2. Using Best Practices in Treatment of Dual Diagnosis and Pathological Gambling Henry R. Lesieur, Ph.D., Psy.D. Pawtucket, Rhode Island hlesieur@gmail.com © Henry R. Lesieur, Ph.D., 2014

3. Topics to be discussed Pathological gambling and Physical Health Pathological gambling and Mental Health Assessment The Basic CBT Model Modifications for Different Disorders

4. Poor Health and Pathological Gambling

5. Inpatient Hospitalization Among Gamblers (Indiana, 1998)

6. Problem Gambling and Physical Health US study of 10,231 adults 55+ (2013) At-Risk & PG had elevated incidences of arteriosclerosis and any heart condition, elevated body mass index Elevated risk of PG in coronary heart disease (CHD) patients compared with NCHD patients (not explained by cigarette smoking)

7. Problem Gambling and Physical Health 10,056 Canadian women (2010) PGs had significantly lower general health chronic bronchitis, fibromyalgia, migraine headaches

8. Unhealthy Lifestyle PG more likely to avoid regular exercise smoke≥1 pack/day drink≥5 servings of caffeine daily and watch television≥20hours/week PG have higher BMI than controls and were more likely to be obese (but not more likely to be in eating disorders programs) PG in ED programs 1% but 5.7% of binge eaters Fights & smoking among adolescent PGs

9. Less Health Care but More Expensive More emergency room visits less likely to have had regular dental visits And more likely to put off medical care due to financial problems. more likely to have been psychiatrically hospitalized in the past year, and were more likely to take psychotropic medication BEST PRACTICE: Medical and Dental exam for PG

10. Studies of Special Populations Of people receiving Free or Low Cost Dental Care (n=723): People on disability have higher rates of PG (26%) than non-disability (14%) Methadone clients (n=156) with PG had poorer mental & physical health than non-PGs Older adults with PG >medical, family/ social, psychiatric, and alcohol problems SUD counselors (n=328) with PG > physical health problems

11. Medical Problems Among Pathological Gamblers Cardiovascular Problems even taking Cigarette smoking into account Oral-Dental Disease Chronic bronchitis (F) Fibromyalgia (F) Migraines (F) Higher BMI More expensive health care Less visits to dentists

12. Health & Problem Gambling National Epidemiological Survey on Alcoholism and Related Conditions 43,093 Americans surveyed in 2006 Pathological gamblers had higher rates of: – Anxiety disorders; depression; alcohol & substance abuse; cigarette smoking – Stress-related health issues like hypertension and migraines – Liver disease, high blood pressure, high heart rate and angina after controlling for demographic characteristics, obesity, cigarette smoking, and mood and anxiety disorders

13. Parkinson’s Among Pathological Gamblers Parkinson’s Disease (PD) patients have higher rates of Pathological Gambling Review of studies up to 2013 (2-7% of PD have PG) 12/250 (5%) PD patients; 17/388 (4.4%) PD patients 26/203 (13%) PD patients vs. 7/236 (3%) ALS patients 13/140 (9.3%) PD patients with problem or pathological gambling 130 out of 3,090 PD patients (6.4% includes problem & PG)

14. Dopamine Agonist Treatment & PG Dopamine agonists used to treat Parkinson’s Disease have been implicated. (untreated PD have 1% rate) Another study N=297 (3.4% PD; 7.2% PD & agonist) Case reports with Huntington’s disease Reports with dopamine agonists & Restless Leg Syndrome – 7% with PG Case reports with dopamine agonists & Fibromyalgia, Schizophrenia & Bipolar Agonists also assoc. binge eating; hoarding; compulsive buying and hypersexuality

15. Dopamine Agonist Treatment & PG Personal or family history of alcohol use disorders and earlier age of PD onset are associated with greater risk when using dopamine agonists Increased activation of reward seeking, reduced inhibition of impulsive drives and increased cravings have been shown in one study of PG with PD vs. PG without PD – neuroimaging study Some research points to dopamine abnormalities in PGs but one recent study questions that conclusion

