1. Gambling Disorder Best Practices

2. What is Gambling Disorder? Sometimes called problem gambling or compulsive gambling by treatment providers Known as gambling addiction by Twelve-Step or Recovery community Categorized as an impulse control disorder in the DSM-IV (APA, 2000) Only addictive disorder meeting inclusion criteria for the Substance Related and Addictive Disorders section of DSM-V (APA, 2013)

3. What is Gambling Disorder? Results of content analyses of historical literature of problem gamblers in the United States and England, indicated that the DSM-IV diagnostic criteria may represent medicalized previous moral objections to gambling (Bernhard, 2007)

4. DSM-V Diagnostic Criteria A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12 month period – Needs to gamble with increasing amounts of money in order to achieve the desired excitement – Is restless or irritable when attempting to cut down or stop gambling

5. DSM-V Diagnostic Criteria A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12 month period – Has made repeated unsuccessful efforts to control, cut back, or stop gambling – Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)

6. DSM-V Diagnostic Criteria A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12 month period – Often gambles when feeling distressed (e.g., helpless, guilty, anxious, distressed) – After losing money gambling, often returns another day to get even (“chasing” one’s losses)

7. DSM-V Diagnostic Criteria A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12 month period – Lies to conceal the extent of involvement with gambling – Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling

8. DSM-V Diagnostic Criteria A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12 month period – Relies on others to provide money to relieve desperate financial situations caused by gambling

9. DSM-V Diagnostic Criteria B. The gambling behavior is not better explained by a manic episode – Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months – Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years

10. DSM-V Diagnostic Criteria B. The gambling behavior is not better explained by a manic episode – In early remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met for at least 3 months but for less than 12 months – In sustained remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met during a period of 12 months or longer

11. DSM-V Diagnostic Criteria B. The gambling behavior is not better explained by a manic episode – Current severity: Mild: 4-5 criteria met Moderate: 6-7 criteria met Severe: 8-9 criteria met

12. DSM-V Diagnostic Criteria Most common symptoms – Preoccupation with gambling – Chasing losses Least often endorsed, but most common among those with severe gambling disorder – Jeopardizing relationships or career opportunities – Relying on others to provide money for gambling losses

13. DSM-V Diagnostic Criteria Those individuals presenting for treatment of gambling disorder usually have moderate to severe forms of the disorder 6-9 symptoms

14. DSM-V Diagnostic Criteria Essential diagnostic criterion of impairment manifested in disruption of personal, family, and/or vocational pursuits (Criterion A, APA, 2013, p. 586) Progression of the disorder is manifested by “chasing losses,” in which an individual keeps gambling by placing larger bets, taking greater risks, or abandoning all gambling strategies in desperate attempt to win back losses all at once (p. 586)

15. DSM-V Diagnostic Criteria Individuals may lie to family members, therapists, or others to conceal the extent of gambling (Criterion A7, p. 586) Some of these individuals may progress to forgery, fraud, theft, or embezzlement to obtain money to gamble and to conceal increasing financial consequences

16. Associated Features Distorted thinking – Denial, minimization – Superstitious and/or ritualistic behavior – Illusory sense of power or control over chance events – Overconfidence Belief that money is cause and solution of problems (APA, 2013, p. 587)

17. Associated Features Three basic manifestations – Impulsive, competitive, energetic, restless, easily bored (especially younger and male gamblers) – Overly concerned with approval of others and generous to point of extravagance – Depressed, lonely, helpless, guilty (older, later stage of progression, and female gamblers) Half of individuals in treatment have suicidal ideation and about 17% have attempted suicide (APA, 2013, p. 587)

18. Prevalence Past year prevalence rate 0.2-0.3% of general population (APA, 2013, p. 587) Lifetime prevalence of 0.4-1.0% of population Females 0.2%; Males 0.6% African Americans 0.9%; Whites 0.4%; Hispanics 0.3% (APA, 2013, p. 587)

