and pathological gambling.

Very few studies have investigated motivational differences between pathological gamblers (PG) and non-problem gamblers (NPG), or between men and women. Motives for starting gambling have not been distinguished from motives for continuing gambling. From a community survey questionnaire listing reasons generated from the population studied, the motives of 103 current PG met the DSM-IV-TR criteria of five or more symptoms within the 12 months to October 2004. NPG assented to less than three symptoms. Generally, PG had significantly stronger motives than NPG and preferred continuous forms of gambling. There were no overall gender differences in motives, but electronic gaming machines and bingo were the primary choices for female PG. Gambling to escape from stress and troubles increased for PG but not for NPG, while gambling for social reasons decreased for both groups. Because of disproportionate numbers of PG and NPG in the Caucasian, Maori, Pacific Island and Asian groups, ethnic differences were not examined. The findings supported some aspects of theories of gambling motivation. Lowering stress for PG, raising community awareness of the risk of gambling to socialize and undertaking longitudinal research in community samples were suggested.

Recent data suggest the importance of identifying subtypes of pathological gamblers. This research studies sensation seeking, alexithymia and depression among a general population of French gamblers who play different types of game. Those games include games available in cafés (two cafés located in Paris suburb) like lottery, scratch-cards, etc., horse betting at the racetrack (five racetracks closest to Paris), slot machines and traditional games (roulette and card games) at the casino of Enghien-les-Bains (casino nearest to Paris). Sensation seeking was measured with the SSS form V, alexithymia with the TAS-20, and depression with the BDI-13. Pathological racetrack gamblers (42 males; mean age 29.1 years), who play active games involving skills, have the highest sensation seeking scores and are the most prone to alexithymia. Pathological gamblers playing the slot machines (12 males; 15 females; mean age 35.7 years) and games available in cafés (57 males; mean age 32.6 years), thus playing passive games that involve chance only, have low sensation seeking scores. Slot machines gamblers display alexithymia and have the highest depression scores. Pathological gamblers playing traditional games (15 males; mean age 37.8 years), games that involve strategy, do not perform well on any of these scales. These findings are consistent with the idea that clinically distinct subgroups of pathological gamblers can be identified. People displaying typical features could be attracted by specific games.

Commonality in etiology and clinical expression plus high comorbidity between pathological gambling and substance use disorders suggest common underlying motives. It is important to understand common motivators and differentiating factors. An overarching framework of addiction was used to examine predictors of problem gambling in current electronic gaming machine (EGM) gamblers. Path analysis was used to examine the relationships between antecedent factors (stressors, coping habits, social support), gambling motivations (avoidance, accessibility, social) and gambling behavior. Three hundred and forty seven (229 females: M = 29.20 years, SD = 14.93; 118 males: M = 29.64 years, SD = 12.49) people participated. Consistent with stress, coping and addiction theory, situational life stressors and general avoidance coping were positively related to avoidance-motivated gambling. In turn, avoidance-motivated gambling was positively related to EGM gambling frequency and problems. Consistent with exposure theory, life stressors were positively related to accessibility-motivated gambling, and accessibility-motivated gambling was positively related to EGM gambling frequency and gambling problems. These findings are consistent with other addiction research and suggest avoidance-motivated gambling is part of a more generalized pattern of avoidance coping with relative accessibility to EGM gambling explaining its choice as a method of avoidance. Findings also showed social support acted as a direct protective factor in relation to gambling frequency and problems and indirectly via avoidance and accessibility gambling motivations. Finally, life stressors were positively related to socially motivated gambling but this motivation was not related to either social support or gambling behavior suggesting it has little direct influence on gambling problems.

Familial and twin studies suggest the implication of a genetic factor in pathological gambling, but mainly assess probands through treatment settings or advertisements. The question raised here is: are parents of casino pathological gamblers using slot machines more affected with pathological gambling than nonpathological gamblers, all interviewed on site at the same casino? Three hundred and fifty-five casino gamblers on slot machines, which included 96 pathological gamblers, 116 problem gamblers, and 143 nonproblem gamblers, were recruited in situ at the largest casino in the Paris suburbs. We evaluated pathological gambling and two addictive disorders (alcohol dependence and tobacco consumption) in the gamblers and their 690 parents (through the proband). Familial aggregation of pathological gambling was confirmed, with a risk of 3.3 for being a pathological gambler when at least one of the parents has problematic gambling. No familial co-aggregation of pathological gambling with alcohol or tobacco dependence was observed. Pathological gambling is found in excess in the parents of pathological casino gamblers, in accordance with previous aggregation studies devoted to other types of gambling, and with studies recruiting gamblers in different settings.

