Relapse in disordered gambling: a systematic review from a biopsychosocial perspective

In Japan, problem gambling has been assumed to be a serious issue, but until recently, no reliable epidemiological data for the country have been available. In 2017, the first national survey focusing on gambling behavior and gambling disorder (GD) was conducted. Study participants comprised 10 000 Japanese men and women aged 18 years or older, selected using stratified two-step random sampling. Results estimated the lifetime prevalence of GD, using the Japanese version of the South Oaks Gambling Screen (SOGS), as 3.8% and the prevalence for the previous 12 months as 0.8%.1 Prior to this, the SOGS included in a national survey on drinking behavior conducted in 2013 revealed an even higher estimated lifetime prevalence of GD – 4.8%.1 According to a recent review, the 12-month prevalence is comparable to reported estimates in other countries, while the lifetime prevalence tends to be higher.2 Of the different types of gambling and amusement activities, the greatest contributor to this heightened prevalence of GD has been pachinko and slot machines in pachinko parlors called ‘pachi-slot.’ Although the market size of pachinko/pachi-slot has declined, it still generated approximately ¥21 trillion in Japan in 2019, accounting for 3.7% of GDP. One small-scale study reported that about 90% of GD treatment seekers were addicted to pachinko/pachi-slot with similar findings replicated.3 It was in this context that the Japanese government legalized casinos in venues described as integrated resorts (IR), with the aim of revitalizing local economies. The relevant legislation – the IR Promotion Act and the IR Implementation Act – were enacted in 2016 and 2018, respectively. Included in the 2018 act were measures intended to prevent GD, including: (i) a casino admission fee of ¥6000; (ii) the number of entries permitted for Japanese nationals and foreign residents restricted to three in a 7-day period and 10 in a 28-day period; and (iii) self-exclusion and family exclusion systems (individuals or their families could voluntarily register to be barred from entering casinos). Three IR sites will be chosen by the government and the casinos are expected to begin operating by the mid-2020s. Casinos have struggled to attract public support in Japan, as reflected in opinion polls conducted by various mass media outlets. A major concern is that casinos will exacerbate preexisting health and social issues related to GD. To address concerns, the government enacted the Basic Act on Measures Against Gambling Addition immediately prior to the IR Implementation Act becoming law. In April 2019 the Cabinet approved a plan for the implementation of this act, which has since been executed. This plan appears comprehensive. It includes self-regulation of existing gambling providers, including pachinko, horse-, bicycle-, motorcycle-, and boat-racing operators. It also includes other important measures, such as improvement of consultation and treatment services, manpower development, measures on gambling debt, societal support, and promotion of gambling-related research. A major deficiency, however, is the lack of regulations pertaining to gambling providers. The act is expected to be amended to include measures focusing on casino-related problems. We anticipate the successful implementation of these measures at both the national and local level. One of our responsibilities is to monitor their actual effectiveness and the extent of gambling-related problems, which will contribute to improved understanding of measures targeting GD in Japan and around the globe.

Association of cognitive distortions with problem and pathological gambling in adult male twins

Psychosocial characteristics of adolescent problem gambling

Background and aimsProblem gambling has been identified as an emergent public health issue, and there is a need to identify gambling trends and to regularly update worldwide gambling prevalence rates. This paper aims to review recent research on adult gambling and problem gambling (since 2000) and then, in the context of a growing liberalization of the gambling market in the European Union, intends to provide a more detailed analysis of adult gambling behavior across European countries.MethodsA systematic literature search was carried out using academic databases, Internet, and governmental websites.ResultsFollowing this search and utilizing exclusion criteria, 69 studies on adult gambling prevalence were identified. These studies demonstrated that there are wide variations in past-year problem gambling rates across different countries in the world (0.12–5.8%) and in Europe (0.12–3.4%). However, it is difficult to directly compare studies due to different methodological procedures, instruments, cut-offs, and time frames. Despite the variability among instruments, some consistent results with regard to demographics were found.Discussion and conclusionThe findings highlight the need for continuous monitoring of problem gambling prevalence rates in order to examine the influence of cultural context on gambling patterns, assess the effectiveness of policies on gambling-related harms, and establish priorities for future research.