16. What to do with Parkinson’s, Restless Leg Syndrome, etc. Get in contact with the neurologist or PCP Mention the relationship between PG and dopamine reward pathway (neurologists are aware) Mention that remission often occurs when agonists are removed. Some with restless leg respond to klonopin. Ask about binge eating, buying, hoarding, hypersexuality Work with the spouse, significant others. Discuss feelings of dependency & loss of employment in therapy for PD-PGs as well as fibromyalgia. Advocate for self-exclusion & control over finances when appropriate (problems with shifting set for PD-PGs)

17. PG, Alcohol Abuse & SUD All studies (US & international) of Alcohol and SUD populations have found higher rates of PG than in general population US– 11-14% pathological; 22-23% problem of Alc/SUD in treatment & in community US – 11% of repeat DUI offenders France 6.5% of Alcohol treatment patients Ontario 10.5% of Alc/SUD clients Sweden 9% of males; 2% of females

18. PG and Dual Diagnosis Study of 464 men and 301 women in outpatient treatment in Minnesota (Stinchfield et al, 2005) PGs with concurrent Alc/SUD have more serious gambling problems and more severe psychosocial problems than PGs without Alc/SUD 5 yr follow-up of 101 recent quitters found PGs with Alcoholism diagnosis took longer to reach 3 months continuous abstinence and had inc. odds of relapse in 6 months (Hodgins & el-Guebaly, 2010)

19. Daily Cigarette Smokers PGs in Treatment gamble on more days and spend more money gambling (several studies) crave gambling more and have lower perceived control over their gambling. (several studies) more likely to be taking psychiatric medications, and experience psychiatric symptoms, especially anxiety symptoms, on a greater number of days than non-daily smokers Same patterns are found in those with history of SUD; however, outcomes are not affected

20. Mental Health and Gambling Problems -- NORC, 1999

21. Pathological Gambling Among Mental Patients Note: All studies based on structured interviews; chart reviews excluded as they under-report diagnoses

22. PG & Mental Health Germany 15,023 individuals surveyed – 94% of PGs had lifetime Axis I disorder Risk increased with increased # DSM criteria met Scotland 2,259 surveyed (age 16+) – treatment seeking PGs had higher rates of MDD than non- treatment seeking PGs Alberta (n=101 followed for 5 yrs) Lifetime mood disorder was associated with a longer time to achieve 3 months of stable abstinence

23. PG and Mental Health N=10,056 Canadian women PG has decreased psychological well-being, increased distress, depression, mania, panic attacks, social phobia, agoraphobia, alcohol dependence, any mental disorder, suicidal ideation and attempts, multiple mental disorders

24. Korean epidemiological study N=6,510 adults PG higher rates of alcohol use disorder, nicotine dependence mood disorder anxiety disorder suicidality

25. Prevalence of Comorbid Disorders Among Pgs in US Gen’l Population Source: Lorains, Cowlishaw & Thomas, 2011; Eleven surveys; total n=122,230; 1,453 PGs; Mood disorder includes depression, dysthymia and bipolar; anxiety includes GAD, Panic, Phobias; 60% figure also includes PTSD

26. Prevalence of Comorbid Disorders Among Pgs in US Gen’l Population Source: Lorains, Cowlishaw & Thomas, 2011; Abuse & dependence included; ASPD involves 2 studies with 365 PGs

27. PG & Homelessness All studies analyzing homelessness have found higher rates of PG among homeless than in the general population National comorbidity study found PGs (vs. non-PG homeless) had higher rates of: ASPD, PTSD, Bipolar disorder, Alcoholism, Nicotine Dependence, SUD, and any mental disorder

28. Studies of PGs in Prison PG associated with: social anxiety depression substance abuse Impulsiveness current and childhood attention-deficit/ hyperactivity disorder (ADHD) symptoms Canadian study found rates of mental disorders similar to PGs in general population studies

29. Clinical Studies of Mental Illness Among PGs Studies find similar results that occur internationally: 32% to 78% with MDD 8-24% with bipolar disorder (& hypomanic disorder) Mean prevalence for “any mood disorder” among PGs in general population studies = 38% 27-60% (Avg.=37%) with anxiety disorders including GAD, PTSD, phobias and panic disorder 34% PTSD 19-25% with ADD or ADHD Studies point to wide range of personality disorders with Cluster B the most frequent followed by Cluster C.

