Pathological Gambling Disorder Research Articles

Demographic and Clinical Features of 150 Pathological Gamblers Referred to a Community Addictions Programme

Pathological gambling has been defined as a persistent and recurrent maladaptive gambling behaviour that disrupts personal, family and work life. The present study reports on the sociodemographic features, gambling activity, comorbidity and legal problems in a sample of 150 pathological gamblers who sought treatment from the Community Addiction Management Programme (CAMP), Singapore over a 4-year period from 2002 to 2006. Data were collected on 150 consecutive subjects who sought treatment at CAMP. Patients were administered a semi-structured interview to elicit demographic data, age of onset, family history, onset games and types of games ever played, largest debt incurred due to gambling, triggers, illegal activities and suicidal attempts by their counsellor. Patients were then assessed by the clinicians to establish the primary and comorbid diagnoses. The mean age of the subjects was 42.5 [standard deviation (SD) 10.2] years. The majority of them were males (87.3%) and of Chinese origin (97.3%). The most common comorbid disorders were mood disorders (n = 22, 14.7%), substance abuse (n = 11, 7.3%) and alcohol abuse or dependence (n = 7, 4.7%). Sixteen (10.7%) subjects had a history of suicidal attempts which had been precipitated by gambling-related issues. Pathological gambling in our subjects appears to be associated with significant comorbidity and financial problems. These are the preliminary findings and further research is needed regarding the phenomenology, profile, course and response to treatment of pathological gambling disorders.

Drs. Barzman and DelBello Reply

Back to table of contents Previous article Next article Letters to the EditorFull AccessDrs. Barzman and DelBello ReplyDREW H. BARZMAN M.D.MELISSA P. DelBello M.D., M.S.,DREW H. BARZMAN M.D.Search for more papers by this authorMELISSA P. DelBello M.D., M.S.Search for more papers by this author,Published Online:1 Mar 2007https://doi.org/10.1176/ajp.2007.164.3.527AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Although the underlying biology of binge eating disorder, borderline personality disorder, pathological gambling, and disruptive behavior disorders remains largely unknown, our clinical observations, along with randomized controlled data, have shown that topiramate is effective for treating these psychiatric disorders, which are phenomenologically linked by impulse dyscontrol (1 – 4) . Furthermore, following our case report (5) , there have been two open-label studies confirming our preliminary finding that topiramate is effective for the treatment of disruptive and impulsive behavior in children and adolescents with psychiatric illnesses (6 – 7) . Additionally, in contrast to the statement by Drs. Kruszewski and Klotz, a review of the literature reveals that the aforementioned disorders may be genotypically related. For example, the G allele of the 5H-T2A receptor gene (1438A/G polymorphism) is associated with both binge eating and borderline personality disorder (8) . More strikingly, a specific gene, GABRA2, has been associated with conduct disorder and adult alcohol dependence (9) . Finally, topiramate is a novel broad-spectrum anticonvulsant that inhibits glutamate activity at a subtype of glutamate receptors and augments the effects of GABA receptor subtypes (GABA A ) (10) . Therefore, contrary to the assertion by Drs. Kruszewski and Klotz, topiramate may be effective for impulse control disorders through its effect on glutamate as well as other receptors (11) . We agree that it is important to consider both efficacy and tolerability when prescribing any medication. However, topiramate is generally well tolerated in children and adolescents. In fact, data suggest that topiramate may be better tolerated in children and adolescents than in adults (12) ; for example, only 14% of 56 children and adolescents experienced paresthesia, and 14% experienced somnolence in a recent double-blind placebo controlled trial of topiramate for pediatric mania (13) . Cincinnati, OhioDr. Barzman has received support (research, consulting fee and/or speaker fees) from AstraZeneca, Pfizer, Eli Lilly, and Jannsen. Dr. DelBello has received support (research, consulting fee, and/or speaker fees) from Abbott Laboratories, AstraZeneca, Eli Lilly, Johnson and Johnson, Shire, Pfizer, Bristol Myers Squibb, and GlaxoSmithKline.