In the psychological literature, many studies have investigated the neuropsychological and behavioral changes that occur developmentally during adolescence. These studies have consistently observed a deficit in the decision-making ability of children and adolescents. This deficit has been ascribed to incomplete brain development. The same deficit has also been observed in adult problem and pathological gamblers. However, to date, no study has examined decision-making in adolescents with and without gambling problems. Furthermore, no study has ever examined associations between problem gambling, decision-making, cognitive distortions and alcohol use in youth. To address these issues, 104 male adolescents participated in this study. They were equally divided in two groups, problem gamblers and non-problem gamblers, based on South Oaks Gambling Screen Revised for Adolescents scores. All participants performed the Iowa gambling task and completed the Gambling Related Cognitions Scale and the alcohol use disorders identification test. Adolescent problem gamblers displayed impaired decision-making, reported high cognitive distortions, and had more problematic alcohol use compared to non-problem gamblers. Strong correlations between problem gambling, alcohol use, and cognitive distortions were observed. Decision-making correlated with interpretative bias. This study demonstrated that adolescent problem gamblers appear to have the same psychological profile as adult problem gamblers and that gambling involvement can negatively impact on decision-making ability that, in adolescence, is still developing. The correlations between interpretative bias and decision-making suggested that the beliefs in the ability to influence gambling outcomes may facilitate decision-making impairment.

Depression Research and Treatment has issued a second compendium of papers focused on temperament, character, and depression. The psychobiology theory of personality proposed by Cloninger is a currently prevailing theory of personality that has been extensively investigated in the context of many different types of mental and personality disorders. This special issue reports up-to-date research findings on the psychobiology theory and depression from different countries. The current issue consists of six reports. Miettunen and colleagues in Finland present findings from a longitudinal birth cohort study (N = 4941). Participants with depression at 31 years of followup had higher rates of harm avoidance (HA) than participants without any psychiatric disorders. Participants without any psychiatric history were followed for another 12 years. Those who subsequently developed depression had high HA in 1997. The authors hypothesize that high HA is a potential indicator for subsequent depression. This study only used temperament scales and thus no information was available on the association between character and depression. Students in senior high schools (N = 1234) who were invited to participate in an internet-based intervention program for depression were studied by Christian and colleagues in Norway. High HA and low self-directedness (SD) emerged as strong predictors of adolescent depression. Interestingly, use of the internet intervention program was associated with low reward dependence (RD) in addition to depression severity. Garcia and colleagues studied an adolescent population (N = 304) in Sweden. Based on positive affect (PA) and negative affect (NA) scores derived from the Positive Affect and Negative Affect Schedule, the participants were categorized into four groups: self-fulfilling (high PA and low NA), high affective (high PA and high NA), low affective (low PA and low NA), and self-destructive (low PA and high NA). The self-fulfilling group was characterized by higher persistence (PS), SD, and cooperativeness (CO) than the three other groups. The self-destructive group was characterized by high HA and RD. The authors claim character maturity (expressed as high SD and CO) is important for psychological well-being. In Japan, Lu and colleagues followed graduate students (N = 184) on two occasions separated by a five-month interval. In a structural regression model, they posited that trait anxiety and depression constructs were linked to high HA and low SD. Although trait anxiety and depression scores were moderately correlated with each other, these two constructs showed different associations with Temperament and Character Inventory (TCI) subscale scores. Thus, trait depression was linked to high self-transcendence (ST) whereas trait anxiety was linked to low RD, PS, and CO. The authors claim that character maturity is linked to trait rather than state aspects of depression and anxiety. Directly exposed survivors of the Oklahoma City bombing randomly selected from a bombing survivor registry (N = 151) were examined by North and colleagues in the USA. Posttraumatic stress disorder (PTSD) after the bombing was associated with low SD and CO together with high ST and HA. Postdisaster major depression (MD) was more prevalent among those with PTSD than those without it, but low SD and CO could not be predicted by post-disaster MD. The authors emphasized the importance of developing and validating measures of resilience. A unique measure of temperament, the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS), was used by Tei-Tominaga and colleagues to study job stress among employees in one Japanese company (N = 728). Depression was predicted by high levels of cyclothymic and anxious temperament traits even after controlling for the effects of work-related stressors such as demanding work conditions and overcommitment. These articles all indicate the importance of temperament and character traits in the development of depression among a variety of populations across different countries. Despite some differences between the studies, a common theme may be that low SD and high HA are predictors of depression either directly or being mediated by third variables. Toshinori Kitamura C. Robert Cloninger Andrea Fossati Jorg Richter