19. Pathogenesis Onset of most serious cases begin in adolescence or young adulthood; some grow out of the disorder Gradual progression over the years More rapid progression in females; mid- and later life onset more common in females Most gamblers report problems with one or two types of gambling; some present multiple types Accessibility to certain types of gambling (e.g., scratch off tickets) associated with more frequent gambling Amounts of money wagered not indicative of gambling disorder; rather extent of losses and related financial consequences determine a problem (APA, 2013, p. 587)

20. Pathogenesis Early life gambling more likely to be associated with impulsivity and substance abuse Later life onset associated with depression, anxiety disorders, and bipolar disorder Younger gamblers involved in sports betting, cards, and horse racing and older gamblers develop problems with slot machines and bingo Younger and male gamblers least likely to seek treatment; older and female gamblers seek treatment more often and sooner, but treatment seeking is less than 10% for gambling disorder Gambling disorders aggregate in families with younger onset typically associated with gambling with family members Gambling disorder associated with course of antisocial personality disorder and alcohol disorders, especially in males Gender differences may be becoming less, especially with increasing accessibility of gambling opportunities (APA, 2013, pp. 587-588)

21. Internet Gambling Beginning in the mid-1990s Internet expansion contributed to dramatic increases in worldwide gambling As many as 10.5% of individuals in the United Kingdom participate in online gambling in a myriad of forms Internet gambling presents virtually all of the forms of tradition, land-based gambling (Wood & Williams, 2011)

22. Internet Gambling Online gamblers more likely to be males and younger (45.7 years) compared to land-based gamblers (51.2 years) Few under age 18 (0.4%) Less likely to be married (53.2%) More likely to be employed fulltime (62.7%) and reporting higher than average household income ($60,100 USD) (Wood & Williams, 2011, p. 1127)

23. Internet Gambling Higher rates of substance use disorders (13%) than non-Internet gamblers Higher rates of addictive disorders (10.4%) Involved in a wider array of gambling formats and games (4.1 types versus 2.6 types for non-Internet gamblers) Males involved in games of skill, while females likely to be involved in chance games such as bingo Online poker was highest rate of participation of Internet gamblers (54.1%) (Wood & Williams, 2011, p. 1129)

24. Internet Gambling Using the Canadian Problem Gaming Index, 16.4% of Internet gamblers could be classified as moderate to severe problem gamblers Only 39.9% of Internet gamblers, were classified as non- problem gamblers compared to 82.1 % of non-Internet gamblers (a major difference) 9.4% of problem gamblers seek treatment (similar to DSM- V estimate) Those seeking help for Internet gambling typically attended Gamblers Anonymous 29.8% of those interested in help said they would be most comfortable seeking an Internet-based counseling service (Wood & Williams, 2011, p. 1129)

25. Risk Factors Gambling disorders most common in first-degree relatives with moderate to severe alcohol use disorder Past gambling problems best predictor for gambling disorder Some individuals experience brief problems with loss of control over gambling behavior, but do not develop gambling disorder Gambling disorder can be distinguished from social and professional gambling (APA, 2013, pp. 588-589) In 2002, 10-15% of children and adolescents were estimated to be at risk for developing significant pathological problems with gambling (Hardoon & Derevensky, 2002)

26. Differential Diagnosis Social, recreational and professional gambling are considered nondisordered gambling Problem gambling may be associated with the loss in judgment and discipline associated with a manic episode; the key to differential diagnosis is the absence or decline in manic-like symptoms when away from gambling Some patients taking dopaminergic medications (e.g., for Parkinson’s disease) may experience irresistible urges to gamble Personality disorders, especially antisocial personality disorder co-occur with gambling disorder (APA, 2013, p. 589)

27. Comorbidity Gambling disorder is associated with poor general health, including tachycardia and angina, even when other lifestyle problems such as tobacco or substance use are controlled in studies Individuals with gambling disorder have high rates of comorbidity with mental disorders with symptoms of mental disorders either preceding diagnosis of gambling disorder or emerging after the gambling disorder (APA, 2013, p. 589)

