Gambling within the Biopsychosocial framework Jason Mahmoud

Introduction Jason Mahmoud Psychology teacher at Killester College 15 years Psychology teaching experience both in V.C.E. and A levels in the UK No expert A lot of the information taken from new Grivas et al text book. Thanks for coming to the session!

Aims of the session 1. To provide power points that you can use in your teaching. 2. U tube clips have been embedded in the presentation that are relevant to the topic. 3. Revision questions have also been included as a word document that accompany presentation.

Session Outline Unit 4: Area of Study 2 Mental Health Optional selected mental disorder (Major depression or Schizophrenia other alternatives) Addictive disorder: gambling – biological contributing factors: role of the dopamine reward system and as a target for treatment – psychological contributing factors: social learning theory and schedules of reinforcement; the use of psychotherapies in treatment including cognitive behavioural and psychodynamic therapies – socio-cultural contributing factors: social permission of gambling opportunities; management including social network and recovery groups – the interaction between biological, psychological and socio-cultural factors which contribute to an understanding of the disorder and its management

Addiction and Gambling Addiction occurs when an: Individual ‘feels’ a constant desire to use a specific substance or engage in certain activities. Despite the potentially negative consequences. This can cause: Physical dependence: Evident by withdrawals or cravings when activity is withdrawn or unavailable. Psychological dependence: The mental desire to experience the effects of the activity.

Symptoms of Addictions Griffiths (2005) proposed that all addictions have seven distinctive characteristics: Salience: This activity has a high level of importance in a persons life. Mood modification: Change in feelings as a result of activity ‘high or buzz’. Tolerance: Decreased sensitivity to activity over time such as betting larger amounts over time to get same feeling.

Symptoms of Addictions 4. Withdrawal: Unpleasant psychological and/or physical reactions when activity is reduced such as sadness or nausea. 5. Conflict: Clashes that arise due to addiction that may be intrapersonal or interpersonal conflicts. 6. Relapse: After a period of control the recurrence of earlier patterns of behaviour occur. 7. Impaired self control: Lack the ability to suppress urges. http://www.youtube.com/watch?v=L7UVO5_zXj0

When is Gambling considered a Problem? Problem gambling is when an individual has difficulties in limiting money and/or time spent on gambling (Grivas et al. 2010). The limitation however is there is no clear distinction between a ‘recreational gambler’ in comparison to a ‘problem gambler’ (Productivity Commission 2009). A pathological gambling disorder is characterised by continuous gambling behaviour that disrupts personal, family and/or work related activities.

Impulse Control Disorder Currently in the DSM and ICD there is no category for an ‘addictive disorder’. Gambling comes under a type of impulse control disorder in the DSM-IV-TR. In the DSM-IV-TR there are six different types of impulse control disorders such as pyromania and trichollomania (pulling one’s hair out for pleasure). In the new DSM-V it has been proposed that ‘pathological gambling disorder’ will be replaced with the term ‘disordered gambling’ in a new category called addiction and related disorders within the subcategory behavioural addictions.

How can you be diagnosed with a pathological gambling disorder? According to the DSM-IV-TR a person must experience at least five of the following ten symptoms to be diagnosed as a pathological gambler: Preoccupation with gambling (salience): At least two weeks or more thinking about gambling. Tolerance: Increasing size of bets or time spent gambling. Loss of control: Individual has tried several unsuccessful attempts to stop gambling. Withdrawal: Unpleasant psychological and/or physical reactions when activity is reduced such as irritability or insomnia.

How can you be diagnosed with a pathological gambling disorder? 5. Escape: Some psychologists propose that all gamblers do so for escape from the hassles that daily life creates. When the gambler is addicted, gambling then becomes an escape from the problems associated with it creating a ‘vicious cycle’. Chasing: A pathological gambler will chase their loses and not walk away. Lying: To conceal the extent of gambling. There are two types: Reactive lying-Being dishonest in response to questions that may expose one’s gambling.