Drs. Barzman and DelBello Reply

Back to table of contents Previous article Next article Letters to the EditorFull AccessDrs. Barzman and DelBello ReplyDREW H. BARZMAN M.D.MELISSA P. DelBello M.D., M.S.,DREW H. BARZMAN M.D.Search for more papers by this authorMELISSA P. DelBello M.D., M.S.Search for more papers by this author,Published Online:1 Mar 2007https://doi.org/10.1176/ajp.2007.164.3.527AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Although the underlying biology of binge eating disorder, borderline personality disorder, pathological gambling, and disruptive behavior disorders remains largely unknown, our clinical observations, along with randomized controlled data, have shown that topiramate is effective for treating these psychiatric disorders, which are phenomenologically linked by impulse dyscontrol (1 – 4) . Furthermore, following our case report (5) , there have been two open-label studies confirming our preliminary finding that topiramate is effective for the treatment of disruptive and impulsive behavior in children and adolescents with psychiatric illnesses (6 – 7) . Additionally, in contrast to the statement by Drs. Kruszewski and Klotz, a review of the literature reveals that the aforementioned disorders may be genotypically related. For example, the G allele of the 5H-T2A receptor gene (1438A/G polymorphism) is associated with both binge eating and borderline personality disorder (8) . More strikingly, a specific gene, GABRA2, has been associated with conduct disorder and adult alcohol dependence (9) . Finally, topiramate is a novel broad-spectrum anticonvulsant that inhibits glutamate activity at a subtype of glutamate receptors and augments the effects of GABA receptor subtypes (GABA A ) (10) . Therefore, contrary to the assertion by Drs. Kruszewski and Klotz, topiramate may be effective for impulse control disorders through its effect on glutamate as well as other receptors (11) . We agree that it is important to consider both efficacy and tolerability when prescribing any medication. However, topiramate is generally well tolerated in children and adolescents. In fact, data suggest that topiramate may be better tolerated in children and adolescents than in adults (12) ; for example, only 14% of 56 children and adolescents experienced paresthesia, and 14% experienced somnolence in a recent double-blind placebo controlled trial of topiramate for pediatric mania (13) . Cincinnati, OhioDr. Barzman has received support (research, consulting fee and/or speaker fees) from AstraZeneca, Pfizer, Eli Lilly, and Jannsen. Dr. DelBello has received support (research, consulting fee, and/or speaker fees) from Abbott Laboratories, AstraZeneca, Eli Lilly, Johnson and Johnson, Shire, Pfizer, Bristol Myers Squibb, and GlaxoSmithKline.

Gambling and Substance Use Disorders: Current Status and Future Directions

This paper briefly reviews the clinical presentation of pathological gambling and presents data related to the co-occurrence of pathological gambling and substance use disorders. Both epidemiological and treatment data are reviewed. The putative physiological substrates underlying pathological gambling are described, along with the limited genetics data. Types of treatments applied to gamblers are described, including data on efficacy and overlap of issues that relate to both gambling and substance use disorders. Finally, areas for future research are suggested to advance our understanding of pathological gambling and its relationship to substance use disorders.

Pharmacotherapy of pathological gambling: review of new treatment modalities

Pathological gambling is classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition as an impulse-control disorder. In the International Classification of Diseases of the WHO, pathological gambling is coded under the heading of ‘Habit and Impulse Disorders’. Pathological gambling is a chronic, progressive disorder, which has a prevalence of 1–3.4% among western civilizations. The enormous personal and social consequences of this disorder include a high rate of suicide attempts, job loss, marital and family problems, legal problems, and criminal behavior. Recent studies have demonstrated that pathological gambling patients respond well to treatment with selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists. These findings support the idea that pathological gambling and other disorders of impulse control may be conceptualized as part of the obsessive–compulsive spectrum disorders or addictive disorders. This article will discuss possible treatment strategies according to different behavior patterns in pathological gambling and also remind the physicians who intend to treat this disorder of the possible diagnosis of pathological gambling.