30. Personality Disorders Borderline & Antisocial are the most common in treatment groups and in general population surveys but other personality disorders (typically from clusters B & C) are also more common among PGs than in the general population PGs with personality disorders (esp ASPD & Borderline) have more severe gambling problems and more likely to be suicidal

31. Alcohol Use Disorders, PG & Mental Disorders National Epidemiological Survey on Alcohol and Related Conditions (n = 43,093) Non-AUD respondents – increasing gambling severity associated with increasing odds for Axis I and II disorders AUD respondents –adding PG to AUD does not increase odds of having another Axis I or II disorder

32. PG, Mental Health & SUD US study of 512 treatment SUD & 478 community SUD – high rate of PG was secondary to ASPD

33. Physical & Sexual Trauma 23% of male VA inpatients (1987) 64% emotional; 40% physical; 24% sexual in VA patients (2006) 33% mixed gender Minn. outpatient (1996) Emotional trauma: 82% of women/32% of men (Maryland outpatient) PGs Childhood Trauma Quest. Scores F > M PG associated with high rates of both perpetration and victimization of dating violence, marital violence, and severe child abuse (2009)

34. Interpersonal Violence by PGs N=248 Canadian PGs in treatment 62.9% of participants reported perpetrating (P) and/or being the victims (V) of IPV in the past year 64.5% also had clinically significant anger problems that inc. risk of both P&V; lifetime SUD increased risk of P&V 25.4% reporting perpetrating severe IPV

35. PG and Violence 341 males in Batterer Intervention Program 9% Pathological and 17% problem gamblers; more likely to perpetrate sexual aggression than alcoholics (Brasfield et al., 2011) National Comorbidity Survey Replication (n=3,334) PG 6 times more likely to perpetrate dating violence; 20 X severe marital violence; 13 X severe child abuse (Afifi et al., 2010) 180 female SUDs in HIV prevention trials; those with violent tendencies (ASPD) were 3 X more likely to be PGs than those without (Cunningham-Williams et al., 2007) Results may be explained by high rate of ASPD in PG

36. Pathological Gambling Among Substance Abuse Clients

37. Influence of Substance Abuse, Substance Dependence and Mental Disorder on Rates of PG in Canadian Population (n=36,885) SA=substance abuse; SD=substance dependence; MD=mental disorder Source: Rush, B.R., Bassani, D.G., Urbanowski, K.A. & Castel, S. (2008) Influence of co-occurring mental and substance use disorders on the prevalence of problem gambling in Canada. Addiction, 103, 1847-1856.

38. What comes First, PG or Other Disorder? DisorderPG FirstOther Disorder First Onset at Same Time Any Mood Disorder*23%65%12% Any Anxiety Disorder* 13%82%5% Any Impulse Control Disorder 0100%0 Any SUD*36%57%6% Source: National Comorbidity Survey Replication n=9,282; Kessler et al., 2008) * These disorders more common among PGs compared to rest of US population

39. Behavioral Addictions and Problem Gambling Compulsive buying Shoplifting/theft Sexual addiction Internet Addiction

40. Dysfunctional Behaviors Among Ontario Women Who Play Bingo Boughton & Brewster (2002) Process Addiction Current/Past – Bingo Players (n=69) Current/Past – Slots Players (n=96) Compulsive Shopping 36/69=45%19/96=49% Shoplifting9/69=30%4/96=16% Sexual Behavior13/69=33%6/96=26%

41. Pathological Gambling in Substance Abusers and Sexual Risk Taking -- Petry Higher SOGS associated with >50 sex partners SOGS associated with exchange of sex for money/drugs SOGS associated with anal intercourse Ergo – PG & Substance Abuse may increase risk for AIDS and other STDs

42. Compulsive Sexual Behavior (CSB) PG more frequent in Compulsive Sexual Behavior In epidemiological survey – 20% of PG also had CSB – rates in men>women