How can you be diagnosed with a pathological gambling disorder? b) Deceptive lying: Dishonesty planned in advance. 8. Illegal activity: In order to obtain money for addiction. 9. Risked relationships: Such as leaving a child in the car to place a bet. 10. Bailout: Receive money from family or friends to bail them out. http://www.youtube.com/watch?v=7aQgpcxVtu0 http://problemgambling.securespsites.com/ccpgwebsite/for-gamblers/gambler-self-assessment.aspx

Gambling Statistics According to the Productivity Commission (2009): 125 000 Australians are problem gamblers. 29 0 000 Australians are at risk of developing the problem or disorder. 61.2% are of problem gamblers are male with the age range between 35-64 being most prevalent. http://www.youtube.com/watch?v=pHDYk15V6hE

The Biopsychosocial Model

Biological Perspective: The dopamine reward system The effects of dopamine on gambling addiction have become of interest to researchers due to Parkinson’s disease suffers who reported gambling addiction soon after treatment for the disease with dopamine. Many sufferers of Parkinson’s disease however have not reported gambling addictions despite taking dopamine. Research has indicated however that dopamine although found in a few areas of the brain has a role in the development and maintenance of addictive gambling.

The dopamine reward system Dopamine is a neurotransmitter that is involved in pleasure, reward, motivation and emotional arousal. The release of dopamine also contributes to planning and complex motor movements. Researchers have identified a pathway in the brain where dopamine is concentrated producing a distinct sense of pleasure. This pathway is known as the ‘dopamine reward system’.

The dopamine reward system Is located in the medial forebrain bundle that ascends from the midbrain through the hypothalamus into the nucleus accumbens.

The dopamine reward system Research by Gray 2007 has shown that dopamine is also released in anticipation of receiving a reward. Research done on animals with the use of classical conditioning and schedules of reinforcement showed that dopamine was released at the presence of light without the UCS (food). This creates an interaction between psychological and biological perspectives as it is conditioning and schedules of reinforcement that establishes the dopamine reward system.

The dopamine reward system In relation to gambling fMRI imaging has shown that chance monetary rewards activate the brain’s dopamine reward system. As the reward is never predictable the gambler receives a burst of dopamine into the brain every time they play. This is also reinforced by social environmental cues resulting in the development and maintenance of a strong response that is very resistant to extinction. Classical conditioning and Gambling. CS Gambling (anticipation of reward) UCS Receiving Reward UCR Dopamine released CR

The dopamine reward system http://www.youtube.com/watch?v=DwNPTP40yy8 http://www.youtube.com/watch?v=xHm-my2wNGE Gambling addiction and Genetics: http://www.youtube.com/watch?v=33llCR48Zws

Gambling addiction and Genetics Researchers from the University of Missouri and the Queensland Institute of Medical Research in 2007 used an Australian population to show evidence of a link between genetics and gambling. In this study 2,889 pairs of twins investigated the role of genetic and environmental factors in the development of gambling addiction. The study found that identical twins who were gamblers were more likely to have a twin who was also a gambler than non-identical twins. The researchers suggest that this association was more to do with a genetic link than environmental factors. http://www.nhs.uk/news/2010/06June/Pages/Gambling-addiction-and-genetics.aspx

Biological Treatment for Gambling Naltrexone has been used as an antagonist inhibiting the neurotransmitter dopamine at the synapse. It does not cause physical dependence and can be stopped without withdrawal symptoms at any time. It is also used to treat alcohol dependency and addiction to heroin. A study conducted by Kim and Grant (2001) showed naltrexone to be very effective in treating participants gambling addiction. Limitation is side effects that naltrexone causes which is predominately nausea but also can have toxic effects on the liver.

Psychological Perspective: Social Learning Theory The social learning theory/observational learning is a combination of learning and cognitive processes used to explain the onset and/or maintenance of addictive gambling. Bandura had four condition for social learning to take place attention, retention, reproduction and motivation to perform the behaviour. A key variable that influences motivation to perform gambling is whether gambling behaviour is observed as being reinforced or punished. Researchers have demonstrated that the media portrays gambling by using vicarious reinforcement rather then vicarious punishment.