To identify Gambling Disorder (GD) subtypes, in a population of men seeking treatment for GD, according to specific executive function domains (i.e., cognitive flexibility, inhibition and working memory as well as decision making) which are usually impaired in addictive behaviors. A total of 145 males ranging from 18 to 65years diagnosed with GD were included in this study. All participants completed: (a) a set of questionnaires to assess psychopathological symptoms, personality and impulsivity traits, and (b) a battery of neuropsychological measures to test different executive functioning domains. Two clusters were identified based on the individual performance on the neuropsychological assessment. Cluster 1 [n=106; labeled as Low Impaired Executive Function (LIEF)] was composed by patients with poor results in the neuropsychological assessment; cluster 2 patients [n=46; labeled as High Impaired Executive Function (HIEF)] presented significantly higher deficits on the assessed domains and performed worse than the ones of LIEF cluster. Regarding the characterization of these two clusters, patients in cluster 2 were significantly older, unemployed and registered higher mean age of GD onset than patients in cluster 1. Additionally, patients in cluster 2 also obtained higher psychopathological symptoms, impulsivity (in both positive and negative urgency as well as sensation seeking) and some specific personality traits (higher harm avoidance as well as lower self-directedness and cooperativeness) than patients in cluster 1. The results of this study describe two different GD subtypes based on different cognitive domains (i.e., executive function performance). These two GD subtypes display different impulsivity and personality traits as well as clinical symptoms. The results provide new insight into the etiology and characterization of GD and have the potential to help improving current treatments.

Background: Gambling addiction was the first addictive behavior not related to substance use that was recognized by the DSM-5. It shares diagnostics and comorbidity with other addictions. Extensive studies have investigated the clinical variables involved, but there have been fewer studies of related cognitive and social variables. In this research, an integrative model was developed to advance the understanding of gambling addiction, and an explanatory model was created based on the concept of cognitive distortions. Methods: The sample comprised 258 university students (59.5% women) with a mean age of 20.95 years (SD = 2.19). A series of questionnaires were administered to measure gambling addiction, depression, coping with stress, prosocial behavior, susceptibility to priming and cognitive distortions about gambling. In addition, correlations, multiple linear regressions and a simple mediation model of these variables were analyzed. Results: The results indicated that gambling addiction was correlated with a variety of clinical, social and cognitive factors. These factors contributed to a model that predicted 16.8% of the variance in gambling addiction and another model using cognitive distortions as a predictor and the maximum bet as a mediator that predicted 34.5% of the variance. Conclusions: The study represents an advance by developing a theoretical model from an integrative perspective and providing a new explanatory model. The findings of this research are of great importance in the development of prevention and intervention programs for gambling addiction.

The goal of the present systematic review is to identify emerging gambling problems and the harm minimization strategies proposed to address them. Our interdisciplinary research team conducted this systematic literature review in 5 nations between which there is significant gambling research exchange. A keyword search of the Scopus and Web of Science databases followed by filtering using inclusion criteria identified 1292 empirical gambling studies from peer-reviewed journals. The data obtained from the articles were analyzed using the content analysis technique. We then used a unique approach to identify relationships between harm minimization strategies and gambling problems. The findings reveal that the most frequently reported gambling problems are related to young gamblers, online gambling, electronic gaming machines, and children and adolescents (underage gamblers). Harm minimization strategies to address these included creating educational and awareness programs, further restrictions on gambling advertising, developing an intervention mechanism for online gambling, and remote gambling-related help (i.e., online counseling, online treatment).

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

Cognitive distortions have been thought to play an important role in the development and maintenance of pathological gambling. The present study investigated whether severity of gambling problems and gamblers' preference for chance or skill games were related to two sub-factors of cognitive distortions as measured by the Gamblers Belief Questionnaire: Luck/Perseverance, which reflects an individual's perception that chance is favorable to him/her, and Illusion of Control, which reflects an individual's perception that his/her behavior influences chance occurrences. Participants (N = 166) were recruited from a race track (n = 79), off-course betting facilities (n = 50) and from an online treatment program for problem gamblers (n = 49). Gambling severity was measured by the South Oaks Gambling Screen, and 73 were classified as pathological gamblers whereas 93 were classified as non-pathological gamblers. The present study supports previous proposals that cognitive distortions are core processes related to gambling behavior as pathological gamblers reported more cognitive distortions than did non-pathological gamblers. A preference for skill games was also associated with greater Illusion of Control compared to a preference for chance games. For gamblers preferring skill games there were no differences in Luck/Perseverance or Illusion of Control between pathological and non-pathological gamblers.