43. Internet Addiction Online Internet addicts more likely to have problems with Internet gambling (several studies – odds ratio = 1.8 when compared with non Internet addicts) Other adolescent surveys replicate these findings College students with pathological Internet use more likely to experience online gambling addiction, cybersexual addiction, suicidal ideation and alcohol abuse, compared with other groups

44. Epidemiological Surveys find higher rates of suicidality in PGs E.g. South Korea; N=6,510 adults -- PG sig. correlated with suicidal ideation Canada (n=36,984) odds ratio= 3.4 Several studies show rates are explained by Depression and PTSD Depression + PG rate higher than PG alone PTSD + PG rate higher than PG alone

45. Suicidal Ideation Among Gamblers Anonymous Members

46. Suicidal Ideation of Pathological Gamblers by SOGS Score (Pct)

47. Suicidal Gamblers in Treatment CT – 48% ideation; 12% attempted Canada – 81% SI; 30% attempted in past yr Higher SOGS scores (several studies) Spent more money prior to treatment Higher cravings Greater likelihood of SUD & psychiatric disorder (many studies)

48. SUICIDE AND DUAL TROUBLE

49. Psychological Autopsies of PG Suicides Canada 49 PG vs. 73 NPG suicides: PG 2X more likely to have personality disorder; less likely to have mental health contact Hong Kong 17 out of 150 suicides were PGs (all had unmanageable debt); 14/17 had other psychiatric disorders, Depression (10/17) and SUD (3/17); none sought treatment

50. Outcome Data PG with Depression had increased chance of problem gambling during and after tx (Australia; study n=127); treatment for depression recommended PG with SUD had higher rates of relapse than non-SUD; PG with mood disorder took longer to reach 3 months continuous abstinence (Canada; n=101); need treatment for both

51. Outcome Data in SUD programs PGs more likely to use cocaine while in methadone program and more likely to drop out (n=62; small sample size) Consensus of researchers is the need for dual diagnosis programs that include gambling

52. Treatment of PG with other problems Study compared gambling treatment outcomes using CBT (n=231) No difference in outcomes for individuals with and without self ‐ reported mental health treatment utilization (those with MH treatment had more severe psychiatric problems); replicated in other studies

53. Personality Disorders & PG Cluster B personality disorders related to higher dropout and relapse Gambling and ASPD treatment not studied Cochrane review found CBT with “standard maintenance,” Contingency Management with standard maintenance; DWI program show some success with SUD but not ASPD; (studies done only by one research group each; none is best practice);

54. DBT (Treatment for Borderlie Personality Disorder) DBT was used with 14 treatment resistant PGs – small sample and no control group 83% abstinent or reduced gambling Needs further research

55. Treatment of PG in Depressed Clients Internet CBT effective for PGs with depression (no control group) Prospective cohort study of problem gamblers (n=127) individuals with higher depression levels had a greater likelihood (13% increase in odds [95% CI, 1%-25%]) of problem gambling during treatment and at follow-up (dual approach recommended)

56. Problem Gambling and Mood Disorders Mood Gambling Euphoria Depression Win Lose Can’t gamble

57. Combined Treatments (no control groups) Treatment for PG & SUD using traditional 12-step facilitation – effective for dually diagnosed gamblers (n=72; no control group) Treatment for PTSD & PG using “Seeking Safety” CBT treatment effective for both (n=8)

58. Treatment for PG Among Individuals with Physical Problems PG + Parkinson’s (n=15) compared with PG w/out (n=45) – no differences in treatment outcome (Spain) Brain Injured Clients treated for PG -- Behavior Analytic Treatment (ABC model that included motivations to gamble) with 3 patients reduced both urges and actual gambling (small sample and no control)

59. Treatment – PG & Schizophrenia PG schizophrenics using CBT and medication was more effective than medication alone (Spain; n=44) 74% vs. 19% significantly reduced or gave up gambling at 3 month follow-up

60. Lithium Treatment of Bipolar & PG Studies show conflicting results Treatment of PG and bipolar with lithium effective in placebo-controlled study (no randomization), improvement in gambling severity was significantly correlated with improvement in mania ratings Another study introduced quetiapine after PG treatment failure on lithium