28. Comorbidity Substance use disorders occur in approximately 50% of pathological gamblers Anxiety disorders including obsessive-compulsive disorder, agoraphobia, and panic are more common in pathological gamblers than the general population 72-76% of pathological gamblers were found to suffer from depression 13-20% attempted suicide 48-70% reported suicidal ideation 93% met criteria for a personality disorder in descending rank order: obsessive compulsive (59%), borderline (57%), histrionic (54%), avoidant (50%), and narcissistic (47%) 15-40% of pathological gamblers met criteria for diagnosis of antisocial personality disorder Pathological gamblers with concurrent borderline personality disorder or antisocial personality disorder presented more psychosocial dysfunction, impulsivity, and severity of symptoms (Korman, Toneatto, & Skinner, 2010)

29. History of Trauma in Pathological Gamblers 64% of pathological gamblers in a gambling treatment program in a VA medical center reported a history of emotional trauma 40.5% reported physical abuse trauma 24.3% reported sexual trauma High trauma patients in this treatment program were more depressed, anxious, and likely to abuse drugs and alcohol than other gamblers (Kausch, Rugle, & Rowland, 2006)

30. History of Trauma in Pathological Gamblers 73% of pathological gamblers in Oregon reported trauma from prior abuse or neglect prior to the onset of problem gambling 60% of female and 16% of males involved in outpatient treatment for pathological gambling reported PTSD and other mental disorders arising from sexual abuse 29% of pathological gamblers admitted to a private psychiatric treatment program reported physical and/or sexual abuse in childhood 13% of Gamblers Anonymous members in a sample from the United States and Canada had been abused as a child In a related study of 20,611 veterans diagnosed with substance use disorders, 63% of women and 25% of men experienced lifetime physical abuse and 51% of women and 8% of men reported lifetime sexual abuse (Kausch, Rugle, & Rowland, 2006)

31. Gambling in Forensic Populations Although antisocial personality disorder has been associated with gambling disorder, the prevalence of gambling in correctional facilities (40%) is lower than in the general population However, 50% of the crimes committed by pathological gamblers in this forensic population were reportedly committed to support gambling Those who gamble in the forensic population attempt to gamble frequently and may represent problem gamblers in need of specialized treatment (Williams, Royston, & Hagen, 2005)

32. Gambling in Older Adults Elderly (aged 60 and older) veterans in a residential gambling treatment program in the VA had similar scores on the Addiction Severity Index to younger problem gamblers; similarly they evidenced about the same rates of co-occurring mental disorders as the younger cohort with lifetime histories of depression and suicidal ideation (Kausch, 2004) Active older adults (aged 65 and older) given the South Oaks Gambling Screen presented lifetime rates of combined problem and pathological gambling of 10.6-12.9% (Ladd, Molina, Kerins, & Petry, 2003) Three fourths of pathological gamblers over age 60 in a community sample indicated an interest in gambling treatment; they were depressed and lonely (Pietrzak & Petry, 2006)

33. Assessment of Gambling Disorder South Oaks Gambling Screen (SOGS) Canadian Problem Gambling Index (CPGI)

34. Empirically Supported Treatments Behavioral treatments – Stimulus control – Exposure-response prevention Cognitive-behavioral treatments – Cognitive restructuring – Motivational interviewing – Relapse prevention Emotion-focused treatment – Affect regulation Self-help treatments – Self-help manuals – Gamblers Anonymous Pharmacotherapy – Selective serotonin reuptake inhibitors – Naltrexone – Stimulants Integrative treatment – Group and individual interventions – Self help and professional – Pharmacotherapy and psychotherapy – Initial treatment and relapse prevention – Outpatient and inpatient models