Language and Addiction

Back to table of contents Previous article Next article Letters to the EditorFull AccessLanguage and AddictionSHANNON C. MILLER M.D., F.A.S.A.M., F.A.P.A., C.M.R.O.,SHANNON C. MILLER M.D., F.A.S.A.M., F.A.P.A., C.M.R.O.Search for more papers by this author,Published Online:1 Nov 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I wish to support the editorial published by Dr. O"Brien et al. Clearly, our field of addiction medicine has been plagued by problematic language (1) . As the authors point out in their editorial, this affects the interaction between patient and clinician when dealing with pain and prescribing. However, the impact of such language on the practice of addiction medicine extends to two larger, and arguably more pervasive, issues in clinical practice. In my experience, the use of the term “dependence” when working with patients with addiction disorders is highly problematic to the earliest stages of developing a therapeutic alliance and helping the patient gain insight into her/his disease. When patients hear this term applied to them, they often have difficulty internalizing this term as an accurate descriptor of their substance use. When asked how they themselves would define the clinical appearance of someone who is “substance dependent,” they often focus more on physical manifestations of the illness (tolerance and withdrawal). Not surprisingly then, they describe an individual who daily uses or needs the drug regularly in order to display adaptive psychosocial functioning. This observation appears most pronounced for patients in the precontemplation or contemplation stages of change. Moreover, when asked to describe someone who is “addicted” to a substance, more accurate descriptions are given, including discussions about the behavioral and psychological manifestations of the illness. A second additional problem this term creates is that its use automatically excludes nonsubstance-related behaviors from future consideration for a diagnosis of addiction; the best example being pathological gambling disorder. The categorization of pathological gambling has been previously debated in DSM planning meetings: Is it an impulse control disorder or in the same diagnostic cluster as substance use disorders (2) ? Pathological gambling disorder has been increasingly defined by scientific and biological findings akin to substance use disorders, arguing for its diagnostic reclassification. Moreover, it has been recognized as perhaps one of the best sources of study for addiction disorders in humans because it is devoid of drug (of abuse) effects which may confound biological research findings (3) . I support the authors’ timely discussion toward re-assessing the DSM’s language prior to its next revision. Replacing “substance use disorders” with “addiction disorders” could benefit not only the care of patients with pain, but could also enhance the patient’s understanding and acceptance of their newly diagnosed disease as well as open future options with respect to potential nondrug addictions and their classification.Cincinnati, Ohio

Please, Not “Addiction” in DSM-V

Back to table of contents Previous article Next article Letters to the EditorFull AccessPlease, Not “Addiction” in DSM-VCARLTON K. ERICKSON PH.D.RICHARD E. WILCOX PH.D.,CARLTON K. ERICKSON PH.D.Search for more papers by this authorRICHARD E. WILCOX PH.D.Search for more papers by this author,Published Online:1 Nov 2006https://doi.org/10.1176/ajp.2006.163.11.2015aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the May 2006 issue of the Journal , Drs. O’Brien, Volkow, and Li touch on a very serious issue regarding the proper labeling of a drug-induced brain disease known as either “addiction” or “dependence.” We agree with the authors’ concerns and with the need to have a better word than “dependence” in the DSM-V. However, “addiction” is not the word. “Addiction” is unscientific, overused, misunderstood (e.g., addicted to my cell-phone), and clinically inaccurate (e.g., addicting antidepressants). What we have found in working with people in recovery is that the word is incredibly stigmatizing. The popular press is flooded with stories of crack-addicted babies and heroin addicts being thrown in jail. Sadly, in everyday use, “addiction” fails to differentiate between the medical (brain) disease associated with drug use by at-risk people and over-involvement with drugs (abuse) or activities.Stigma-driven discrimination is seen when those with “addiction” cannot use our newest scientific advances in treatment because of insurance problems. Stigmatization is one reason we have insufficient research dollars for the study of drug actions on the brain. We fear that continued use of the term “addiction” would forever prevent society from destigmatizing this chronic medical illness.Our Center faculty believes that the answer lies in proper education regarding the now-diagnosable differences between pathological chemical dependence and “bad-choice” drug abuse. We indicate that the old (1950) World Health Organization terms “psychological dependence” and “physical dependence” are outmoded and are being phased out. We teach that the term “dependence” is a specific descriptor of the adapted brain state studied so intensively by neuroscientists (1) . Our publications on neuroscience-based workshops clearly show that these professionals “get it” (2) . We believe the field terminology is changing (e.g., gambling “addiction” has been replaced in many treatment centers with “pathological gambling disorder”). To reduce confusion about “dependence,” the use of a qualifier such as “chemical dependence” could be used. It is only through such diagnosable (and clearly articulated) distinctions that we can hope to convince policy makers and the public that a major drug-overuse problem we are treating is truly a chronic medical illness (called “chemical dependence”), for which we need more treatment and research funds.Austin, Tex.