61. Extended Assessment (Maurer) 1. Assess Alcohol/Drug Use 2. Assess Need for Medication – lethargic? manic? schizophrenic? – best not to make referral too soon unless disabling (if in doubt, refer) – educate about gambling-related depression – withdrawal may mimic depression – differential diagnosis issues – revisit suicidal/homicidal ideation (refer if yes)

62. Extended Assessment (Maurer) Hospital referral A. Detox (if actively using drugs will relapse) B. Inpatient Psychiatric – Actively suicidal/ homicidal – Floridly manic (evidence apart from gambling) – Psychotic (not just confusion and disorientation produced by gambling difficulties) C. Inpatient Gambling Program (none locally available) – Needs safe environment to avoid illegal acts – Outpatient treatment failure

63. Extended Assessment (Maurer) continued Issues to Avoid Early in Treatment A. Early Life Issues B. Trauma* C. PTSD* D. COA / COCG issues E. Harm to Children (may promote excess guilt) – unless needed to motivate client *Recent evidence supports treatment of PTSD first or conjointly in substance use disorder clients with PTSD

64. The Basic CBT Model Motivational interviewing -- Join with the patient – Discuss stages of change and find ambivalence Costs-Benefits Triggers Experience Cycle Leisure Activities

65. Basic CBT Model cont’d Randomness, randomness, randomness Safe@Play (for slots players and as relapse prevention) Gambling specific cognitive distortions – use GRCS, GBS (zero in on their gambling preferences) Relapse prevention – Planning, planning, planning Schema questionnaire and schema focused therapy

66. Treatment Guidelines Motivational Interviewing-- “Meet ‘em where they’re at” why are they seeking treatment NOW? how ambivalent are they? let them know they are not alone/crazy discuss how people change (Stages of Change) assess THEIR goals ACCEPTANCE: un-manageability, $$

67. Stages of Change Prochaska & DiClemente Precontemplation-- Resisting Change Contemplation -- Change is Needed Preparation -- Readying for Change Action -- Time to change Maintenance -- Continue Change Relapse -- What did person learn?

68. Treatment Guidelines Cost/Benefit Analysis consequences/benefits of changing or not changing write it down! resisting urge to gamble: delay 15 minutes, review C&B, make decision Understand triggers

69. Coping Skills “The Experience Cycle” event thoughts emotions impulse options choice

70. Conduct Behavioral Analysis Using Experience Cycle Events Thoughts Feelings Impulses – TURTLE – stop…breathe…think for 15 minutes then decide Options – what options are there for dealing with the situation? Get them to list at least 8 options using a pie chart Choices – be rational, logical, recognize consequences

71. Early Treatment Guidelines You’re not gambling, now what? Leisure Activities Make Plans for free time Involve family/friends: “coming clean” Relapse Prevention

72. Leisure Activities Non-gambling Non-substance using Inexpensive (videos at library; reduced price cinemas) Focus on time when they typically gambled Increase social contact Alternative activities

73. Cognitive Focus Gambler’s Irrational Beliefs “Suck the fun out of it” How random events dictate outcome slot machine tutorial While I am speaking about slots, the focus on rational thinking also applies to horses, scratch tickets, sports betting, Blackjack, roulette, poker, etc.

74. Safe@PlaySafe@Play Slots Tutorial Safe@Play

75. Changes for Dual Diagnosed Clients More sessions needed because of complex PG Need to be flexible about progress through the CBT model

76. Structure of the Session - 1 Any pressing issues this week? (set aside time) “Any gambling?” “any Powerball?” etc. “Any alcohol?” “Feeling depressed/suicidal?” If suicidal – focus on instilling hope; assess risk Experience cycle for gambling, alcohol, etc. CBT for depression, anxiety, assertiveness, etc.