Although it is often assumed that electronic gaming machines (EGMs) are associated with the highest level of risk, it has proved difficult to find reliable evidence in support of this proposition. In this paper, we analysed statistics from major Australian community prevalence studies for the period 2011-2020 to investigate whether EGMs (in comparison to racing and casino table games) have a stronger association with problem gambling. All prevalence studies reviewed used telephone sampling and the Problem Gambling Severity Index to assess problem gambling. In this paper, we examine the principal hypothesis using several lines of evidence, including whether problem gamblers are more likely to gamble and gamble regularly on EGMs as opposed to racing and casino games and if the EGM-problem gambling association was maintained after controlling for other forms of participation. Results showed that of all gambling activities, EGMs do appear to have the strongest association with problem gambling. Despite having a disproportionately higher level of participation on racing and casino games as compared with other gamblers, problem gamblers are more likely to report regular or weekly participation in EGM gambling and this may be the reason why this activity emerges most strongly as a predictor of problem gambling in multivariate models. This finding is particularly salient, given the very high prevalence of EGM participation, compared to other risky gambling forms. The findings underscore the importance of survey reporting that presents results in a form that can inform policy relevant research relating to the potential impact of different gambling activities.

To analyse problem gamblers' decision-making under conditions of risk and ambiguity, investigate underlying psychological factors associated with their choice behaviour and examine whether decision-making differed in strategic (e.g., sports betting) and non-strategic (e.g., electronic gaming machine) problem gamblers. Cross-sectional study. Out-patient treatment centres and university testing facilities in Victoria, Australia. Thirty-nine problem gamblers and 41 age, gender and estimated IQ-matched controls. Decision-making tasks included the Iowa Gambling Task (IGT) and a loss aversion task. The Prospect Valence Learning (PVL) model was used to provide an explanation of cognitive, motivational and response style factors involved in IGT performance. Overall, problem gamblers performed more poorly than controls on both the IGT (P = 0.04) and the loss aversion task (P = 0.01), and their IGT decisions were associated with heightened attention to gains (P = 0.003) and less consistency (P = 0.002). Strategic problem gamblers did not differ from matched controls on either decision-making task, but non-strategic problem gamblers performed worse on both the IGT (P = 0.006) and the loss aversion task (P = 0.02). Furthermore, we found differences in the PVL model parameters underlying strategic and non-strategic problem gamblers' choices on the IGT. Problem gamblers demonstrated poor decision-making under conditions of risk and ambiguity. Strategic (e.g. sports betting, poker) and non-strategic (e.g. electronic gaming machines) problem gamblers differed in decision-making and the underlying psychological processes associated with their decisions.

There is a paucity of treatment-outcome research for problem or pathological gambling. Single-session exposure therapy has been used successfully with a broad range of psychological disorders such as panic disorder and the phobias. This article will describe the use of single-session graded exposure to treat problem gambling with an Electronic Gaming Machine (EGM) gambler. Pretreatment to 6-month follow-up repeated measures showed a significant reduction in clientrated gambling severity, that is, showed a significant reduction in client-rated gambling severity (Gambling Severity Checklist [GSCL]), the Symptom Checklist-90-Revised (SCL-90-R) and the Beck Depression Inventory (BDI). This case demonstrates a novel intervention which is brief, convenient and accessible to the client, and which resulted in gains maintained over the medium-term. This promising single case indicates the need for further research to determine whether positive benefits are realised in larger randomised control designs.

Prevalence rates of at risk, problematic and pathological gambling in Switzerland

To provide an overview of gambling in the Netherlands, focusing on historical background, policy, legislation, prevalence of problem gambling, availability of treatment options and research base. Literature review. Contradictions between gambling policy and practice have been present in the past 15-20 years, and have led to an increasingly stricter gambling regulation to retain the government policy to restrict gambling within a national monopoly. Conversely, political efforts have been made to legalize internet gambling, but have not yet been approved. Compared to other European countries, slot machine gambling and casino gambling are relatively popular, whereas betting is relatively unpopular. Last-year problem gambling prevalence (South Oaks Gambling Screen score > 5) is estimated at 0.22-0.15% (2005, 2011). Treatment for problem gambling is covered by health insurance under the same conditions as substance dependence, but only a small proportion of Dutch problem gamblers seeks help at addiction treatment centres. Gambling policy in the Netherlands has become stricter during recent last years in order to maintain the Dutch gambling monopoly. Problem gambling in the Netherlands is relatively stable. Dutch research on problem gambling has a lack of longitudinal studies. Most of the epidemiological gambling studies are reported in non-peer-reviewed research reports, which diminishes control by independent peers on the methodology and interpretation of results. Recent efforts to enhance consistency in research methods between gambling studies over time could enhance knowledge on changes in (problem) gambling in the Netherlands.