Epidemiologic and clinical updates on impulse control disorders: a critical review.

The article reviews the current knowledge about the impulse control disorders (ICDs) with specific emphasis on epidemiological and pharmacological advances. In addition to the traditional ICDs present in the DSM-IV—pathological gambling, trichotillomania, kleptomania, pyromania and intermittent explosive disorder—a brief description of the new proposed ICDs—compulsive–impulsive (C–I) Internet usage disorder, C–I sexual behaviors, C–I skin picking and C–I shopping—is provided. Specifically, the article summarizes the phenomenology, epidemiology and comorbidity of the ICDs. Particular attention is paid to the relationship between ICDs and obsessive–compulsive disorder (OCD). Finally, current pharmacological options for treating ICDs are presented and discussed.

Topiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior Disorders

Back to table of contents Previous article Next article Letters to the EditorFull AccessTopiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior DisordersDREW H. BARZMAN M.D.MELISSA P. DELBELLO M.D.,DREW H. BARZMAN M.D.Search for more papers by this authorMELISSA P. DELBELLO M.D.Search for more papers by this author,Published Online:1 Aug 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Although studies have suggested that topiramate is helpful in the treatment of bipolar disorder, no study, to our knowledge, has examined its usefulness in treating co-occurring bipolar disorder and disruptive behavior disorders in children and adolescents (1) . The literature on co-occurring bipolar disorder and disruptive behavior disorders is rather limited. In our case study presented here, we defined response with an endpoint Clinical Global Impression (CGI) improvement rating of 1 (“very much improved”) or 2 (“much improved”) for both mania and overall illness (including bipolar disorder and disruptive behavior disorders). Six (67%) out of nine of our hospitalized patients (ages 10 to 14) with bipolar disorder and disruptive behavior disorders responded to adjunctive topiramate with good tolerability. The mean dose was 78 mg/day (range=50–150 mg/day).“Miss A” was a 14-year-old African American girl with conduct disorder, bipolar disorder, and reactive attachment disorder. She had no history of substance abuse. She was arrested for domestic violence and had a history of lying, running away, felony assault, stealing, carrying firearms, truancy, destroying property, and arson. Approximately 2 months prior to being detained in juvenile detention, the patient had discontinued her medications, which included haloperidol, aripiprazole, quetiapine, and glucophage because of weight gain. She subsequently lost approximately 40 pounds. While in juvenile detention, the patient continued to display prominent disruptive behaviors of arguing, physical fighting, destroying property, deceitfulness, oppositionality, and defiance. Besides mood lability, distractibility, and acts of self-harm, there was no evidence of depression or mania. The patient refused mood stabilizers and atypical antipsychotics because of the possibility of weight gain.Doses of topiramate started at 25 mg once in the morning for 5 days and then increased to 25 mg twice daily. After 15 days taking 50 mg/day, the patient’s dose of topiramate was increased to 25 mg in the morning and 50 mg at bedtime. For the next 7 days, she was administered a dose of 75 mg/day and had no behavioral outbursts. She became more cooperative with staff and did not require restraints. The staff noted a significant improvement in her disruptive behaviors as well.Although her mania was much improved, she continued to display some emotional lability and distractibility. Therefore, her disruptive behavior symptoms improved independently and more significantly than her mood-related symptoms. She had CGI improvement ratings of 2 for mania and 1 for overall illness. Despite her reports of poor concentration and transient hyperactivity, there was no evidence for these or other side effects, such as weight gain or difficulties with verbal communication.As illustrated, topiramate monotherapy may be effective in treating disruptive behavior disorders, independent from its therapeutic effect for mania that is possibly related to its efficacy in decreasing impulsivity in binge eating disorder, borderline personality disorder, and pathological gambling disorder in adults. Because of a favorable side effect profile, including possible weight loss, medication compliance may be less of a problem. Further randomized controlled studies of adjunctive and monotherapy topiramate treatment are needed. Future studies should assess aggression as an outcome measure with the Overt Aggression Scale.Cincinnati, OhioReference1. Barzman DH, DelBello MP, Kowatch RA, Warner J, Rofey D, Stanford K, Rappaport K, Daniels JP, Strakowski SM: Adjunctive topiramate in hospitalized pediatric patients with bipolar disorders. J Child Adolesc Psychopharmacol 2005; 15:931–937Google Scholar FiguresReferencesCited byDetailsCited ByTopiramate augmentation of clozapine in schizophrenia: a double-blind, placebo-controlled study8 July 2010 | Journal of Psychopharmacology, Vol. 25, No. 5Determination of plasma topiramate concentration using LC-MS/MS for pharmacokinetic and bioequivalence studies in healthy Korean volunteersBiomedical Chromatography, Vol. 22, No. 8Medical Management of Pediatric Mood DisordersPediatric Annals, Vol. 36, No. 9Pharmacotherapy for Child and Adolescent Mood DisordersPsychiatric Annals, Vol. 37, No. 7Effects of TopiramateSTEFAN P. KRUSZEWSKIM.D.,STEVEN G. KLOTZM.D.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Drs. Barzman and DelBello ReplyDREW H. BARZMAN, M.D.MELISSA P. DelBelloM.D., M.S.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Current awareness: Pharmacoepidemiology and drug safety1 January 2007 | Pharmacoepidemiology and Drug Safety, Vol. 16, No. 2 Volume 163Issue 8 August, 2006Pages 1451-1452THE AMERICAN JOURNAL OF PSYCHIATRY August 2006 Volume 163 Number 8 Metrics PDF download History Published online 1 August 2006 Published in print 1 August 2006

Topiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior Disorders

Back to table of contents Previous article Next article Letters to the EditorFull AccessTopiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior DisordersDREW H. BARZMAN M.D.MELISSA P. DELBELLO M.D.,DREW H. BARZMAN M.D.Search for more papers by this authorMELISSA P. DELBELLO M.D.Search for more papers by this author,Published Online:1 Aug 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Although studies have suggested that topiramate is helpful in the treatment of bipolar disorder, no study, to our knowledge, has examined its usefulness in treating co-occurring bipolar disorder and disruptive behavior disorders in children and adolescents (1) . The literature on co-occurring bipolar disorder and disruptive behavior disorders is rather limited. In our case study presented here, we defined response with an endpoint Clinical Global Impression (CGI) improvement rating of 1 (“very much improved”) or 2 (“much improved”) for both mania and overall illness (including bipolar disorder and disruptive behavior disorders). Six (67%) out of nine of our hospitalized patients (ages 10 to 14) with bipolar disorder and disruptive behavior disorders responded to adjunctive topiramate with good tolerability. The mean dose was 78 mg/day (range=50–150 mg/day).“Miss A” was a 14-year-old African American girl with conduct disorder, bipolar disorder, and reactive attachment disorder. She had no history of substance abuse. She was arrested for domestic violence and had a history of lying, running away, felony assault, stealing, carrying firearms, truancy, destroying property, and arson. Approximately 2 months prior to being detained in juvenile detention, the patient had discontinued her medications, which included haloperidol, aripiprazole, quetiapine, and glucophage because of weight gain. She subsequently lost approximately 40 pounds. While in juvenile detention, the patient continued to display prominent disruptive behaviors of arguing, physical fighting, destroying property, deceitfulness, oppositionality, and defiance. Besides mood lability, distractibility, and acts of self-harm, there was no evidence of depression or mania. The patient refused mood stabilizers and atypical antipsychotics because of the possibility of weight gain.Doses of topiramate started at 25 mg once in the morning for 5 days and then increased to 25 mg twice daily. After 15 days taking 50 mg/day, the patient’s dose of topiramate was increased to 25 mg in the morning and 50 mg at bedtime. For the next 7 days, she was administered a dose of 75 mg/day and had no behavioral outbursts. She became more cooperative with staff and did not require restraints. The staff noted a significant improvement in her disruptive behaviors as well.Although her mania was much improved, she continued to display some emotional lability and distractibility. Therefore, her disruptive behavior symptoms improved independently and more significantly than her mood-related symptoms. She had CGI improvement ratings of 2 for mania and 1 for overall illness. Despite her reports of poor concentration and transient hyperactivity, there was no evidence for these or other side effects, such as weight gain or difficulties with verbal communication.As illustrated, topiramate monotherapy may be effective in treating disruptive behavior disorders, independent from its therapeutic effect for mania that is possibly related to its efficacy in decreasing impulsivity in binge eating disorder, borderline personality disorder, and pathological gambling disorder in adults. Because of a favorable side effect profile, including possible weight loss, medication compliance may be less of a problem. Further randomized controlled studies of adjunctive and monotherapy topiramate treatment are needed. Future studies should assess aggression as an outcome measure with the Overt Aggression Scale.Cincinnati, OhioReference1. Barzman DH, DelBello MP, Kowatch RA, Warner J, Rofey D, Stanford K, Rappaport K, Daniels JP, Strakowski SM: Adjunctive topiramate in hospitalized pediatric patients with bipolar disorders. J Child Adolesc Psychopharmacol 2005; 15:931–937Google Scholar FiguresReferencesCited byDetailsCited byTopiramate augmentation of clozapine in schizophrenia: a double-blind, placebo-controlled study8 July 2010 | Journal of Psychopharmacology, Vol. 25, No. 5Determination of plasma topiramate concentration using LC-MS/MS for pharmacokinetic and bioequivalence studies in healthy Korean volunteersBiomedical Chromatography, Vol. 22, No. 8Medical Management of Pediatric Mood DisordersPediatric Annals, Vol. 36, No. 9Pharmacotherapy for Child and Adolescent Mood DisordersPsychiatric Annals, Vol. 37, No. 7Effects of TopiramateSTEFAN P. KRUSZEWSKIM.D.,STEVEN G. KLOTZM.D.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Drs. Barzman and DelBello ReplyDREW H. BARZMAN, M.D.MELISSA P. DelBelloM.D., M.S.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Current awareness: Pharmacoepidemiology and drug safety1 January 2007 | Pharmacoepidemiology and Drug Safety, Vol. 16, No. 2 Volume 163Issue 8 August, 2006Pages 1451-1452THE AMERICAN JOURNAL OF PSYCHIATRY August 2006 Volume 163 Number 8 Metrics PDF download History Published online 1 August 2006 Published in print 1 August 2006