77. Structure of the Session - 2 Ask about GA, AA, NA meeting attendance – steps; sponsor Ask about homework and go over it Discuss new topic. Introduce new topic or decide to continue old topic next session; assign homework

78. Psychotic Disorders Medication management Double stigma, increased shame CBT therapy after medication is managed; offer alternative explanations May need a payee if buying scratch tickets Family involvement when possible Assess Ability to participate in GA

79. Depression CBT oriented First focus on suicidality (thoughts of death, suicidal ideation, plans, attempts) – Do not focus on cost/benefits of gambling until stable Activity – get the person active – move leisure activities up sooner Discuss CBT model and separate out thoughts, feelings, and behaviors Get person to identify how she/he thinks

80. Mind over Mood D. Greenberger & C. Padesky Physical Reaction Thought Mood Behavior Event

81. Distressing Thought Record Event Who, what, when, where Mood 0-100 Automatic Thoughts (Images) Evaluate evidence supporting hot thoughts Deceased Mother’s birthday Lonely; Depressed 70/100 I’ll always be alone. I can’t stand it.

82. Recording Thoughts and Types of Thinking Errors ThoughtsThinking Errors I will always be alone. I’m a piece of shit. She thinks I’m stupid. I should have a new house. Etc. “All or nothing thinking” as well as “fortune telling” Labeling. Mind reading. “Should” statements Etc.

83. CBT focus on Core Beliefs and Life Schemas Need to challenge core beliefs E.g. “If you don’t have money you are a nobody.” “If my house is not neat that means I am a slob.” “The world is a dangerous place and you have to always be on your guard.” “If I fail that is because I did not work hard enough.” “If I ask someone to do something for me and I do it, that means I am weak.”

84. Bipolar Disorder Medications need to be stabilized first In contact with psychiatrist Monitor bipolar symptoms weekly MIND over MOOD interspersed with CBT for gambling E.g., Monica Basco The Bipolar Workbook – CBT for bipolar disorder

85. Dealing with Anxiety Gambling is a SAFETY BEHAVIOR that increases anxiety Relaxation exercises; diaphragmatic breathing; progressive muscle relaxation; guided imagery (peaceful place); mindfulness CBT focus (mind over mood) Hypnotic exposure using SUD hierarchy Delay exposure only after gambling under control for 2 months or more (6 months if anxiety severe) (assumption needs testing)

86. PTSD Relaxation training and CBT Grounding and mindfulness to help with focus (or “Seeking Safety” Therapy) Exposure oriented therapy or EMDR Use Mindfulness & DBT for complex PTSD; hypnosis very is useful Evidence exists that this therapy can be initiated concurrently with addiction tx

87. ADHD Very high rates among PGs Do not do homework (often lose it) Forget appointments I give them pads to write things down Emphasize the turtle Structure, visual information, structure Kohlberg & Nadeau ADD-Friendly Ways to Organize your Life – excellent resource Get person evaluated for medication for ADHD

88. Personality Issues Schema Focused Therapy (empirically validated treatment) – Jeffrey Young Combines CBT with Transtheoretical Model (variety of psychodynamic therapies) Reinventing Your Life J. Young & J. Klosko – discusses Lifetraps (suggest to client)

89. Lifetraps Abandonment Emotional Deprivation Mistrust/Abuse Social Isolation Failure Defectiveness/Shame Subjugation Self-sacrifice Unrelenting Standards Insufficient self-control Entitlement See J. Young, J. Klosko & M. Weisharr (2003) Schema therapy: A Practitioner’s Guide. Guilford Press.

90. Borderline Personality Disorder I use a Dialectical Behavior Therapy focus A. Validate, validate, validate B. Problem Solving (gambling & other) – Mindfulness – Emotion Regulation – Distress Tolerance – Interpersonal Effectiveness C. I also use “Ideal Parent” hypnosis to help with distress tolerance.

91. Antisocial Personality Disorder Studies point to high rate (15%) Can be highly destructive of group process Studies of SUD treatment point to ASPD as predictive of poor outcomes

92. Anger Management (e.g. damaged video machines) Anger as Normal Emotion that can be controlled (Cow in the Parking Lot) Stress Management Assertiveness vs. Aggression DEAR and other DBT interpersonal skills Importance of Validation DBT and CBT focus Role plays

93. Now What? Instill hope

94. Further Information Henry R. Lesieur, Ph.D., Psy.D. Pawtucket, Rhode Island Tel: (401) 727-4748 Cell: (347) 410-2902 hlesieur@gmail.com