Social Learning Theory It is common for younger people to be targeted by the gambling industry such as a ‘young members club’ providing free drinks and free gambling tokens. Even in Tattslotto and school fetes the emphasis is on winning but never on losing. This creates misconceptions and false beliefs about gambling. http://www.crowncasino.com.au/

Social Learning Theory: Real-life models Some parents expose children to gambling from an early age by ‘family days’ at horse-racing carnivals or children amusement facilities at some gaming establishments. This creates the impression to children that gambling is a socially acceptable family activity. There is considerable research that shows if children are first exposed to gambling by their parents and it is seen to be socially acceptable this can lead to the development of problem gambling later in life.

Social Learning Theory: Symbolic models Research indicate the higher the status of the model the more the observer will imitate the behaviour. Gambling providers spent large sums of money to encourage symbolic models to display their company. Such as Shane Warne and ‘888.com’ or the AFL Brownlow Medal awards being held at Crown Casino. There is clear interaction between social factors (being exposed to gambling) creating erroneous cognitive psychological thoughts about it. http://www.youtube.com/watch?v=ta0AIFaW0Z4 http://www.youtube.com/watch?v=ohBDEZLQA64

Psychological Perspective: Schedules of Reinforcement It is commonly known that a variable schedule of reinforcement promotes a steady response rate over a longer period of time and is much more resistant to extinction in comparison to a fixed schedule. Gambling and in particular poker machines are often described as using a variable ratio reinforcement schedule however they actually use a schedule known as random ratio (Haw, 2008).

Psychological Perspective: Schedules of Reinforcement If you had a variable ratio of 20 (VR20) that would mean that although unpredictable over a large number of correct responses say 100 would equal 20 payouts. This is not truly random as there is an upper limit on the maximum number of responses given before reinforcement occurs. In contrast in a random ratio schedule there is no predetermined upper limit before reinforcement is given. Each spin is completely independent of the next and it may take 100 0r 1 000 000 responses before the RR20 is achieved.

Psychological Perspective: Schedules of Reinforcement Unfortunately many gamblers believe that each time they don’t receive a pay out they are getting closer to winning. When a random ratio schedule is used this is a false belief as each event is mutually exclusive (haw, 2010).

Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) CBT treatment aims to assist the individual to examine their thought processes and examine other alternatives when looking at their situation. Many gambling addicts have cognitive distortions with two of the most common being illusions of control and gambler’s fallacy. Illusions of control occurs when the gambler thinks they can beat the odds using their knowledge or skills. The gambler would attribute wins due to their personal actions and losses to factors outside their control. By using this thought process the gambler will be able to maintain their false belief that their gambling strategies are effective.

Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) Gambler’s fallacy refers to the belief that future events can be predicted by past events in a series of independent chance events. This is evident in coin tosses or ‘hot streaks’. Most people with gambling problems are unaware that they have cognitive distortions. The first step of the cognitive component when using CBT is to obtain information of the individuals gambling patterns and distortions. This may involve role plays, diaries or simulations.

Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) The next step involves educating the person to develop an awareness of concepts such as probability, random and chance events. An important aspect of CBT is to encourage the individual to directly challenge and correct their distorted thoughts and provide problem solving strategies to gain control over their impulses. The behavioural component of CBT assists the individual to manage the arousal, anxiety or tension that is associated with the urges to gamble.

Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) A common method of achieving this is using imaginal desensitisation. In this technique the gambler is asked to imagine being in a typical gambling situation while in a state of relaxation. The goal being to extinguish the arousal and gambling and replace it with relaxation. Imaginal desensitisation is a three step process. http://www.youtube.com/watch?v=JSO6iAFekPw http://www.youtube.com/watch?v=5g2-qzYhwgY&feature=related

Psychological Treatment for Gambling: Psychodynamic psychotherapy Based on Freud’s theory that all mental disorders are caused by unresolved psychological conflicts that occur in the unconscious with their origins being in early childhood. The aim of this treatment is to help people to understand the cause of the emotional distress which for problem gambling revolves around the Oedipal complex (Freud, 1928). When using the psychodynamic approach the therapist will try to achieve abstinence from gambling which can be a lengthy process thus it is important that the client is an active participant.