On the Limits of Cross-Sectional Retrospective Data for Characterizing the Course of Pathological Gambling and its Relation With Comorbid Psychopathology: A Reply to Afifi, Cox, and Sareen

TO THE EDITOR: Using two epidemiological surveys, Wendy S. Slutske, PH.D. (1) conducted important investigations on the persistence and chronicity of pathological gambling. Dr. Slutske found that one-third of the pathological gamblers made a “natural recovery” (p. 300), as indicated by the absence of symptoms in the previous year without treatment-seeking for their gambling problems. Dr. Slutske concluded that pathological gambling may not be as chronic and persistent as commonly believed, and results from epidemiological surveys “may eventually overturn the established wisdom about pathological gambling disorder” (p. 301). Further discussion of the findings is necessary. Using the National Epidemiologic Survey on Alcohol and Related Conditions data, the same data used by Dr. Slutske, a separate study by Petry and colleagues found that pathological gambling was highly comorbid with other mental disorders, including alcohol use and mood disorders (2). It is therefore likely that individuals with pathological gambling disorder may seek help for alcohol use or mood disorders and not seek help specifically for their gambling problems. In addition, it is highly plausible that seeking services for alcohol use or mood disorders may improve gambling problems. We conducted an additional analysis using the National Epidemiologic Survey on Alcohol and Related Conditions data to investigate treatment-seeking for alcohol and mood problems among pathological gamblers. Individuals were asked if they had ever sought help 1) for alcohol problems or 2) to improve mood. When considering treatment-seeking for conditions found to be highly comorbid with pathological gambling, a “natural recovery” among pathological gamblers was reduced by approximately one-half, from 34% in the study by Dr. Slutske, to 18% in the current National Epidemiologic Survey on Alcohol and Related Conditionsbased analysis. Although some pathological gamblers are able to overcome their gambling problems, it is important to emphasize that the majority of individuals with a lifetime diagnosis of pathological gambling continue to experience some level of gambling-related problems in the past year. Interestingly, the prognosis of pathological gambling as indicated by Dr. Slutske’s investigation is almost identical to the natural course of other mental disorders such as major depression, with approximately 40% continuing to meet DSM criteria for a diagnosis, 20% meeting subthreshold criteria, and 40% experiencing no symptoms (3). Dr. Slutske’s analytical approach found that 40% of pathological gamblers continued to meet criteria, 22% had subdiagnostic symptoms, and 38% had no symptoms. Therefore, using this criterion to conclude that pathological gambling may not be a chronic disorder would have the same implications for major depression, which is well recognized as being a chronic disorder. Finally, it must be mentioned that Dr. Slutske’s study relied on retrospective data to assess the onset and offset of pathological gambling. Firm conclusions regarding chronicity and persistence will ultimately require the use of longitudinal prospective data. We hope that our commentary and additional analysis contribute to the important ongoing discussion of pathological gambling initiated by Dr. Slutske.

