Gambling Disorder

Overview

Definition 

• Gambling disorder:
  • Characterized by repeated betting behavior
  • Can have negative effects on a person’s finances, profession, personal life, or other relationships
  • Mostly a chronic condition
  • High risk of relapse Relapse Relapsing Fever
• Gambling: risking the loss of something (e.g., cash or property) for the possibility of winning something with a higher value.

Epidemiology

• Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in the general population is between 0.4% and 1%.
• More common in men 
• < 10% of adult gamblers develop a gambling disorder.
• Increased incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency in individuals with a family history Family History Adult Health Maintenance of psychiatric disorders

Pathophysiology

• The impulsive and risky behaviors are thought to arise from issues with neurocognitive functioning in the frontostriatal circuitry. 
• Compared with healthy controls, those with gambling disorder have deficits in:
  • Inhibition 
  • Planning 
  • Time management 
• Neuroimaging Neuroimaging Non-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities. Febrile Infant shows decreased activity in ventral striatum Striatum Striped gray matter and white matter consisting of the neostriatum and paleostriatum (globus pallidus). It is located in front of and lateral to the thalamus in each cerebral hemisphere. The gray substance is made up of the caudate nucleus and the lentiform nucleus (the latter consisting of the globus pallidus and putamen). The white matter is the internal capsule. Basal Ganglia: Anatomy and ventromedial/ventrolateral prefrontal cortex during rewarding events.

Diagnosis

Clinical diagnostic criteria:

• Persistent and recurrent problematic gambling behavior results in clinically notable impairment or distress.
• Criteria (requires 4 or more of the following):
  • Constantly preoccupied and thinking about gambling
  • Has the urge to gamble with extra money to increase excitement
  • Fails to control or stop gambling
  • When cutting down on gambling, becomes restless or irritable
  • Gambles to escape from problems
  • Gambles after losing money (“chasing”) 
  • Lies to hide severity of gambling
  • Significant effect on professional and personal life
  • Asks others for money to relieve a desperate financial situation
• Manic mood features must be excluded.
• Lasts at least 12 months

Management

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

• 1st line: cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy (CBT)
• Goals:
  • Emphasize psychoeducation Psychoeducation Psychotherapy.
  • Identify urges to gamble.
  • Create other activities to mitigate the triggers. 
• Alternative: group therapy Group therapy A form of therapy in which two or more patients participate under the guidance of one or more psychotherapists for the purpose of treating emotional disturbances, social maladjustments, and psychotic states. Psychotherapy with a 12-step program (Gamblers Anonymous)

Pharmacotherapy

Opioid Opioid Compounds with activity like opiate alkaloids, acting at opioid receptors. Properties include induction of analgesia or narcosis. Constipation antagonists ( naltrexone Naltrexone Derivative of noroxymorphone that is the n-cyclopropylmethyl congener of naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. Opioid Analgesics) are commonly used.

• Mechanism of action: thought to influence the mesolimbic pathway  
• Studies show reduced gambling urge and behavior.

Differential Diagnosis

• Bipolar Bipolar Nervous System: Histology disorder: a highly recurrent psychiatric illness characterized by fluctuating periods of manic/hypomanic features (distractibility, impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, increased activity, decreased sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep, talkativeness, grandiosity, flight of ideas) and depressive symptoms. Management includes mood stabilizers such as lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly, anticonvulsants, and antipsychotics. Loss of judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment and gambling are common features of a manic episode. Careful history taking must rule out bipolar Bipolar Nervous System: Histology disorder as underlying the gambling behavior.
• Nonpathologic gambling: when a patient does not meet the criteria for diagnosis or participates in professional or social gambling. This type of gambling typically has a reduced or acceptable amount of risk compared with that found in gambling disorder.