Psychological Treatment for Gambling: Psychodynamic psychotherapy When treating problem gambling therapists use a range of techniques such as free association, dream interpretation, identification of defence mechanisms and displays of transference. Free association is when the client is encouraged to say whatever comes to their minds in order to identify the themes involved in their gambling. Dream interpretation involves clients sharing their dreams as the psychodynamic perspective has the belief that dreams symbolically represent information stored in the unconscious mind.

Psychological Treatment for Gambling: Psychodynamic psychotherapy Identification of defence mechanisms is essential for treatment to work as it prevents the unconscious conflicts from being explored and resolved. Denial and omnipotence are two common defence mechanisms that gamblers use. Transference provides a valuable source of information by the client unconsciously responding to the therapist as though they significant person in their life. Limitation of this approach is it is hard to scientifically examine the unconscious and obtain empirical data. http://www.youtube.com/watch?v=oS_L8efaJ-E&feature=related

Socio-cultural Perspective: Social permission to Gamble Many psychologists believe that an important factor for problem gambling is that it is considered as acceptable within a socio-cultural context. Gambling is regarded by many Australians as part of their cultural heritage. Around in three in four Australians gamble at some time in the year. There is the Melbourne Cup, two-up during Anzac day and constant advertising that provides and reinforces a positive image of gambling in our society. Research indicates that when there is a perception that gambling is socially acceptable younger people are more likely to try gambling and less likely to associate negative consequences with it (Australian Psychological Society, 1997).

Socio-cultural Perspective: Social permission to Gamble There is also research to indicate that the number of people in a community that undertake gambling is related to promotion, accessibility and availability of gambling outlets. Some other social factors that can contribute to gambling problems include: boredom, unemployment and relationship issues (ANU, 2004).

Social Treatment for Gambling: Social networks The term social network refers to various individuals or groups who maintain a relationship within an individual in different aspects of their lives. The main benefit of a social network is social support in the form of appraisal, information and emotional support as well as tangible assistance. One limitation with social networks for gamblers is that is usually involves other problem gamblers which makes it very difficult for abstinence to occur.

Social Treatment for Gambling: Recovery groups A recovery group is typically a non profit organisation facilitated by someone who has usually suffered from the addiction in someway. The assumption of all support groups is that recovery is possible and that by drawing on the groups experiences this will be achieved using a step by step process. There are open groups where individuals can join at any time or closed groups that have no additional admittance to the sessions once started.

Social Treatment for Gambling: Recovery groups Typically a psychologist, social worker or someone who has recovered from pathological gambling is invited to the session. Gamblers anonymous (GA) best known recovery groups was established in 1957 in California. Sessions run for 90 minutes, there are no fees with the only requirement for membership being a desire to stop gambling. The initial process in recovery for the problem gambler is admitting they are powerless in controlling their gambling and surrendering to a ‘higher power’.

Social Treatment for Gambling: Recovery groups Another key feature of GA is having a sponsor who is a former problem gambler who has remained abstinent and can provide support and guidance through the recovery process. GA although social in its structure does use some psychological theories such as: Positive reinforcement when the gambler is given rewards from not gambling for a period of time. Behavioural techniques that provide different social activities other then gambling.

Social Treatment for Gambling: Recovery groups 3. Cognitive approaches encourage problem gamblers to take one day at a time thus decisions are more likely to be rational and self-controlling (Grant, 2007). Some of the limitations of GA is that: 1. It believes that abstinence is the only solution for problem gambling. There has been empirical research to show a reduced and responsible gambling behaviour for some people can be a realistic goal. 2. GA is more likely to be effective when used in combination with psychological therapy. http://www.youtube.com/watch?v=M7Ddmf8VNDQ

Conclusions Problem gambling is a complex issue that is becoming more prevalent in our society and starting at an earlier age due to technology. It seems that it is caused by the interaction of a combination of biological, psychological and socio-cultural factors rather then one single cause. It is essential that people are educated about gambling and the odds of winning to make more informed decisions if they choose to gamble.

ANY QUESTIONS?