35. Gamblers Anonymous Gamblers Anonymous: a peer-support, self-help group based on the Twelve Steps and Traditions of Alcoholics Anonymous Promising in maintaining abstinence from gambling, but difficult to research effectiveness due to lack of standardized approach Most participants (70%) drop out after 10 th session Up to 48% abstinence two months into treatment; abstinence at 1 year follow-up was 8% and 7% at two-year follow-up Greater abstinence for GA members who also received individual professional treatment (Ledgerwood & Petry, 2005)

36. Phamacological Treatment Modafinil (Provigil), a wakefulness promoting (sympathomimetic-like agent) agent, used to treat narcolepsy and excessive daytime sleepiness, increases dopamine levels This atypical stimulant has been used to treat cocaine abuse and ADHD Modafinil decreased desire to gamble, disinhibition, and risky-decision making in high-impulsivity pathological gamblers engaged in slot machine gambling, but actually increased the symptoms in low- impulsivity pathological gamblers (Zack & Poulos, 2009)

37. Guided Self-Change Approach Pathological gamblers are prone to leave treatment early Brief treatments enhance motivation, increasing likelihood of short-term treatment compliance A clinical case study involving a 5-session treatment of pathological gambling in a 36 year-old gambler focused on cognitive-behavioral guided self-change Gambling symptoms were reduced in terms of the frequency of gambling, the duration of episodes, and the amount of money wagered at 1-month and 6- months follow-up (Lipinsky, Whelan, & Meyers, 2007)

38. References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text-revision). Washington, DC: American Psychiatric Association. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Washington, DC: American Psychiatric Association. Bernhard, B.J. (2007). The voices of vices: Sociological perspectives on the pathological gambling entry in the Diagnostic and Statistical Manual of Mental Disorders. American Behavioral Scientist, 51, 8- 32. Hardoon, K.K., & Derevensky, J.L. (2002). Child and adolescent gambling behavior: Current knowledge. Clinical Child Psychology & Psychiatry, 7, 263-281.

39. References Kausch, O. (2004). Pathological gambling among elderly veterans. Journal of Geriatric Psychiatry and Neurology, 17, 13-19. Kausch, O., Rugle, L., & Rowland, D.Y. (2006). Lifetime histories of trauma among pathological gamblers. The American Journal on Addictions, 15, 35-43. Korman, L.M., Toneatto, T., & Skinner, W. (2010). Pathological gambling. In J.E. Fisher & W.T. O’Donohue (Eds.), Practitioner’s guide to evidence-based psychotherapy (pp. 291-300). NY: Springer Ladd, G.T., Molina, C.A., Kerins, G.J., & Petry, N.M. (2003). Gambling participation and problems among older adults. Journal of Geriatric Psychiatry and Neurology, 16, 172-177. Ledgerwood, D.M., & Petry, N.M. (2005). Current trends and future directions in the study of psychosocial treatments for pathological gambling. Current Directions in Psychological Science, 14, 89-94. Lipinski, D., Whelan, J.P., & Meyers, A.W. (2007). Treatment of pathological gambling using a guided self-change approach. Clinical Case Studies, 6, 394-411,

40. References Pietrzak, R.H., & Petry, N.M. (2006). Severity of gambling problems and psychosocial functioning in older adults. Journal of Geriatric Psychiatry and Neurology, 19, 106-113. Williams, R.J., Royston, J., & Hagen, B.F. (2005). Gambling and problem gambling within forensic populations: A review of the literature. Criminal Justice and Behavior, 32, 665-689. Wood, R.T., & Williams, R.J. (2011). A comparative profile of the Internet gambler: Demographic characteristics, game-play patterns, and problem gambling status. New Media & Society, 13(7), 1123- 1141. Zack, M., & Poulos, C.X. (2009). Effects of the atypical stimulant modafinil on a brief gambling episode in pathologicakl gamblers with high versus low impulsivity. Journal of Psychopharmacology, 23, 660-671.