An Insider's Look into the Process of Recovering from Pathological Gambling Disorder: An Existential Phenomenological Inquiry

An existential phenomenological method of study was implemented to better understand the recovery process of 11 pathological gamblers. After analysis, seven recovery themes were generated, which brought to light that recovery from pathological gambling may take place over several years and cycle through successive stages. These stages demonstrate and suggest that recovering from pathological gambling is more cyclical and spiral in nature as opposed to being linear, and is reflective of a continuous, ever evolving process. Specifically, recovering from pathological gambling may take place over several years and cycle through stages of heavy gaming, periods of abstinence, relapse, and re-commitment to recovery, with the recovering gambler gradually moving towards stability through embracing the flow of life and a new identity, and over time finding meaning through extending hope to other troubled gamblers.

Natural Recovery and Treatment-Seeking in Pathological Gambling: Results of Two U.S. National Surveys

Pathological gambling is described in DSM-IV as a chronic and persisting disorder, but recent community-based longitudinal studies that have highlighted the transitory nature of gambling-related problems have called into question whether this is an accurate characterization. This emerging evidence of high rates of recovery coupled with low rates of treatment-seeking for pathological gambling suggests that natural recovery might be common. The purpose of the present study was to document the rates of recovery, treatment-seeking, and natural recovery among individuals with DSM-IV pathological gambling disorder in two large and representative U.S. national surveys. Prevalences of recovery, treatment-seeking, and natural recovery were estimated among individuals from the Gambling Impact and Behavior Study (N=2,417) and the National Epidemiologic Survey on Alcohol and Related Conditions (N=43,093) who reported a lifetime history of DSM-IV pathological gambling disorder (N=21 and N=185, respectively). Among individuals with a lifetime history of DSM-IV pathological gambling, 36%-39% did not experience any gambling-related problems in the past year, even though only 7%-12% had ever sought either formal treatment or attended meetings of Gamblers Anonymous. About one-third of the individuals with pathological gambling disorder in these two nationally representative U.S. samples were characterized by natural recovery. Pathological gambling may not always follow a chronic and persisting course. A substantial portion of individuals with a history of pathological gambling eventually recover, most without formal treatment. The results of large epidemiological surveys of pathological gambling may eventually overturn the established wisdom about pathological gambling disorder.

Using Problem Gambling Helpline Data to Inform Addiction Education

ABSTRACT There appears to be an association between substance use and pathological gambling disorders in the research. This will present concerns for clinicians in substance use treatment programs as clients present with the co-occurring disorders. This exploratory study provides descriptive information learned from calls made to a problem gambling helpline by people reporting co-occurring substance use and gambling disorders. The information can be used by educators to inform students of the characteristics of this population.

S.10.04 Neurocognitive deficits in pathological gambling and related disorders

S.10.04 Neurocognitive deficits in pathological gambling and related disorders

Assessment and Management of Pathological and Problem Gambling Among Older Adults

The incidence of gambling among older adults has risen significantly over the last decade. Pathological and problem gambling disorders among older adults have devastating consequences including stress, alcohol abuse, loss of income and assets, treatment nonadherence, malnutrition, safety risks related to associated alcohol usage and financial losses, and increased psychiatric problems such as depression. This article reviews the theoretical frameworks and literature concerning gambling incidence, prevalence, behavior, diagnostic tools and interventional strategies for older adults, as well as nursing assessment, care planning, and management of gambling disorders.