Aims: Due to the increasing evidence of shared vulnerabilities between addictive behaviors and excessive food intake, the concept of food addiction in specific clinical populations has become a topic of scientific interest. The aim of this study was to validate the Yale Food Addiction Scale (YFAS) 2.0 in a Spanish sample. We also sought to explore food addiction and its clinical correlates in eating disorder (ED) and gambling disorder (GD) patients.Methods: The sample included 301 clinical cases (135 ED and 166 GD), diagnosed according to DSM-5 criteria, and 152 healthy controls (HC) recruited from the general population.Results: Food addiction was more prevalent in patients with ED, than in patients with GD and HC (77.8, 7.8, and 3.3%, respectively). Food addiction severity was associated with higher BMI, psychopathology and specific personality traits, such as higher harm avoidance, and lower self-directedness. The psychometrical properties of the Spanish version of the YFAS 2.0 were excellent with good convergent validity. Moreover, it obtained good accuracy in discriminating between diagnostic subtypes.Conclusions: Our results provide empirical support for the use of the Spanish YFAS 2.0 as a reliable and valid tool to assess food addiction among several clinical populations (namely ED and GD). The prevalence of food addiction is heterogeneous between disorders. Common risk factors such as high levels of psychopathology and low self-directedness appear to be present in individuals with food addiction.

Understanding how emotion regulation and gambling-related cognitive distortions relate to gambling problems has direct relevance for problem gambling prevention and treatment. Although these factors have been identified as robust psychological correlates for problem gambling, the interplay between emotional regulation and cognitive biases in influencing problem gambling behaviours is yet to be fully understood. Accordingly, this study examined the explanatory role of cognitive distortions in the association between emotion regulation difficulties and problem gambling behaviours and also explored the interaction between emotion regulation and cognitive distortions in predicting gambling severity. A total of 301 adults (182 males and 119 females; age range: 18-71years, M = 32.62, SD = 10.03) completed an online questionnaire comprising measures of emotional regulation difficulties, gambling-related beliefs and problem gambling severity. Analyses revealed that emotion regulation difficulties and erroneous gambling beliefs were positively related to problem gambling severity. Further, cognitive distortions partially accounted for the relationship between emotional regulation difficulties and problem gambling, although emotion regulation retained a direct relationship with problem gambling. There was no interaction between emotional regulation and cognitive distortions. The findings indicate that emotion regulation may serve as a precursor to the development of cognitive distortions, while also directly influencing problem gambling. Implications for assessment and treatment of problem gambling are discussed.

Background and aimsMental disorders with high levels of impulsivity such as bulimic spectrum eating disorders (BSED) and gambling disorder (GD) are associated with high risk of suicidal behavior. The aim of the present study was to identify the common and differential vulnerability factors behind suicide attempts in a sample of patients with BSED compared to patients with GD.MethodsA total of 6,077 adults who sought treatment and met criteria either for BSED (n = 2,391) or GD (n = 3,686) were assessed at a specialized hospital unit. Personality traits, psychopathological symptomatology, lifetime history of suicide attempts and socio-demographic variables were evaluated.ResultsThe prevalence of suicide attempts was higher for BSED patients (26.2%) compared to GD patients (7.1%) being anorexia nervosa (Binge/Purge type) and bulimia nervosa the most affected subtypes. In the predictive model, the transdiagnostic vulnerability factors with the highest contribution to the risk of suicidal behavior both in BSED and GD were unemployment, early age of onset of the disorder, worse psychopathological state, and self-transcendence personality trait. However, specific risk factors for suicidal acts were identified in each disorder: longer duration of the disorder, lower education levels and reward dependence were exclusively associated with BSED while female gender, older age, and higher harm avoidance were associated with GD.DiscussionPatients with GD and BSED share certain vulnerability factors although certain factors are exclusive to each disorder.ConclusionsInterventions need to pay special attention to both common and specific vulnerability factors to mitigate the risk of suicidal acts in these disorders.

The transition time to gambling disorder: The roles that age, gambling preference and personality traits play