Cue reactivity is an established procedure in addictions research for examining the subjective experience and neural basis of craving. This experiment sought to quantify cue-related brain responses in gambling disorder using personally tailored cues in conjunction with subjective craving, as well as a comparison with appetitive non-gambling stimuli. Participants with gambling disorder (n=19) attending treatment and 19 controls viewed personally tailored blocks of gambling-related cues, as well as neutral cues and highly appetitive (food) images during a functional magnetic resonance imaging (fMRI) scan performed ~2–3 h after a usual meal. fMRI analysis examined cue-related brain activity, cue-related changes in connectivity and associations with block-by-block craving ratings. Craving ratings in the participants with gambling disorder increased following gambling cues compared with non-gambling cues. fMRI analysis revealed group differences in left insula and anterior cingulate cortex, with the gambling disorder group showing greater reactivity to the gambling cues, but no differences to the food cues. In participants with gambling disorder, craving to gamble correlated positively with gambling cue-related activity in the bilateral insula and ventral striatum, and negatively with functional connectivity between the ventral striatum and the medial prefrontal cortex. Gambling cues, but not food cues, elicit increased brain responses in reward-related circuitry in individuals with gambling disorder (compared with controls), providing support for the incentive sensitization theory of addiction. Activity in the insula co-varied with craving intensity, and may be a target for interventions.

The widespread introduction of electronic gaming machines (EGMs) in Australia has seen problem gambling (PG) rates soar over the past decade. This has been particularly apparent among women, with presentations to gambling help services increasing fivefold, and 90% of them indicating EGMs as the problem. Prisoners represent a group containing the highest PG rate found in any population. Despite a sharp increase in PG among women and the well-established link between offenders and PG, little data exists concerning PG among female prisoners. This study examined lifetime prevalence of PG among female prisoners in South Australia. The Early Intervention Gambling Health Test was administered to 74 female prisoners. Previous help-seeking behaviour and association with incarceration were also examined. Sixty-four percent of respondents indicated PG with one in six reporting they were incarcerated due to PG-related offending. Problem gamblers whose incarceration was related to PG were more likely to indicate they had gambled to try and win money to repay debts than problem gamblers incarcerated for unrelated offending. Given high levels of PG and overall low rates of help-seeking, women’s prisons may provide an opportunity to engage this high-risk population with effective treatment.

BackgroundMany jurisdictions regularly conduct surveys to estimate the prevalence of problem gambling in their adult populations. However, the comparison of such estimates is problematic due to methodological variations between studies. Total consumption theory suggests that an association between mean electronic gaming machine (EGM) and casino gambling losses and problem gambling prevalence estimates may exist. If this is the case, then changes in EGM losses may be used as a proxy indicator for changes in problem gambling prevalence. To test for this association this study examines the relationship between aggregated losses on electronic gaming machines (EGMs) and problem gambling prevalence estimates for Australian states and territories between 1994 and 2016.MethodsA Bayesian meta-regression analysis of 41 cross-sectional problem gambling prevalence estimates was undertaken using EGM gambling losses, year of survey and methodological variations as predictor variables. General population studies of adults in Australian states and territory published before 1 July 2016 were considered in scope. 41 studies were identified, with a total of 267,367 participants. Problem gambling prevalence, moderate-risk problem gambling prevalence, problem gambling screen, administration mode and frequency threshold were extracted from surveys. Administrative data on EGM and casino gambling loss data were extracted from government reports and expressed as the proportion of household disposable income lost.ResultsMoney lost on EGMs is correlated with problem gambling prevalence. An increase of 1% of household disposable income lost on EGMs and in casinos was associated with problem gambling prevalence estimates that were 1.33 times higher [95% credible interval 1.04, 1.71]. There was no clear association between EGM losses and moderate-risk problem gambling prevalence estimates. Moderate-risk problem gambling prevalence estimates were not explained by the models (I2 ≥ 0.97; R2 ≤ 0.01).ConclusionsThe present study adds to the weight of evidence that EGM losses are associated with the prevalence of problem gambling. No patterns were evident among moderate-risk problem gambling prevalence estimates, suggesting that this measure is either subject to pronounced measurement error or lacks construct validity. The high degree of residual heterogeneity raises questions about the validity of comparing problem gambling prevalence estimates, even after adjusting for methodological variations between studies.

A survey of U.K. secondary school children (aged 11–16 years) was undertaken to enquire into the prevalence of adolescent gambling and pathological gambling on fruit machines, and related behaviours. Sixty-two percent of the children gambled on fruit machines, 17.3% at least weekly and 5.7% pathologically. Pathological fruit machine gambling was correlated with gambling for money on other games, cigarette and alcohol use, video playing, parental gambling, playing alone and an early start (8 years or younger). It was not correlated with age, gender or religion, and only weakly with parental occupation. The implications of the findings for future research and social policy are discussed.