S.10.02 Genetics of pathological gambling and substance use disorders

The term treatment-resistant depression (TRD) has been the focus of hundreds of studies and clinical trials, though it is not a diagnosable mental health condition according to current clinical standards. The term implies depression that is particularly difficult to treat. However, as we illustrate here, the use of the TRD construct creates significant concerns regarding patient welfare and optimal distribution of resources. First, TRD is frequently defined as depression that failed to respond to antidepressant medication. Therefore, patients may be labeled with TRD after having tried just one medication, without consideration of effective non-pharmacological treatments such as psychotherapy or holistic interventions to improve sleep, nutrition, and exercise. Second, TRD implicitly contextualizes depression as a problem within an individual's brain, ignoring larger systemic, developmental, and sociological factors known to be depressogenic. Important structural determinants of health such as social isolation, environmental stressors, systemic oppression, unmet basic needs for shelter, food, and safety are excluded. Third, TRD does a disservice to patients when it rapidly escalates treatment decisions to increasingly risky and experimental options. And finally, the existing concept of TRD is used to justify enormous financial investment – on the order of billions of dollars - in research aimed at identifying precise biological treatment targets. The quest for biomedical treatments struggles to provide the anticipated return on investment in the form of decreased depression burden despite over 50 years of costly effort. Drawing from historical perspectives, we highlight these issues and propose recommendations to address them.

Pathologic gambling disorder

PREVIEWPathologic gambling disorder and problem gambling are becoming increasingly common in the United States as more states legalize gambling. Although gambling-related disorders can cause devastating consequences, well-studied treatments are few. Fortunately, clinical experience suggests that pathologic gambling disorder is highly treatable. In this article, Drs Sumitra and Miller briefly summarize gambling-related disorders and discuss available, effective treatments.

Comorbidity of DSM-IV Pathological Gambling and Other Psychiatric Disorders

To present nationally representative data on lifetime prevalence and comorbidity of pathological gambling with other psychiatric disorders and to evaluate sex differences in the strength of the comorbid associations. Data were derived from a large national sample of the United States. Some 43,093 household and group quarters residents age 18 years and older participated in the 2001-2002 survey. Prevalence and associations of lifetime pathological gambling and other lifetime psychiatric disorders are presented. The diagnostic interview was the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. Fifteen symptom items operationalized the 10 pathological gambling criteria. The lifetime prevalence rate of pathological gambling was 0.42%. Almost three quarters (73.2%) of pathological gamblers had an alcohol use disorder, 38.1% had a drug use disorder, 60.4% had nicotine dependence, 49.6% had a mood disorder, 41.3% had an anxiety disorder, and 60.8% had a personality disorder. A large majority of the associations between pathological gambling and substance use, mood, anxiety, and personality disorders were overwhelmingly positive and significant (p < .05), even after controlling for sociodemographic and socioeconomic characteristics. Male sex, black race, divorced/separated/widowed marital status, middle age, and living in the West and Midwest were associated with increased risk for pathological gambling. Further, associations between alcohol dependence, any drug use disorder, drug abuse, nicotine dependence, major depressive episode, and generalized anxiety disorder and pathological gambling were stronger among women than men (p > .05). Pathological gambling is highly comorbid with substance use, mood, anxiety, and personality disorders, suggesting that treatment for one condition should involve assessment and possible concomitant treatment for comorbid conditions.

Heart Rate Increase to Alcohol Administration and Video Lottery Terminal (VLT) Play Among Regular VLT Players.

The authors examined heart rate responses to video lottery terminal (VLT) play and alcohol intake. Forty-four VLT players were randomized to an alcohol (mean blood alcohol concentration=0.06%) or a control beverage condition. Heart rate was recorded at pre- and postdrinking baseline and during VLT play. Alcohol participants displayed elevated heart rates relative to controls at postdrinking and VLT play. Controls displayed elevated heart rates during VLT play relative to both pre- and postdrinking baselines, whereas alcohol participants displayed elevations at post- relative to predrinking and at VLT play relative to postdrinking. Heart rate increases from predrinking to VLT play were greater among alcohol participants relative to controls. Results provide novel information that the combination of VLT play and alcohol further intensifies heart rate increase relative to either alone. Implications for pathological gambling and alcohol use disorder comorbidity are discussed.